Anchoring too close to each other and without due regard to the changeable weather conditions in the anchorage off Newcastle were the major causes of the collision between two bulk carriers, according to an Australian Transport Safety Bureau (ATSB) investigation report released today.

The ATSB report into the incident states that at 0939 on 24 June 2005, the bulk carrier Pilsum collided with another bulk carrier, China Steel Growth, while dragging its anchor. The two ships were anchored off the New South Wales port of Newcastle.

On the morning of 24 June, a southerly weather front came through the anchorage. At 0900 on 24 June, the officer of the watch on Pilsum detected that the ship was dragging its anchor. The master was informed, and he decided to weigh anchor and depart the anchorage.

Pilsum's crew encountered difficulties recovering the anchor. While trying to weigh anchor Pilsum drifted towards China Steel Growth, which was anchored to the north.

At 0935 Pilsum pitched heavily, the propeller came clear of the water and the main engine was shut down by the overspeed trip. Pilsum's main engine was restarted, however at 0939 Pilsum collided with China Steel Growth. The two ships moved apart and made contact a second time before Pilsum finally made its way clear.

The report concludes that the ships in the anchorage off Newcastle on 24 June 2005 were anchored too close to each other. Pilsum did not have enough anchor cable laid out, and the officer of the watch did not fully utilise all available equipment while keeping the anchor watch.

The report also concludes that the advice to masters in the Australian Pilot publication does not sufficiently highlight the shortcomings of the Newcastle anchorage in adverse weather conditions.

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

The Australian Transport Safety Bureau (ATSB) is investigating the circumstances surrounding the Piper Navajo Chieftain four-fatality accident near Condobolin on 2 December 2005.

Four ATSB investigators have been on site near Condobolin since Saturday morning.

The Piper Navajo Chieftain was reportedly being flown by a commercial pilot and was en route from Archerfield to Swan Hill via Griffith. Weather in the Condobolin area was severe with extremely strong wind and thunderstorms across the aircraft's track. The pilot reported diverting around weather and shortly after this communication was lost.

Wreckage was found over a wide area in excess of 3.5 kms. A section of the tail was found about 3.5 kms from the main wreckage and one engine, with cowling and propeller attached, was found 500 metres from the main wreckage. All four (4) occupants of the aircraft received fatal injuries.

The investigation is continuing and will include examination of the wreckage and analysis of weather, air traffic control and radar information.

Witnesses to this accident are asked to contact the ATSB on 1800 020 616.

The Australian Transport Safety Bureau (ATSB) is investigating the circumstances surrounding a Virgin Blue Boeing 737 emergency descent incident on 2 December 2005.

The Boeing 737 was being flown from Townsville to Brisbane with a total crew and passengers of 104. During the rapid descent, a number of passengers suffered ear discomfort and some minor injuries.

On arrival at Brisbane the injured passengers were taken to hospital for observation and treatment and were discharged following treatment. None of the passengers were admitted to hospital.

The flight recorders are being replayed and analysed at the ATSB in Canberra.

The investigation is continuing and will include analysis of the cabin pressure rise and the reason for the cracked windscreen.

As part of its national safety awareness campaign for commercial fishermen, announced in December 2004, the Australian Transport Safety Bureau (ATSB) will be conducting a series of informal face-to-face meetings with fishermen in two ports in northern WA, this week.

The aim of the meetings is to raise the awareness of commercial fishermen to similar causal factors, identified by the ATSB during investigations of 23 collisions between trading ships and fishing vessels conducted since 1990.

The meetings will complement a safety bulletin, published by the ATSB in December 2004, and form an important part of the safety awareness campaign.

The ATSBs safety awareness meetings will be held in conjunction with seafood safety and handling training workshops, which are being held by the Western Australian Fishing Industry Council (WAFIC), Challenger TAFE and WA's Department of Fisheries during the last week in July.

All commercial fishermen are encouraged to participate in the meetings, which will be held immediately after the training workshops in Broome and Point Sampson.

SEAFOOD SAFETY AND HANDLING TRAINING WORKSHOPS SCHEDULE

• BROOME - Wednesday 27 July between 1:00 pm and 5:00 pm| Mangrove Hotel.
• POINT SAMPSON - Friday 29 July between 12:00 pm and 4:00 pm| Point Sampson Community Hall.

Further information on the safety awareness campaign and the ATSB meetings can be obtained by contacting the ATSB on 1800 0200616 or by emailing the Marine Investigation Unit at: marine@atsb.gov.au.

The electrician on board the Marshall Islands registered Probo Panda died from a heart attack following a suspected electric shock while the ship was at anchor off Gladstone in Queensland on 11 May 2005, according to an Australian Transport Safety Bureau (ATSB) investigation report released today.

The electrician died while working on one of the ship's engine room light fittings. He had been missing for several hours and was only found after a search of the vessel was instigated by the master.

The ATSB report into the fatality on board the products / oil / bulk / ore carrier Probo Panda, states that it is likely that the electrician was crouching on a deep frame at the lowest level of the engine room so he could reach the light fitting. He may have received an electric shock which knocked him off balance, causing him to fall between the deep frame and an adjacent pipe. The subsequent exertions, attempting to climb free probably induced a coronary artery occlusion.

The report concludes that the electrician had a pre-existing heart condition, coronary artery atheroma and, that the medical examination standards used to assess him were inadequate in terms of detecting conditions such as coronary heart disease.

The report also concludes that working on live electrical equipment and not implementing the measures outlined in the ships safety management system increased the likelihood of the electrician receiving an electrical shock. Also, working alone in an isolated area for an extended period of time without supervision or monitoring resulted in the electrician not being found in time to administer first aid.

Copies of the report can be downloaded from the website.

A 20-year-old engineer cadet died from severe head injuries after falling seven metres while working in a ship's engine room, according to an Australian Transport Safety Bureau (ATSB) investigation report released today.

The ATSB report into the incident states that, at about 0920 (local time) on 16 May 2005, the engineer cadet on board the South Korean bulk carrier Golden Bell was working with other engine room staff when he fell through an open section of deck grating. The cadet landed seven metres below, on the engine room's bottom deck plates. He suffered severe head and internal injuries.

The cadet had apparently failed to see that a section of deck grating had been removed, in order to facilitate the placement of a ladder. The opening was not physically guarded in any way and only had an inappropriately placed sign to warn engine room staff of the danger that existed.

The ship was at anchor of the Western Australian port of Dampier when the incident occurred.

The cadet was evacuated by helicopter to the Nickol Bay Hospital in Karratha (20 km from Dampier), and despite the efforts of medical staff at the hospital, he died later that afternoon.

The report concludes that the open section of grating was not roped off or otherwise protected, and the danger sign was poorly sited and manifestly inadequate. Additionally, the ship's operating procedures did not specify that any open areas of deck grating should be roped off or otherwise protected.

The report's recommendations include that ship owners, managers and masters should revise operational procedures to reflect the need to ensure that open deck areas on board their ships are adequately safeguarded.

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

Failing to keep a proper lookout was the major cause of yet another collision between a trading ship and a commercial fishing vessel, according to an Australian Transport Safety Bureau (ATSB) investigation report released today.

The ATSB report into the incident states that, at 0535 (local time) on 15 April 2005, the Greek registered bulk carrier Spartia and the Western Australian cray fishing vessel Hannah Lee collided 17 nautical miles west of Cape Bouvard. Spartias crew had detected the fishing vessel about 20 minutes prior to the collision, using the ships radars. They had assessed that a risk of collision existed but, as Hannah Lee was on their port side, they maintained Spartias course and speed, in accordance with the international collision regulations. Hannah Lees skipper was preoccupied with keeping his vessel on course and had failed to see Spartia in the time leading up to the collision.

When it became obvious to Spartia's bridge team that Hannah Lee was not going to give way, the master ordered avoiding action. This manoeuvre was ineffective and Hannah Lee hit Spartia a short time later. No one was injured in the collision and there was no pollution.

The report concludes that the lookout being kept by the skipper of Hannah Lee in the period leading up to the collision was manifestly inadequate. In addition, his judgement, actions and situational awareness, with regard to what was happening around his vessel, were affected by fatigue. This was probably as a result of his work routine and other activities he had undertaken in the week prior to the collision. The report recommends that State and Territory marine authorities consider reviewing current work practices on fishing vessels, with a view establishing crew fatigue management guidelines.

The report also concludes that the action taken by the crew of Spartia to avoid the collision, when Hannah Lee was only one nautical mile away, was too little, too late.

The ATSB has investigated 23 collisions between ships and fishing vessels since 1990. The failure to keep a proper lookout was identified as a factor in each of the collisions.

The report (Marine Safety Investigation Report 211) can be obtained from the website.

The ATSB's final investigation report has found that an Airbus A330 passenger aircraft that landed at Sydney in fog on 6 April last year did so because the adverse weather conditions were unforecast and the flight crew continued to manoeuvre the aircraft for a landing at Sydney past the time they had previously nominated as the latest time for a diversion to Canberra.

Since the occurrence safety action has been taken by the air traffic services provider and the Bureau of Meteorology to improve the reporting of weather information to flight crews and to improve the accuracy of fog forecasting at Sydney airport.

On 6 April 2004, at about 0625 EST, an Airbus A330-301 aircraft, registered VH-QPC, landed on runway 34L at Sydney airport in weather conditions that were below the landing minima. The aircraft was being operated on a scheduled passenger flight from Perth to Sydney and it had departed Perth with sufficient fuel for the flight based on the current Sydney aerodrome forecast. This forecast indicated that, when the aircraft was due to arrive at Sydney, the weather conditions would be adequate for a landing. However, when the aircraft was about 110 km southwest of Sydney the weather conditions deteriorated due to unforecast fog.

The crew used weather information provided by controllers when making decisions in response to the deteriorating visibility at Sydney airport. However, not all of the weather information was passed to the crew. This resulted in a reduction in the level of appreciation by the crew about the dynamic weather situation and, in particular, the rapid progression of fog across the runway complex.

The crew initially required an instrument landing system approach to runway 16 Right based on runway visual range information from Sydney Airport runway observers which did not reflect the actual visibility conditions. After being advised of a report from the crew of another aircraft about the visibility being better at the threshold of runway 34 Left, the crew of VH-QPC then decided to conduct an approach to that runway.

The crew had previously advised the air traffic controller that they would need to divert to Canberra at 0618. On the basis of the information available to them, the crew decided to continue manoeuvring the aircraft for an approach to runway 34L past that nominated time. However, while the crew were making the approach the fog moved across the threshold of runway 34L. The crew then conducted an autoland onto that runway in conditions that were worse than the landing minima specified by the Civil Aviation Safety Authority.

The report (Aviation Safety Investigation Report 200401270) can be obtained from the website.

The ATSB investigation into the fatal Piper Seneca accident on 11 November 2003, at Bankstown Airport has found that the aircraft departed from controlled flight at a height from which recovery was not possible. The reason for the loss of control could not be determined.

The aircraft was being operated on a multi-engine aircraft training flight with a flight instructor and student pilot on board. After commencing a go-around, the aircraft was observed to diverge to the right of the runway centreline, climb and bank steeply to the right before impacting the ground in a steep nose-down attitude.

The aircraft was destroyed by impact forces and the post-impact fire. The student was fatally injured in the accident and the instructor received severe burns and died three and a half weeks after the accident.

On 1 December 2003, the Minister for Transport and Regional Services signed an Instrument of Direction to the Australian Transport Safety Bureau (ATSB). That instrument directed the ATSB to 'investigate the effectiveness of the firefighting arrangements for Bankstown Airport, as they affected transport safety at Bankstown Airport on 11 November 2003'. That investigation was conducted in conjunction with the accident investigation and a separate report (200305496) was issued on 24 December 2004.

The final investigation report (Aviation Safety Investigation Report 200304589) can be downloaded from the ATSB website.

The engineers placed themselves in danger to save a ship in gale force weather conditions in Bass Strait after its main engine became disabled according to an Australian Transport Safety Bureau (ATSB) investigation report released today. The ATSB report states that the Hong Kong registered container ship, Maersk Tacoma, spent 19 hours adrift before being taken in tow on 8 August 2001.

The incident is still the subject of legal action in London between the ship's owners and various other parties. The ATSB waited for 34 months to obtain the engineering report from the owner's representatives on the main engine failure.

Maersk Tacoma had departed Melbourne in the afternoon of 7 August 2001 heading to Brisbane. In the early hours of 8 August one of the ship's main engine bottom end bearings failed which left the ship drifting in Bass Strait in deteriorating westerly weather conditions. After being informed of the situation, the ship's management company in Hong Kong implemented their emergency response plan to arrange the salvage of the ship.

While awaiting the towing vessel, Maersk Tacoma drifted 45 miles eastward passing very close to both Cutter Rock and the Hogan group of islands. On both occasions the damaged main engine had to be run for short periods to prevent the ship from grounding. By 2125 on 8 August, Pacific Conqueror, an offshore towing and supply vessel based in Gippsland, had taken the ship in tow. By the following afternoon, the ship had been towed to a safe anchorage on the eastern side of Wilson's Promontory.

The ATSB report concludes that main engine was disabled when the main engine bottom end bearing failed as a result of its pre-existing condition in combination with reduced lubricating oil flow. It also concludes that Maersk Tacoma's engineers placed themselves in significant danger by running the damaged main engine to save the ship on two occasions and that Australian authorities should have been notified of the ship's situation sooner.

The report recommends that ship owners and operators should ensure that they have procedures for notifying local rescue coordination authorities promptly if their ship becomes disabled.

Copies of the report (Marine Safety Investigation Report 171) can be downloaded from the website.