Marine safety investigations & reports

Serious injury on board Berge Daisetsu, Portland, Victoria on 11 January 2018

Investigation number:
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

Download Final report
[Download  PDF: 1.17MB]

What happened

On 11 January 2018, a team of six crewmembers was conducting cargo hold cleaning and painting under the supervision of the chief mate on board Berge Daisetsu. While working aloft, on a jury-rigged platform suspended from a cargo crane, the crane falling block and hook caught and then suddenly released from the hatch coaming. That resulted in shock loading of the platform and serious injuries to two crewmen.

What the ATSB found

The ATSB’s investigation found that prior to starting the work, the ship’s crewmembers had several discussions, made plans, and completed a risk assessment. However, the work was not conducted in accordance with company safety management procedures or industry best practice with regard to risk management and working aloft permit requirements.

Additionally, the deck crane was being operated with its working limits bypassed when used to support the ship’s crew during the painting task. This enabled the crane to reach a position which allowed the block to contact and catch on the hatch coaming.

Finally, the fall arrest equipment used by the crew on the platform was incorrectly attached. As such, had either of the crewmen fallen from the platform the equipment would not have worked correctly, resulting in serious or fatal injuries.

What's been done as a result

Berge Bulk Maritime has completed the supply of approved working aloft equipment to its geared bulk carriers and is progressing modification of vessel cranes for personnel lifting. Specific working aloft and bulk carrier safety training has been conducted and made mandatory for crewmembers every two years. In addition, a fleet-wide assessment of safety maturity is progressing.

Safety message

This accident illustrates the consequence of deviating from accepted safety management procedures and industry best practice. The use of machinery and equipment contrary to its intended purpose makes hazard identification difficult and exposes those directly involved to significantly increased risk.

Download Final report
[Download  PDF: 1.17MB]

The occurrence


Safety analysis


Safety issues and actions

Ship details

Sources and submissions

Safety Issue

Go to MO-2018-001-SI-01 -

Knowledge and use of fall arrest safety equipment

The fall arrest equipment used was incorrectly attached to the workers on the suspended platform. Consequently, had either of them fallen from the platform the equipment would not have worked correctly, resulting in serious or fatal injuries.

Safety issue details
Issue number: MO-2018-001-SI-01
Who it affects: All workers on ship
Status: Closed – Adequately addressed
General details
Date: 11 January 2018   Investigation status: Completed  
Time: 15:10 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Smelter Berth, Portland   Investigation phase: Final report: Dissemination  
State: Victoria    
Release date: 30 October 2019   Occurrence category: Incident  
Report status: Final   Highest injury level: Serious  
Anticipated completion: 4th Quarter 2019    

Vessel details

Vessel details
Operator Berge Bulk Maritime  
Vessel Berge Daisetsu  
Flag Isle of Man  
IMO 9713179  
Sector Bulk carrier  
Type of operation Cargo operations  
Damage to vessel Nil  
Departure point Portland, Victoria  
Destination Wallaroo, South Australia  
Last update 01 November 2019