Fatality on board Thor Gitta, at sea off Western Australia, on 21 May 2009

265-MO-2009-004

Final report

Abstract

At about 0930 on 21 May 2009, a crew member on board the general cargo ship Thor Gitta was fatally injured while attempting to secure lashing bins in the cargo hold. At the time, the ship was about 390 miles northwest of Fremantle, Western Australia.

The investigation found that a risk analysis had not been undertaken before the bins were introduced into service and that the bins had been inadequately secured in an area where there were no dedicated lashing points. It also found that the crew member was probably affected by fatigue as a result of the duty roster and the ship's movement in the heavy seas.

As a result of this accident, the ship's manager has implemented a range of measures on all its vessels to improve the security of bin lashing arrangements and manage the risks of carrying out tasks associated with operation of the bins. The company has also introduced a different rostering system to better manage the fatigue of watchkeepers when the ship is at sea.

The ATSB has issued one safety recommendation to the Danish Maritime Authority relating to the use of the 6 hour on/6 hour off work routine and the effect that that work routine has on a crew member's level of fatigue.

Occurrence summary

Investigation number 265-MO-2009-004
Occurrence date 21/05/2009
Location At sea, 390 miles off WA coast
State Western Australia
Report release date 16/12/2009
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Marine
Marine occurrence category Fatality
Occurrence class Accident
Highest injury level Fatal

Ship details

Name Thor Gitta
IMO number 9137277
Ship type General cargo vessel
Flag Denmark
Departure point Fremantle, WA
Destination Dar Es Salaam, Tanzania