Marine safety investigations & reports

Independent investigation into the fatality on board the Hong Kong registered chemical tanker Bow De Jin at sea on 24 November 2009

Investigation number:
270-MO-2009-010
Status: Completed
Investigation completed

Summary

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On 24 November 2009, the chief mate on board the Hong Kong registered chemical tanker Bow De Jin died after entering a cargo tank which contained hydrocarbon vapours and was deficient in oxygen.

The ATSB investigation was unable to determine why the chief mate, who had sailed on tankers for most of his seagoing career, did not follow industry standard and specific company safety procedures before he entered the cargo tank.

The investigation found that while enclosed space entry checklists were being filled out by the crew members on board the ship, the checklist system was not being used as a proactive means to ensure that the necessary safety requirements were being met prior to tank entries.

As a result of this incident and the ATSB investigation, Bow De Jin's managers have taken action to improve the ship's enclosed space entry checklist system.

Download Final Report
[Download  PDF: 992KB]
 
 
 

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Safety Issue

Go to MO-2009-010-SI-01 -

Tank entry checklist system

While enclosed space entry checklists were being filled out by the crew members on board Bow De Jin, the checklist system was not being used as a proactive means to ensure that the necessary safety requirements were being met prior to tank entries.

Safety issue details
Issue number: MO-2009-010-SI-01
Who it affects: All ship owners, operators, managers, masters and crews
Status: Adequately addressed
General details
Date: 24 November 2009   Investigation status: Completed  
Time: 0830 (UTC +10)   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): 32 nautical miles ENE of Yamba, northern NSW coast    
State: New South Wales    
Release date: 10 November 2010    
Report status: Final   Occurrence category: Accident  
  Highest injury level: Fatal  

Vessel details

Vessel details
Vessel Bow De Jin  
Flag Hong Kong  
IMO 9200598  
Type of operation Chemical tanker  
Damage to vessel Nil  
Departure point Port Botany, NSW  
Departure time 0715 (UTC +11) 23 Nov '09  
Destination Gladstone, QLD  
Last update 14 November 2018