Summary

On 4 October 1991 the Australian flag bulk carrier TNT Carpentaria was on passage from Weipa to Gladstone with a fill cargo of bauxite and drawing a maximum draught of 12.13m.

At about 1716 Eastern Standard Time, a pilot from the Queensland Coast and Torres Strait Pilot Service boarded the ship about 2.4 miles west of Harrison Rock buoy at the western extreme of the Prince of Wales channel.

After a brief discussion with the Master, the pilot advised that there was insufficient water in certain parts of the Prince of Wales Channel to allow the ship to make a safe passage. It was decided to wait off the channel until the transmitting tide gauges indicated sufficient under-keel clearance to allow the ship to transit the channel.

At about 1736 the pilot ordered the wheel be put hard to port, so as to make a turn on to a reciprocal course to await the tide.

At about 1754 the vessel grounded 0.7 miles north-west of Harrison Rock at the western end of Sunk Reefs.

At about 2103 the vessel refloated under its own power and the passage to Gladstone was resumed.

No-one was injured in the incident and there was no pollution.

Conclusions

It is concluded that:

1. The grounding was caused by an error of judgment by the Pilot turning the ship to port rather than to starboard.
2. The ship's position relative to adjacent shoal water was not known by the Pilot.
3. The Master and Mate failed to fix the ship's position before the turn to port was made and failed to monitor the ship's position through the course of the turn.
4. The Master and Mate failed to properly assess the option of turning to starboard.
5. It would have been prudent for the Pilot to establish the tidal conditions before arriving on board the ship.
6. Notwithstanding the pilot's error of judgment and his failure to make an early appraisal of the tidal situation, he was placed in an invidious position by the arrival of the TNT Carpentaria at a time when there was insufficient water to navigate the Prince of Wales Channel.
7. The Master, having completed a passage plan, did not properly appraise and appreciate the significance of the transmissions from tidal stations.
8. The Second Mate failed to advise the Master of his concern with regard to the passage plan, and also failed to properly monitor the tidal heights and advise the Master of their significance.
9. The Mate failed to discuss the passage plan with the Master and, with the benefit of his considerable experience in the trade, properly advise him on alternative plans.
10. The consumption of alcohol was not a factor in the grounding.
11. There is no evidence that either the Master, or Pilot, or Mate, or Second Mate, were affected by acute fatigue.

Summary

Shortly before 0200 Eastern Standard Time 3 September 1991, the Russian container ship Khudozhnik Ioganson, whilst on passage from Manila to Melbourne, was in collision with the Australian prawn trawler Zodiac off Cairns.

No persons were injured, but the Zodiac sustained damage to the starboard fishing boom, the deckhouse starboard awning and to the stem post.

Conclusions

It is considered that:

1. The Khudozhnik Ioganson was proceeding at a speed commensurate with the visibility and traffic density.
2. The Khudozhnik Ioganson was an overtaking vessel within the meaning of the International Regulations for the Prevention of Collisions at Sea (Colregs) and had a duty to keep clear of the Zodiac, irrespective of whether or not the Zodiac was engaged in fishing, until finally passed and clear.
3. The Master's actions of passing fishing vessels at a distance of 0.2 miles when in coastal waters were in accordance with common practice and not unduly hazardous when both vessels comply fully with the Colregs.
4. Prior to 0145 the Zodiac was proceeding on a slightly converging course with that of the Khudozhnik Ioganson of around 148 degrees True.
5. Had both vessels maintained their courses and speeds of prior to 0145 a collision would not have occurred.
6. The Khudozhnik Ioganson maintained a straight and steady course until taking evasive action shortly before the collision.
7. The Zodiac altered course to starboard at approximately 0146.
8. The Master of the Khudozhnik Ioganson did not ascertain that the Zodiac had altered course to starboard until such time as collision was unavoidable by the actions of the Khudozhnik Ioganson alone.
9. The Master and Second Mate of the Khudozhnik Ioganson failed to fully utilise the radars and the observed visual bearings and radar distances to ascertain the course and speed of the Zodiac [Rule 7(b) of the Colregs].
10. After the collision the Master of the Khudozhnik Ioganson failed in his responsibility to ascertain whether the Zodiac crew had sustained injury and whether assistance was required.
11. The Skipper of the Zodiac failed in his responsibilities by leaving the navigation of the vessel in the charge of an unqualified deckhand.
12. The Zodiac failed to maintain course and speed as required under Rule 17(a)(i) (Action by Stand-on Vessel) of the Colregs.
13. The Deckhand of the Zodiac failed to keep a proper lookout as required by Rule 5 of the Colregs and failed to ascertain that it was safe to alter course before doing so.
14. Alcohol was not a contributing factor to the incident.
15. Fatigue cannot be ruled out as having affected judgements prior to the collision.
16. The glare of the working lights of the Zodiac was such as to obscure the navigation/fishing lights and therefore their display was contrary to Rule 20(b) of the Colregs.
17. The siting of the Zodiac's all-round green and white lights on the same structure as the working lights was instrumental in their being obscured by the glare of the working lights. 

Outline of incident

On the evening of 20 July 1991, the Greek. registered oil tanker Kirki (call sign SVRVV) was about 55 miles off the Western Australian coastal centre of Cervantes on passage from the Arabian Gulf to Kwinana with a cargo of approximately 82,660 tonnes of light crude oil. The weather was severe, with rough seas, heavy swell and southerly force 8 winds increasing in intensity.

At about 2000 Western Australia Standard Time, it was observed that the vessel had a pronounced trim by the head and the ship's speed was reduced and course altered to put the prevailing weather on a more comfortable quarter. On investigation it was established that the fore-peak ballast tank, which should have been effectively dry, had water in it, apparently to sea level. Attempts to pump the forepeak did not succeed in lowering the water level and it became obvious that the forepeak was open to the sea.

At about 0220 (UTC 1820) approximately 22 miles from the coast, in very rough seas and heavy swell, the bow was seen to break away from the ship just forward of No 1 oil cargo tanks. Simultaneously a fire erupted, from a rupture in the forward bulkhead of No 1 cargo tanks fuelled by highly volatile crude oil, and oil was lost to the sea. The engines were immediately stopped. Distress calls were broadcast, and the crew was mustered at the port (leeward) lifeboat. After about 15 minutes the fire forward went out, extinguished by the action of the sea.

At 0302 (1902 UTC) Perth Marine Communications Station monitored a "Mayday" message followed by a two-tone alarm, from the Kirki. The Australian Maritime Safety Authority's Maritime Rescue Coordination Centre was alerted, and measures were put in place to evacuate the crew by helicopter. The off-shore support vessel Lady Kathleen responded by sailing for the casualty and the Western Australian Marine Emergency Operations Centre dispatched the State Department of Marine and Harbours vessel Vigilant. The National Plan to Combat Pollution of the Sea (the National Plan) was activated, and the Marine Emergency Centre became the coordination headquarters for the State Committee of the National Plan.

During the ensuing hours the fire broke out from the Kirki's forward area on a further five occasions, each time being extinguished by the sea.

Helicopters arrived at first light and the evacuation of the crew, in relays to the nearest land, began at 0713 and was completed at 1156.

At 1040 the Lady Kathleen arrived at the casualty. At about 1430 the Lady Kathleen succeeded in securing a tow line to the Kirki's stern. The Kirki was then towed offshore while an assessment of the situation and decisions were taken as to the best course of action.

The Lady Kathleen was relieved of the tow by the offshore vessel Lady Elizabeth on 25 July and, over the next 14 days, the Kirki was towed to an area west-north-west of Dampier, where the remaining cargo was to be transferred to another tanker. On 25 July and again between 3 and 6 August, in high seas and heavy swell, two further quantities of oil were lost.

On 19 August, the remaining cargo and the bulk of the fuel oil was discharged in a ship-to-ship transfer in an area to seaward of the Monte Bello Islands and the Dampier Archipelago. A total of 64,372 tonnes of cargo and 1290 tonnes of heavy fuel oil were transferred, leaving approximately 600 tonnes of crude oil aboard the Kirki. The ship was subsequently towed to Singapore.

About 17,700 tonnes of crude oil was lost.

Note: all times are given in Western Australian Standard Time (Universal Coordinated time + 8 hours), unless otherwise indicated.

Conclusions

The Inspector concludes:

1. The flooding of the fore-peak tank on the evening of 20 July, was due either to a failure in the ship's shell plating forward of frame 93, or the shearing of the fore peak ballast pipeline at the shell plating on the port side.
2. It is not possible to be precise as to the cause of the structural failure forward of frame 93 (the bow). It was either due to the action of sea water, which had flooded the fore-peak, impinging heavily in the area of frame 93, which led to an overload on the structure, or to a loss of bow plating. Either one or a combination of these factors led to excessive stress on an area of the ship's structure already weakened by corrosion and the effects of repair work.
3. The source of the ignition causing the original fire was either sparks caused by the mechanical action of the tearing of the steel work, or the arcing of broken electrical cables forward.
4. The subsequent five fires were caused either by static electrical discharges or by the arcing of broken electrical cables.
5. There is no evidence that the loading operation Jebel Dhanna contributed in any way to the incident.
6. Any stress to the ship's hull caused by maintaining propeller revolutions at 95 rpm through the gales of 4 to 6 July and in the sea conditions of 18 to 20 July was to an area already weakened structurally. It would have been prudent to reduce the revolutions in such weather.
7. The Master acted properly in putting the wind and sea on the starboard quarter, on the evening of 20jtdy, when it became apparent that the fore-peak tank was breached.
8. The Master acted properly and in the best interests of his crew in evacuating the bulk of the crew from the ship.
9. After the evacuation of the bulk of the crew, the Master failed to make a realistic assessment of the situation. The risk to life would have been minimal had a skeleton crew remained to secure a tow and assist the Salvage Master.
10. In evacuating the ship, the crew did not significantly increase the risk of fire by leaving the B and W Holeby generator operating. They were prudent in closing down the boilers.
11. The use of alcohol and/or drugs was not a factor in the conduct of the Master or crew in responding to the fire and during evacuation of the ship.
12. The Master did not initiate adequate direct communications with the shore authorities.
13. The discharge of oil into the sea was as a result of the damage to the ship. Mayamar Marine Enterprises responded immediately, in engaging United Salvage Ltd, to minimise the discharge and effects of possible pollution.
14. The Kirki carried all necessary statutory safety certificates. Safety surveys had been carried out within the schedules required by the relevant international safety conventions. The scheduling of the Kirki's special five-year survey at 22 years, rather than at 20 years, was consistent with the ship's survey program and within the rules covering the frequency of special surveys.
15. The defects in the life-saving appliances, fire-fighting equipment, cargo equipment and the condition of engine room equipment were so numerous and of such a nature that the Inspector cannot accept that they all developed over a short period of time.
16. The patching with canvas and the camouflaging of No7 tank lids was a deliberate attempt to mislead any person undertaking a load line survey. It is not possible to determine when the lids were patched, and it might not have been done with the knowledge of the owners or those on board the Kirki on 21 July 1991.
17. Significant defects should have been observed during surveys by Germanischer Lloyd; inspections by BP Vetting and Mayamar Marine Enterprises; and under Port State inspections by the Australian Maritime Safety Authority.
18. Germanischer Lloyd was responsible for the issue of statutory certificates on behalf of the Hellenic Republic of Greece. The procedures adopted by the Society during structural surveys failed to identify the areas of localised corrosion. The condition of ballast tanks 13 and 14 together with the number and nature of deficiencies in safety equipment, indicates that a number of surveys over a period of time, including surveys that were conducted under international safety conventions, were not performed effectively.
19. The prompt action by the Master and crew of the Lady Kathleen stabilised the situation by preventing the tanker from drifting closer to the shore, where it would have stranded, and allayed immediate concern as to the damage that it and its cargo might cause.

Summary

The Melete sailed from Dampier, Western Australia on 11 August 1991 with 27 persons on board, bound for Port Talbot, Wales with a cargo of 68902 tonnes of iron ore fines.

At 0358Z 24 August the Australian Maritime Safety Authority's Maritime Rescue Coordination Centre in Canberra received a distress call via the Inmarsat A Indian Ocean satellite from the Melete in position 27 41'S 054 13'E. The distress message said that the Melete was in danger of sinking with 27 crew on board. The MRCC advised the Melete to activate their EPERB, shortly after which all contact with the Melete was lost.

Search and rescue operations were coordinated by Marine La Reunion. Aircraft and other ships arriving at the last known position of Melete reported sighting oil slicks and flotsam.

Two crew members of Melete were rescued. Continued searches failed to locate other survivors.

Conclusions

It is considered that:

1. The cargo as presented for loading was in accordance with the Code of Safe Practice for Solid Bulk Cargoes.
2. The cargo loading sequence was in accordance with the Master's instructions.
3. The loading rates were comparable with those normally carried out at the Parker Point berth and not excessive.
4. The pour quantities stipulated by the Master, as percentages of deadweight, were typical of current loading practices. However, this is a subject that requires to be investigated thoroughly.
5. There is no evidence in Australia to indicate that any structural damage may have occurred due to contact with other vessels or the berth whilst Melete was at Dampier.

Summary

On 26 June 1991 the Manila Transporter sailed from Dampier, Western Australia with a crew of 24 and a cargo of 103,001 metric tonnes of iron ore fines for Port Talbot, Wales.

On July 1991, the Master of the ship broadcast a distress message, stating that the ship was taking water in number 3 hold and that assistance was required. The Norwegian bulk carrier Berica responded to the message and rescued all 24 Filipino crew of the Manila Transporter, who abandoned ship in the lifeboats. The Berica then proceeded on passage as the Manila Transporter was believed to be sinking.

On 27 July 1991, the Singapore registered ship Algenib encountered the derelict Manila Transporter and attempted salvage operations. However, the Manila Transporter eventually sank on 7 August 1991.

The Australian Marine Incident Investigation Unit, in accordance with the International maritime Organization Resolution A440(XI) "Exchange of Information for Investigations into Marine Casualties" and under the provisions of the Navigation (Marine Casualty) Regulations, undertook an investigation of the evidence that was available within Australia to assist the Philippine Authorities.

Conclusions

From the findings of the investigation, it is concluded that:

1. The cargo was loaded in accordance with the Master's instructions.
2. The cargo presented by Hamersley Iron for loading aboard the Manila Transporter was in accordance with the IMO Code of Safe Practice for Solid Bulk Cargoes.
3. There was no inherent characteristic in the cargo that made it unsafe.
4. The loading rate of cargo was within rates normally experienced at bulk carrier berths.
5. It is not possible to determine whether the proposed all hold loading would have prevented the subsequent hull failure.
6. In view of the known loss of bulk carriers, two of which had sailed from Dampier in 1991, Pilbara Harbour Services and West Coast Shipping should have ensured immediate delivery of the messages to the ship.
7. With the condition of the ship on the morning of 7 July the Master was prudent in his decision to abandon the vessel once the Berica was in position to stand by the Manila Transporter.
8. The discovery of the deficiencies in the lifeboat equipment during the Port State Control inspection and the rectification of the deficiencies before the vessel sailed from Dampier were instrumental in the successful outcome of the abandonment.

Summary

The Chinese motor bulk carrier Jin Shan Hai of 34,990 tonnes summer deadweight passed Low Isles at about 0000 Eastern Standard Time, 17 June 1991, on a course of 152° at a speed of approximately 13 knots, while on passage from the port of Gove, Northern Territory, to Gladstone, Queensland, with a part cargo of alumina. The vessel was shaping a course for Cairns fairway buoy where the pilot of the Torres Strait and Queensland Coast Pilot Service was to be disembarked.

At the same time the Australian prawn trawler Kekenni was engaged in trawling off Batt Reef steering about 135°, at a speed of about 3 knots.

At about 0035 the two vessels collided in approximate position 16°30.0' South 145°40.2' East, about 26 miles north-north-west of Cairns. The visibility was clear with a calm sea and slight swell. The Kekenni subsequently sank and the three crew took to the trawler's dinghy.

At 0042 Townsville Marine Communications Station received a message from the trawler Prospector reporting the incident and confirming that the Prospector was proceeding to search for the crew.

The Master of the Jin Shan Hai was called to the bridge, and the vessel turned to render assistance.

The three crew members of the Kekenni were rescued from the dinghy by the Prospector. Apart from minor bruises and abrasions the crew of the Kekenni suffered no injury. The Prospector returned to cairns with the crew aboard.

At 0110 the Jin Shan Hai resumed passage for Gladstone.

Conclusions

The Inspector concludes that:

1. The Jin Shan Hai was give way vessel and had a duty to keep clear of the Kekenni as required under Rule 18(a)(iv) of the International Regulations for Preventing Collisions at Sea, 1974 (Colregs).
2. The collision between the Jan Shan Hai and the Kekenni was caused by the failure of the officer of the watch, the Second Mate of the Jin Shan Hai to take early and substantial action to avoid a close quarter situation.
3. The Second Mate failed to keep a proper look-out as defined by Rule 5 of the Colregs and failed to establish the risk of collision as required under Rule 7.
4. The Master of the Jin Shan Hai was not informed of the developing situation and only became aware of the incident after the collision. After the collision the Master acted correctly in returning to render assistance and exchange details of the vessels involved.
5. The Kekenni was engaged in trawling and was a vessel engaged in fishing as defined by Rule3(d) of the Colregs.
6. The Skipper of the Kekenni failed to keep a proper lookout as defined by Rule 5 of the Colregs, in that he failed to maintain a lookout astern by either sight, sound or radar.
7. The Kekenni's A frame probably caused a radar shadow area over an angle of about 15° on either quarter.
8. The Kekenni's working lights were of such intensity as to obliterate the all-round lights and stern light required by Rule 26(b)(i) and (iii) respectively; and were exhibited contrary to Rule 20(b).
9. Neither the use of alcohol or drugs were a contributory factor.
10. Both those involved on the Jin Shan Hai and the Kekenni had maintained a normal daily routine. There is no evidence of any increased fatigue factor outside the normal working parameters.
11. There was no reason why the Queensland Coast and Torres Strait Pilot should have been on the bridge. Navigation in the area would not have been enhanced by local knowledge, and both vessels were south of the recommended two-way route.

Summary

The Australian registered motor tanker Arthur Phillip was on a voyage from the Saladin oil terminal, West Australia, to Botany Bay, New South Wales, with a full cargo of crude oil. At about 2325 (UTC+9½), 5 May 1991, in approximate position 037 degrees 31 minutes South 132 degrees 59 minutes East, the fire alarm sounded, and the bridge alarm panel indicated a fire in the accommodation block at main deck level. A fire was confirmed in the crew recreation room/bar. The master altered course to bring the Arthur Phillip closer to another vessel, the Alcides, in the event that assistance may have been required.

The fire was reported to be extinguished by 2340 and the Arthur Phillip resumed course for Botany Bay. No person was killed or injured, though some affect of smoke inhalation was reported by certain members of the crew. The fire resulted in significant damage to the crew recreation room/bar.

Under the provisions of the Navigation (Marine Casualty) Regulations the Inspector of Marine Accidents undertook an investigation to identify the circumstances in which the fire occurred and to determine its cause.

Conclusions

1. The fire in the crew recreation room/bar aboard the Arhtur Phillip was most probably caused by a discarded cigarette falling from the occasional table into paper towelling on the deck.
2. The responsibility for the presence of the towelling and the associated fire hazard rests, in varying degrees, with Messrs Cannon, Pitts, Hoger and Gregus.
3. The responsibility for the source of ignition rests with the three smokers, Messrs Cannon, Hoger and Gregus.
4. There is no evidence that the fire was in any way the result of a deliberate or malicious act.
5. There is no direct evidence that drugs or alcohol were a contributing factor. However, the Inspector, in considering the issue of the paper towelling, the destruction of the bar records (by persons unknown), the admitted actions of Messrs Gregus and Cannon and the reports from the Master and Officers considers that more beer was consumed than was admitted to and alcohol must be considered a contributor factor in the fire.
6. The fire was effectively extinguished by the initial attack on the fire by Messrs Cannon, Pitts & Gregus, when directing the hose through the recreation room door grill.
7. The Chief Engineer, Mr Craig, assisted by Mr Hoger and supported by Fourth Engineer, Mr Lesmond, extinguished residual smouldering material.
8. The shipboard procedures were followed, however, the Inspector does not believe that the procedures reflect the optimum response, or that they are appropriate for contemporary shipping.
9. The fire hose sited in the accommodation conformed to the statutory requirements, however the length and diameter of the hose were unsuitable for fighting an accommodation fire.

Summary

The Hong Kong registered motor bulk carrier Mineral Diamond of 141028 tonnes summer deadweight, sailed from the Western Australian port of Dampier on 11 April 1991 for the Netherlands port of Ijmuiden, by the way of the Cape of Good Hope. On sailing the vessel filed a voyage plan and indicated that it would participate in the Australian Ship Reporting System (AUSREP).

Six routine AUSREP messages were received by the Marine Rescue Co-ordination Centre, Australia (MRCCAUS), from the Mineral Diamond. The last of these messages at 0600 UTC (1400 Western Australian Standard Time) on 17 April reported that the vessel had reduced speed to six knots in force 9 to 10 winds (45 to 50 knots) in six metre seas, in position 30 degrees 21 minutes South 087 degrees 48 minutes East. When the Mineral Diamond failed to send her next scheduled message officers of the MRCCAUS initiated routine procedures to establish the safety of the ship and crew. When routine procedures failed to establish the ship's safety an air search was launched early on 20 April, coordinated by MRCCAUS and conducted by the Royal Australian Air Force, centred on a position 1500 miles west of Perth. When no trace of either ship or survivors was found the search was abandoned on the evening of 24 April.

It is assumed that the Mineral Diamond foundered with the loss of all hands in a position some 1500 miles to the west of Perth.

The Australian Marine Investigation Unit, in accordance with the International maritime Organization Resolution A440 (XI) "Exchange of Information for Investigations into Marine Casualties" and under the provisions of the Navigation (Marine Casualty) Regulations, undertook an investigation of the evidence that was available within Australia to assist the Hong Kong Authorities.

Conclusions

The re-analysis of the surface pressure field indicates that the strongest surface winds would have been experienced in the 12-hour period from about 0000 UTC 17 April 1991. Satellite pictures indicate a northward surge of cold air and the development of a new front in the vicinity of "Mineral Diamond" at about 1200 UTC leading to very squally conditions. The estimated 10-minute mean winds are in the order of 50 knots. Accordingly, significant waves to about 9 metres can be expected to have developed at this time in the vicinity of "Mineral Diamond" with a maximum wave to around 18 metres. Although the winds then eased, significant waves to 7 metres would have persisted through 18 April with a maximum wave up to 14 metres.

Summary

The Panamanian registered bulk carrier Starfish sailed from Port Walcott, Western Australia on 22 March 1991 with 53549 tonnes of iron ore fines for the Polish port of Swinoujscie.

It is reported that the Starfish diverted to Port Louis, Mauritius on 1 April, when the ship's crew observed the vessel to be riding low in the water and water was discovered in numbers 6 and 7 cargo holds. The vessel arrived off Port Louis on 3 April but was ordered from the outer anchorage on 7 April when the ship threatened to cause a major pollution incident.

The Starfish was escorted to deep water, 40 miles west of Mauritius and some 60 miles north of Ile de La Reunion, by a vessel of the Mauritius National Coast Guard. The crew of the Starfish was taken on board the Coast Guard vessel before the Starfish sank on 8 April.

Conclusions

It is considered that:

1. The cargo of iron ore fines was presented in a proper manner, in accordance with the requirements of the Code of Safe Practice for Solid Bulk Cargoes.
2. The physical properties of the cargo were accurately detailed in documents handed to the Master.
3. The cargo was loaded in accordance with the instructions of the Master and ship's staff.
4. In the event that Starfish foundered as a result of structural failure, in addition to the working stresses pertaining at the time, a relevant factor would be any excess stresses placed upon the hull in recent times. However, in the absence of key witnesses and the ship's longitudinal strength data, the investigation was not in a position to reach any conclusion as to whether the permissible stresses were at any time exceeded during the loading operations at Port Walcott.
5. The issue of interim Statutory certificates provided prima facie evidence that the ship was seaworthy. Unless the Classification Society had recently conducted a comprehensive inspection of the ship, the issue of such certificates on the strength of the existing certificates means that they were issued without a full knowledge of the actual condition of the ship.
6. From the Bureau of Meteorology's analysis, the wind and sea conditions prevailing at the time in the area through which Starfish passed should not have caused problems to a well-found vessel.
7. There is insufficient evidence within Australia to indicate the cause of Starfish taking water into the cargo holds.

Outline of events

At 0320 West Australian time, 14 February 1991, the Panama registered bulk carrier Sanko Harvest grounded in shoal water between Hastings Island and Hood Island, in position 34°07.4' South, 122°05.1' East, approximately 19 miles south-south-east of Esperance while on passage from Tampa, USA, via Cristobal, Panama, to Esperance, West Australia, loaded with 30,791 tonnes of fertiliser.

No person was killed or injured as a result of the grounding, but extensive bottom damage was sustained from the impact with the reef, resulting in the release of heavy bunker oil from the double bottom fuel tanks. The National Plan to Combat Pollution of the Sea by Oil was activated by 0600 14 February.

From the 14 February onwards, the condition of the ship deteriorated, being in a position exposed to the prevailing weather and swell, resulting in the progressive breach of further tanks and cargo holds. On the advice of the ship's owners the Sanko Harvest was evacuated by the crew, for their safety, at 1655 15 February. The ship broke into three sections and sank during the night of 17/18 February.

Captain CW Filor, Inspector of Marine Accidents, undertook an investigation into the circumstances leading to the incident with the object of identifying the cause.

Note:

• The measurements of depth, dimensions, and quantities of cargo and fuel are expressed in metric measurement.
• Distances are expressed in nautical miles (1853.18 metres).
• Times are expressed in 24-hour notation in local ship time. On 14 February this was Western Australian Time (UTC+8).
• All courses and bearings are expressed in 360° notation relative to true north.
• Depths shown on chart extracts from charts Aus 4709 and Aus 119 are shown in metres; and from BA 1059 and BA 3189 in fathoms. 

Conclusions

The inspector concludes that the grounding of the Sanko Harvest was caused by:

1. The lack of appreciation by the Master and Second Officer (and other officers who were aware of the planned approach to Esperance) of the warnings contained on the charts and Australian Sailing Directions, Volume 1.
2. The failure of the Second Officer to properly apply the available corrections to the charts of the area, in particular his failure to enter small correction Aus 219 of Admiralty Notices to Mariners, weekly edition 20 of 21 May 1988, which described the geographical location of the shoal water upon which the Sanko Harvest grounded;
3. The Master's decision to navigate in an area where acceptable hydrographic surveys were either incomplete or had not been undertaken;
4. The ship had on board the appropriate charts, notices to mariners and other publications to allow safe navigation;
5. Had the charts held on board, particularly Aus 119, BA 3189 and BA 1059, been properly corrected, they would have provided proper and reliable navigational information;
6. The 1990 edition of chart Aus 119 was not available to the Master and hence the outcome of the voyage had the ship been in possession of this edition is not an issue;
7. The grounding was caused by human failure alone. Neither the cargo, nor the mechanical equipment, nor navigational equipment contributed to the incident;
8. Neither the master nor the Second Officer were in any way under the influence of drugs or alcohol;
9. There is no evidence that fatigue was a contributing factor.