Marine safety investigations & reports

Fatality on board Thor Gitta at sea off Western Australia, 21 May 2009

Investigation number:
Status: Completed
Investigation completed


Download Final Report
[Download  PDF: 1.89MB]

At about 0930 on 21 May 2009, a crew member on board the general cargo ship Thor Gitta was fatally injured while attempting to secure lashing bins in the cargo hold. At the time, the ship was about 390 miles northwest of Fremantle, Western Australia.

The investigation found that a risk analysis had not been undertaken before the bins were introduced into service and that the bins had been inadequately secured in an area where there were no dedicated lashing points. It also found that the crew member was probably affected by fatigue as a result of the duty roster and the ship's movement in the heavy seas.

As a result of this accident, the ship's manager has implemented a range of measures on all its vessels to improve the security of bin lashing arrangements and manage the risks of carrying out tasks associated with operation of the bins. The company has also introduced a different rostering system to better manage the fatigue of watchkeepers when the ship is at sea.

The ATSB has issued one safety recommendation to the Danish Maritime Authority relating to the use of the 6 hour on/6 hour off work routine and the effect that that work routine has on a crew member's level of fatigue.

Download Final Report
[Download  PDF: 1.89MB]
General details
Date: 21 May 2009   Investigation status: Completed  
Time: 0930 (UTC+7 hours)   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): At sea, 390 miles off WA coast    
State: Western Australia    
Release date: 16 December 2009   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Vessel details

Vessel details
Vessel Thor Gitta  
Flag Denmark  
IMO 9137277  
Type of operation General cargo vessel  
Damage to vessel Nil  
Departure point Fremantle, WA  
Departure time 14:40 19 May, 2009  
Destination Dar Es Salaam, Tanzania  
  Crew Passenger Ground Total
Fatal: 1 0 0 1
Total: 1 0 0 1
Last update 03 April 2020