The ATSB has found that the crew on board the Isle of Man registered oil tanker British Mallard did not prevent the ship's elevator car from moving while they were working in the elevator shaft and, as a result, it moved unexpectedly, trapping and killing the ship's electrical technician.

The Australian Transport Safety Bureau investigation found that the ship's crew were either not aware of, or did not consider, all of the hazards associated with working in the elevator shaft. The investigation also found that the elevator instruction manuals did not provide detailed and unambiguous safety guidance; and that critical safety procedures had not been implemented.

At about 1750 on 27 January 2007, British Mallard's crew attempted to repair an elevator fault before they finished work for the day.

The electrical technician made some adjustments to the second deck elevator landing doors and, at about 1800, he stepped into the elevator shaft.

At the electrical technician's request, the second deck elevator landing doors were allowed to close behind him. When the doors closed, the landing door safety circuit was completed and the elevator control system then reset itself.

It is likely that someone then attempted to use the elevator and did not notice the 'do not operate' signs that had been placed on the elevator doors and was unaware that the elevator was not to be operated.

The elevator car then started to move upwards. Its movement was eventually obstructed by the electrical technician and the resultant damage to the elevator car caused it to stop.

The ATSB has reported safety action already taken and issued one safety recommendation and two safety advisory notices with the aim of preventing similar accidents.

Copies of the report can be downloaded from the ATSB's internet site at

Media contact: 1800 020616
Last update 01 April 2011