Marine safety investigations & reports

Serious injury on board the passenger ship Seven Seas Voyager while berthed in Sydney, NSW on 1 February 2014

Investigation number:
Status: Completed
Investigation completed

Final report

Download Final Report
[Download  PDF: 2.5MB]
Alternate: [Download  DOCX: 906KB]

What happened

On 1 February 2014, a crew member carrying out routine maintenance on the passenger ship Seven Seas Voyager’s waste incinerator was injured when a pneumatically (air) operated valve closed against his body. The ship was berthed in Sydney and the crew member, a fitter, was taken to a local hospital.

The fitter was treated for serious bruising and shock before returning to the ship. While it was expected that the fitter could resume duties after 2 days, his condition did not sufficiently improve and he was later discharged from the ship to recuperate at home.

What the ATSB found

The ATSB found that the incinerator ash dump valve’s control systems had not been properly isolated and residual air pressure remained in the valve’s operating system. The fitter assumed that it was safe to start his assigned task of replacing the incinerator ash grates, and accessed the incinerator through the ash dump valve. He then inadvertently activated the electric sensor that automatically closed the valve – driven by the pressure of the residual air remaining in the valve operating system.

The investigation identified that Seven Seas Voyager’s engineering staff did not have an adequate understanding of the incinerator’s control systems and its maintenance. Furthermore, the task of replacing the ash grates was not adequately planned and shipboard safety management system requirements, including taking necessary risk mitigation measures and completion of a permit to work before the task, were not complied with.

The investigation also found that neither the ship’s planned maintenance system (PMS) nor the incinerator manufacturer’s instruction manual contained any information with respect to the maintenance or replacement of the ash grates. Such information would have been useful to shipboard staff planning the grate replacement task, particularly with identifying all the risks associated with the task.

What's been done as a result

The ATSB has issued a recommendation to Seven Seas Voyager’s manager to take action to address the safety issue with respect to the ship’s PMS. The ATSB has also recommended that the incinerator manufacturer address the safety issue concerning the equipment’s instruction manual.

Safety message

Shipboard equipment and machinery commonly incorporates automated, power-operated systems which must be isolated, stored energy released and locked out before undertaking maintenance or repair tasks. Safely completing a task relies on personnel having a proper understanding of the system involved, coupled with adequate planning, risk assessment and the effective implementation of all safety management system requirements - including permits to work.

Download Final Report
[Download  PDF: 2.5MB]
Alternate: [Download  DOCX: 906KB]

The occurrence


Safety analysis


Safety issues and actions

Sources and submissions


To download, click the link, then right-click and select Save As.

Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations and should be credited accordingly.

Safety Issues

Go to MO-2014-001-SI-01 - Go to MO-2014-001-SI-02 -

Planned maintenance system

Seven Seas Voyager’s planned maintenance system (PMS) contained no information about waste incinerator ash grate replacement, a task that would have been periodically undertaken by different engineering staff since 2003. Therefore, in this respect, the shipboard procedures that documented requirements for the PMS had not been effectively implemented.

Safety issue details
Issue number: MO-2014-001-SI-01
Who it affects: All persons charged with maintaining equipment
Status: Adequately addressed

Manufacturer’s instructions

The manufacturer’s instruction manual for Seven Seas Voyager’s waste incinerator contained no specific instructions for ash grate maintenance or replacement. Such instructions would have provided useful information for the ship’s crew to plan and safely complete periodic ash grate maintenance.

Safety issue details
Issue number: MO-2014-001-SI-02
Who it affects: All persons charged with maintaining equipment
Status: Partially addressed
General details
Date: 01 February 2014   Investigation status: Completed  
Time: 0910 UTC +11   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Sydney    
State: New South Wales    
Release date: 23 January 2015   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: Serious  

Vessel details

Vessel details
Operator Prestige Cruise Services LLC  
Vessel Seven Seas Voyager  
Flag Bahamas  
IMO 9247144  
Sector Passenger  
Type of operation Marine shipboard  
Damage to vessel Nil  
Departure point Melbourne, Vic.  
Destination Sydney, NSW  
Last update 03 April 2020