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What happened

On 23 September 2012, a stevedore working on board the general cargo ship Weaver Arrow while it was berthed in Newcastle NSW, died after being crushed under packs of aluminium ingots which toppled over during loading. Other stevedores raised the alarm and tried to help the crushed man but he showed no signs of life. Paramedics and police officers arrived on the scene shortly afterwards and confirmed that the stevedore was deceased.

What the ATSB found

The ATSB found that the stevedore was climbing down aluminium ingot packs to work on a lower tier of the cargo when the packs toppled over. It was usual for some stevedores to climb up or down ingot packs to work on different cargo tiers instead of using the ladders provided.

The investigation identified that the ingot cargo units or lifts (multiple packs of ingots strapped together) were inherently unstable and prone to toppling over. The stevedoring company’s procedure for loading aluminium products did not adequately address the risk of the cargo toppling over and the implementation of basic precautions, such as using ladders to climb between cargo tiers, was not effectively monitored or enforced.

The ATSB also found that stevedores often worked extended hours, exposing the company’s operations to a level of fatigue-related risk that had not been assessed and treated.

What's been done as a result

Immediately after the accident, Newcastle Stevedores, the stevedoring company, re-assessed the risks involved in loading aluminium ingots and revised its procedures for managing the risk of an ingot lift toppling. The primary measure was establishing an exclusion zone adjacent to a lift. This was included in a revised procedure for ingot loading with other measures such as the use of ladders. Steps to implement the procedure and ensure compliance included increased monitoring of loading operations. Other safety action taken includes an independent review of procedures, retraining of senior grade stevedores in hazard management, developing a process to reject hazardous lifts and suggestions to improve ingot lift configurations.

Patrick Ports and Stevedoring, the company responsible for preparing ingot packs for loading, has taken steps to enhance the stability of ingot lifts and a review is ongoing to identify other ways to address the issue. The main action taken is the addition of vertical straps to hold ingot stacks in a lift together (one strap for each pair of adjacent stacks).

Gearbulk Norway, Weaver Arrow’s manager, has made toppling of cargo a specific agenda item at the daily meetings between senior staff on board its ships and stevedores in all ports. Gearbulk has also introduced a policy of rejecting ingot lifts with broken pack, lifting or unitising straps for loading on any of its ships.

The ATSB has recommended that Newcastle Stevedores address the issue of stevedore fatigue. The ATSB has also issued two safety advisory notices to all stevedoring companies with regard to the issues concerning ingot loading and fatigue risk to promulgate a broad safety message.

Safety message

Individual stacks of aluminium ingots and other similar break-bulk cargoes (whether or not strapped together for carriage on ships) should always be considered unstable and prone to toppling over. No work should be undertaken in the vicinity of ingot stacks unless they have been secured to prevent toppling.

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Safety issues

MO-2012-010-SI-01 - MO-2012-010-SI-02 - MO-2012-010-SI-03 -  

Stability of aluminium ingot lifts

The aluminium ingot lifts in Newcastle, comprising multiple stacks of ingot packs strapped together, with an effective height to width ratio of 5:1 were inherently unstable. Furthermore, handling and stowage of ingot lifts involved the risk of a lift being disturbed and one or more of its packs falling or toppling because the lifting and other straps were not designed to restrain the packs as a single homogenous cargo unit and were prone to failure.

Safety issue details
Issue number:MO-2012-010-SI-01
Who it affects:Cargo handling companies and their employees
Status:Partially addressed


Aluminium ingot loading procedures

While the risk of aluminium ingot stacks toppling over had been identified by the stevedoring company as a result of past incidents, its procedure for loading aluminium products had not evolved to adequately address this risk. Furthermore, the implementation of basic precautions such as using ladders to climb between ingot tiers was not effectively monitored or enforced.

Safety issue details
Issue number:MO-2012-010-SI-02
Who it affects:All stevedoring companies and their employees
Status:Adequately addressed


Stevedore working hours and fatigue

The stevedoring company had not identified stevedore fatigue as a risk to the company or its operations and, as a result, had not implemented a system to manage fatigue. Consequently, its operations were exposed to a level of fatigue-related risk that had not been assessed and treated.

Safety issue details
Issue number:MO-2012-010-SI-03
Who it affects:All stevedoring companies and their employees
Status:Adequately addressed

General details
Date: 23 September 2012 Investigation status: Completed 
Time: 2110 (UTC+10)  
Location   (show map):Newcastle Investigation type: Occurrence Investigation 
State: New South Wales Occurrence type: Fatality 
Release date: 04 June 2013  
Report status: Final Occurrence category: Accident 
 Highest injury level: Fatal 
Vessel details
Vessel: Weaver Arrow 
Flag: Bahamas 
IMO: 9151826 
Type of Operation: Cargo loading operation 
Damage to Vessel: Nil 
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Last update 04 June 2013