Marine safety investigations & reports

Independent investigation into the loss of containers from Pacific Adventurer off Cape Moreton, Queensland, 11 March 2009

Investigation number:
263-MO-2009-002
Status: Completed
Investigation completed

Summary

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At 0312 on 11 March 2009, the container ship Pacific Adventurer lost 31 containers overboard in gale force weather conditions and large swells off Cape Moreton, Queensland. All the containers sank, however, two of the ship's fuel oil tanks were holed as the containers went overboard.

About 270 tonnes of oil leaked from the holed tanks and 38 miles of Queensland's coastline was affected by the oil.

The ATSB investigation found that the ship was probably subjected to synchronous rolling at the time and that the severe and sometimes violent rolling motions caused the lashings on the containers, and possibly some the containers themselves, to fail. In addition, much of the fixed and loose container lashing equipment was in a poor condition and the inspection and replacement regime in the ship's safety management system had not been effectively implemented.

The ATSB identified four safety issues during the investigation: the inspection and maintenance regime of the ship's fixed and loose lashing equipment had been deficient; there was no requirement for a third party to inspect this equipment; the cargo in the containers which were lost overboard was not packaged in accordance with international dangerous goods shipping requirements; and the dangerous goods shipping compliance audit regime did not pick up on this fact.

Safety action to address the safety issues was taken by several of the responsible organisations. The ATSB has issued one safety advisory notice in regard to the outstanding safety issue concerning third party inspections of lashing equipment.

 

Updated: 22 July 2011
Following the release of the Pacific Adventurer investigation report, the ATSB was contacted by the German Federal Bureau of Marine Casualty Investigation (BSU) in relation to a number of accidents involving fatalities and serious injuries on board large German flagged container vessels as a result of severe ship motions in poor sea conditions. The BSU have commissioned a number of studies into container ship stability and the causes of severe rolling motions as part of their investigations and undertook to conduct a further study specifically into the circumstances of Pacific Adventurer's voyage on 10/11 March 2009.  The BSU is currently working through the International Maritime Organization to address the issue of 'excessive stability' on container ships in order to develop of a new generation of intact stability criteria.

The BSU's report: Theoretical Investigations on the Container Loss of MV Pacific Adventurer off Cape Moreton, Queensland; and their reports into two fatal accidents on board merchant ships during typhoons in the sea area off Hong Kong, can be downloaded from this webpage.

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Preliminary

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Preliminary Report Released 14 April 2009

At 0312 on 11 March 2009, the Hong Kong registered container ship Pacific Adventurer lost 31 containers overboard in gale force weather conditions and large swells. The ship was about seven miles east of Cape Moreton, Queensland. All the containers, carrying ammonium nitrate prills, sank. However, two of the ship's fuel oil bunker tanks were holed as the containers went overboard. In all, Pacific Adventurer lost about 270 tonnes of fuel oil into the sea as a result of the damage caused to the bunker tanks.

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Safety Issues

Go to MO-2009-002-SI-01 - Go to MO-2009-002-SI-02 - Go to MO-2009-002-SI-03 - Go to MO-2009-002-SI-04 -

Condition of lashing gear

The poor condition of much of the ship’s container lashing equipment indicates that the inspection and maintenance regime applied to this critical equipment had been inadequate.

Safety issue details
Issue number: MO-2009-002-SI-01
Who it affects: All ship owners, operators, managers and maters
Status: Adequately addressed

Third party inspection of lashing equipment

At the time of the incident, there was no requirement for any third party to inspect or survey the fixed and loose lashing equipment on a ship. Had this been done, the maintenance and replacement regime of such equipment on board Pacific Adventurer might have been more effective.

Safety issue details
Issue number: MO-2009-002-SI-02
Who it affects: All regulators surveyors and inspectors
Status: Adequately addressed

Container packaging completed by shipper.

The ammonium nitrate prills were not packaged in the containers in accordance with the requirements of the IMDG Code. The containers were packed in a way which allowed the prills to move within the container in a way that may have contributed to the failure of the containers and/or the lashing system.

Safety issue details
Issue number: MO-2009-002-SI-03
Who it affects: All shippers of ammonium nitrate
Status: Adequately addressed

IMDG Code requirements oversight

Before the incident, Orica Australia had advised the Australian Maritime Safety Authority (AMSA) that their packaging method for the prills was fully compliant with the IMDG Code’s provisions. However, AMSA’s IMDG Code compliance audit regime had not detected that the method was not compliant.

Safety issue details
Issue number: MO-2009-002-SI-04
Who it affects: All regulators, surveyors and inspectors
Status: Adequately addressed
General details
Date: 11 March 2009   Investigation status: Completed  
Time: 0312 (UTC+10)   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): off Cape Moreton    
State: Queensland    
Release date: 27 January 2011    
Report status: Final   Occurrence category: Serious Incident  
  Highest injury level: None  

Vessel details

Vessel details
Vessel Pacific Adventurer  
Flag Hong Kong China  
IMO 9003847  
Type of operation Container ship  
Damage to vessel Minor  
Departure point Newcastle, New South Wales  
Departure time 1738, 9 March  
Destination Brisbane, Queensland  
Last update 14 November 2018