The ATSB has found that a seaman may have been fatigued when he fell from a bulk carriers cargo hold ladder at the end the working day on 8 August 2007.

The Australian Transport Safety Bureau investigation also found that he may have been distracted by the equipment he was carrying and as a result of a mixture of perspiration and hydrochloric acid that would have caused irritation to his skin and eyes.

On 8 August 2007, Oceanic Angel was about three degrees south of the equator and en-route to Dampier, Australia.

After lunch, the crew were preparing the cargo holds for an upcoming salt cargo and, at about 1515, two seamen started work in number three hold. They began by spraying the dirty areas of the hold with hydrochloric acid, starting at the aft end and moving forward along the port side.

At about 1630, they stopped work for the day. One of the seamen made his way to the cargo holds aft ladder and started climbing out of the hold. The other seaman went to the forward ladder to do likewise. When the seaman on the aft ladder was almost at the ladders top platform, about 11.7 m above the tank top, he heard a loud 'thump'. He turned around and saw his colleague lying on the tank top.

The crew mounted an emergency response but the seaman had died as a result of the fall.

At 2300 on 17 August, Oceanic Angel berthed in Dampier. The local police attended the ship and the deceased seaman was taken ashore.

The ATSB investigation found that the ship's safety management system was not effective in ensuring that the crew carried out a risk analysis for the task of cleaning the cargo holds with hydrochloric acid. It also found that the crew were not aware of the safety information provided by material safety data sheets.

The ATSB has issued two safety advisory notices with the aim of preventing similar occurrences from occurring in the future.

Copies of the report can be downloaded from the ATSB website

The ATSB has determined that the derailment of a freight train on the Defined Interstate Rail Network near Seymour was due to a wagon coupler that fell onto the track and became caught under a trailing wagon.

The Australian Transport Safety Bureau has today released its final report on the investigation of the derailment that occurred near Seymour in Victoria on 12 September 2006.

The train derailed at 0520 while travelling from Griffith NSW to Melbourne and was loaded with food products for export.

The coupler, connecting the seventh and eighth wagons in the train, became dislodged when the draft key holding the coupler in position, slid out following the failure of a locking pin. There have been a number of similar failures involving this type of wagon coupler in the past.

The wagon owner has taken safety action to prevent recurrence of this failure by commencing a rectification programme to fit modified draft key components that meet Association of American Railroad standards.

The ATSB has recommended that all wagons fitted with the modified components be regularly monitored to ensure that the modification is effective.

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

The ATSB has found that a broken rail emanating from rail defect was the most probable cause of the derailment of a freight train in South Australia.

The Australian Transport Safety Bureau has today released its final report into the investigation of a derailment on 10 June 2007 near Bates in SA in which 11 wagons in the middle of the train derailed and 4 overturned and were extensively damaged.

The investigation established that the derailment probably resulted from an undetected flaw in the rail which caused a section to break away under the train. While track at the derailment site had been ultrasonically tested for cracks in the past, the frequency of these inspections did not adequately take into consideration issues such as the rail quality, age, ambient temperature profile and train impact loadings.

In the interests of enhancing future rail safety, the Australian Rail Track Corporation has been proactive in adopting a number of measures to address the safety issues identified by the ATSB. These include an increase in rail testing frequency and a review of their Code of Practice to enhance engineering maintenance/testing procedures in relation to ultrasonic rail flaw detection.

Copies of the report can be downloaded from the ATSB's internet site at www.atsb.gov.au.

The ATSB has found that strong winds during a thunderstorm could have caused a train derailment in central South Australia.

The Australian Transport Safety Bureau has today released its final report into the investigation of a freight train derailment near Tarcoola in South Australia on 1 November 2006.

The FreightLink train, travelling from Darwin to Adelaide, derailed during a thunderstorm about five kilometres east of Tarcoola. Freight wagons in the middle of the train appeared to have 'tipped over' while the train was travelling at about 67km/h in a severe thunderstorm and there was no evidence of any track or train defect that could have caused the derailment.

The investigation established that it was possible that the combined effects of strong winds at the time and the wagons' natural oscillations while travelling could have been sufficient to initiate overturning of the wagons lightly loaded with double stacked freight containers.

In the interests of enhancing future rail safety, FreightLink has been proactive in adopting a number of measures to address the safety issues identified by the ATSB and the ATSB has recommended that further action be considered.

Copies of the report can be downloaded from the ATSB's internet site at www.atsb.gov.au or obtained from the ATSB by telephoning 1800 020 616.

The ATSB has found that a collision between a GrainCorp freight train and overturned truck occurred because train control could not contact the approaching train in the ten minutes or so before the collision.

The Australian Transport Safety Bureau has today released its final report into the investigation of a collision that occurred at the Olympic Highway level crossing at Illabo in New South Wales on 2 November 2006.

At the time of the collision it was dark and raining. The semi-trailer overturned while negotiating the curve prior to the level crossing. The truck driver called '000' and the message was relayed through to the Junee train control centre.

Unfortunately, the emergency message from train control was routed through to the wrong locomotive on the train. Had the message been received by the train crew the collision would probably not have occurred.

The investigation established that the train drivers and train controllers had failed to ensure that the primary radio communication system in the leading locomotive was switched on and registered on the CountryNet train communications system. The investigation also found that the train company's policies and procedures, train control procedures and network rules failed to ensure that the train's communication system was operative at the time.

In the interest of enhancing future road/rail safety, the ATSB has issued a number of recommendations that address various safety issues including the need to ensure that the primary radio communication system, CountryNet, is operational at all times in the leading locomotive of all trains in New South Wales.

The Australian Transport Safety Bureau (ATSB) is conducting an investigation into the circumstances surrounding the reported mid-air collision between a Robinson helicopter and a Piper Cub that occurred during the late afternoon on 13 February 2008, in the ranges north of Gascoyne Junction.

A team of four (4) Transport Safety Investigators is expected to be in Carnarvon later today to commence the on-site phase of the investigation.

Any person/witness with information about the accident is encouraged to contact the ATSB on 1800 020 616.

Further advice will be provided if the ATSB decides to conduct a media conference at the accident site.

The ATSB expects to have a preliminary factual report available for public release in approximately thirty (30) days from the date of the accident.

The ATSB has released a safety bulletin to raise public awareness of the factors which have contributed to a spate of recent tragic rail level crossing accidents.

Since April 2006 the Australian Transport Safety Bureau has investigated 12 significant level crossing accidents of which nine have involved heavy road vehicles.

The terrible tragedy of the Kerang accident in Victoria in June last year is an example of such an accident where 11 people lost their lives and 20 were injured.

The recent investigations conducted by the ATSB have found in almost every case that the motorist failed to stop and give-way to the train at the level crossing and that there was little the train driver could do to prevent or minimise the collision.

Underlying factors such as complacency, fatigue, expectation that no train will be encountered at the crossing, sighting problems, and distraction have all been found to have influenced the motorist's failure to stop.

The ATSB safety bulletin has been compiled with the assistance of the Australian Trucking Association and the Australasian Railway Association and will complement the work already being undertaken by these organisations and by the various state authorities to raise public awareness of these accidents to seek to save lives in the future.

The Australian Transport Safety Bureau (ATSB) is conducting an investigation into the reported mid-air collision between two Air Tractor aircraft that occurred during the morning of 26 February 2008, 8.5 km NE Wee Waa.

A team of four Transport Safety Investigators arrived at the site late Tuesday and has commenced investigating the circumstances of the accident. The team has examined the burnt wreckage of one aircraft and interviewed witnesses. The team will finalise examination of that aircraft today and commence work on the other aircraft.

Initial information indicates that the pilot of an aircraft was transiting the area at the time the pilot of the other aircraft was climbing at the end of a spray run. The scope of the investigation will include the degree of situational awareness of both pilots under the circumstances.

Any person/witness with information about the accident is encouraged to contact the ATSB on 1800 020 616.

The ATSB expects to have a preliminary factual report available for public release in approximately thirty (30) days from the date of the accident.

The ATSB has found that the grounding of Pasha Bulker on Nobbys Beach on 8 June 2007 occurred despite a gale warning that should have prompted the master to ballast the ship for heavy weather and take it to sea. A number of other ships also failed to take to sea.

The Australian Transport Safety Bureau investigation found that Pasha Bulker's master had an inadequate understanding of heavy weather ballast, anchor holding power and the limitations of Newcastle's weather exposed anchorage.

The investigation also found that a number of other ships attempted to ride out the gale at anchor and the majority dragged their anchors. A number of masters did not appropriately ballast their ships and many did not understand Newcastle Vessel Traffic Information Centre's purely advisory role, expecting that it would instruct or inform them to put to sea at an appropriate time. It was also found that the substantial ship queue increased the risks in the anchorage and resulted in another near grounding, a near collision and a number of close-quarters situations at the time.

On 23 May, the Panamanian registered bulk carrier Pasha Bulker anchored about two miles off the coast near Newcastle and joined the queue of 57 ships to wait its turn for loading coal. The ship was ballasted for the good weather conditions. Newcastle anchorage is suitable only in good weather and nautical publications contain warnings about the local weather conditions and recommend that masters put to sea before conditions become severe.

On the morning of 7 June, the Bureau of Meteorology issued a gale warning for the area. Winds were expected to increase to 45 knots, with gusts up to 63 knots, after 0400 on 8 June with high seas and a heavy swell. At midday, Pasha Bulker's master deployed additional anchor cable and decided to monitor the weather and the ship's anchor position.

By midnight, the southeast wind was gusting to 30 knots and ships began dragging their anchors. Newcastle Vessel Traffic Information Centre advised those ships that were dragging their anchors. Only seven ships had put to sea in the deteriorating weather while another had weighed anchor to berth in the port.

By 0600 on 8 June, the wind was gusting to nearly 50 knots and Pasha Bulker was amongst 27 ships still at anchor. At 0637, when the master was certain that the anchor was dragging, he decided to weigh anchor. At 0748, the ship got underway and for more than an hour, moved in a northeast direction parallel to the coast about one mile away with the wind on its starboard bow.

At 0906, the master decided to alter course to put the wind on the ship's port bow and clear the coast in a southerly direction. The course change in the extreme weather was poorly controlled and Pasha Bulker's heading became south-westerly instead of south-southeast as intended. The ship then rapidly approached Nobbys Beach and the master's desperate attempt to turn the ship to starboard to clear the coast inevitably led to its grounding at 0951 with both anchors in their hawse pipes.

The ATSB is pleased to report that safety actions have already been taken following the incident but has issued a number of other recommendations and safety advisory notices with the aim of preventing similar incidents in the future.

Copies of the report can be downloaded from the ATSB's internet site at www.atsb.gov.au

The ATSB has found that the speed boat Norma Jean was travelling too fast in the darkness to avoid a collision that claimed four lives.

The Australian Transport Safety Bureau's final investigation report states that the Norma Jean's probable high speed was inappropriate in the dark conditions and the use of the boat's internal lighting may have restricted the ability of the boat's skipper to see the barge until immediately before the collision.

At about 1500 on 12 March 2007, the unmanned barge Seatow 61 was anchored about three miles off Carnarvon, Western Australia, and the barge's anchor lights were set to operate automatically. The barge had been anchored in this position following advice from the harbour master.

At about 0610 on March 18, Norma Jean left the Carnarvon boat harbour and, at about 0625, it collided with Seatow 61 and sank quickly with the loss of all four of its occupants.

The ATSB investigation also found that, in 2002, another Sea-Tow barge had been involved in a similar accident in New Zealand and that Sea-Tow did not take proactive measures to prevent a recurrence. Further, the harbour master for the port, who was based in Perth, was not sufficiently aware of recreational vessel activities in Carnarvon to be able to adequately assess the risks posed to recreational vessel skippers by the presence of the anchored barge.

The ATSB reports safety action already taken and has issued four recommendations and four safety advisory notices with the aim of preventing further incidents of this type.