Marine safety investigations & reports

Fatality while storing the products tanker British Beech in Brisbane, Queensland on 15 December 2011

Investigation number:
Status: Completed
Investigation completed


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What happened

On 15 December 2011, British Beech was berthed in Brisbane, Queensland, and its crew was taking on stores from a barge. During the return of a stores container from the ship to the barge, the container came free of its slings. It fell to the barge below, striking the master of the barge. The master was attended to by the barge crew and shore paramedics but he died from his injuries while being transported to hospital.

What the ATSB found

The ATSB found that the container had not been appropriately rigged on board the ship and the ship’s crew had not warned the barge crew of its return. The ship’s crew did not view the storing operation as dangerous and had, over time, removed identified safety barriers which would probably have prevented the accident. Compliance auditing processes had not identified and minimised such routine violations of the shipping company’s procedures.

The ATSB also found that the barge master had placed himself in a position of danger under the suspended load, and that the barge crew had not followed their company’s procedures for storing operations. The ATSB further found that the company had not adequately implemented compliance auditing or incident reporting schemes. As a result, the company had not acted on, or learnt from, previous less serious incidents.

What has been done to fix it

The method used for handling containers of this type in Brisbane has been altered so that the containers are top lifted and slings are no longer used.

The ship’s manager, BP Shipping, implemented a requirement to have the lifting point fixed and above the centre of gravity of loads. A thorough review of lifting and slinging processes, practices, procedures and equipment was conducted as well as a review of lifting and slinging job hazard analyses. A fleetwide review and training workshop for lifting and slinging was also completed.

The barge’s operator, Bowen Tug and Barge, undertook a review of its operations and work practices. On 1 July 2012, the company ceased ship storing operations and sold all associated vessels and equipment to another operator.

Safety message

Lifting operations, even when they are routine, involve inherent risks. Therefore, established procedures must be followed, reinforced and audited to ensure vigilance is maintained and complacency avoided. The basic precaution of standing well clear of suspended loads must always be taken.

Download final report
[Download  PDF: 2.45MB]
Alternate: [Download  DOCX: 3.5MB]

Safety Issues

Go to MO-2011-011-SI-01 - Go to MO-2011-011-SI-02 - Go to MO-2011-011-SI-03 - Go to MO-2011-011-SI-04 - Go to MO-2011-011-SI-05 -

Bowen Tug and Barge safety management system adequacy

Bowen Tug and Barge’s safety management system guidance for barge storing operations did not designate roles or responsibilities to specific individuals and a system for communicating with the ship’s crew was not discussed and established.

Safety issue details
Issue number: MO-2011-011-SI-01
Who it affects: All ship storing companies
Status: Adequately addressed

Bowen Tug and Barge compliance auditing

Bowen Tug and Barge did not have an effective compliance auditing process in place to ensure that its employees were following the training they had received and the guidance contained in the safety management system documentation.

Safety issue details
Issue number: MO-2011-011-SI-02
Who it affects: Bowen Tug and Barge
Status: Adequately addressed

BP Shipping compliance auditing

Compliance auditing on board British Beech had not identified that requirements of the job hazard analysis were not being followed by the crew during the storing operations.

Safety issue details
Issue number: MO-2011-011-SI-03
Who it affects: BP Shipping and all ship’s crew members
Status: Adequately addressed

Bowen Tug and Barge incident reporting

The lack of any record of incident reporting by Bowen Tug and Barge, and its employees, indicates an ineffective reporting culture within the company. Hence, the opportunity to learn from previous incidents was lost.

Safety issue details
Issue number: MO-2011-011-SI-04
Who it affects: Bowen Tug and Barge
Status: Adequately addressed

Bowen Tug and Barge stores container handling

Bowen Tug and Barge had identified the need to spread the slings when lifting a stores container. However, there was no process in place to ensure that ships' crews were advised of this to ensure its safe return from the ship.

Safety issue details
Issue number: MO-2011-011-SI-05
Who it affects: All ship’s stores handling organisations
Status: Adequately addressed
General details
Date: 15 December 2011   Investigation status: Completed  
Time: 1413 (UTC+10)   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): BP wharf, Brisbane River    
State: Queensland    
Release date: 07 March 2013   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Vessel details

Vessel details
Operator BP Shipping, UK  
Vessel British Beech  
Flag Isle of Man  
IMO 9266841  
Type of operation Crude Oil Tanker  
Damage to vessel Nil  
Last update 03 April 2020