Executive summary

At about 1540 on 10 July 2006, while Enterprise was in Bass Strait, Australia, an alarm sounded indicating that the main engine lubricating oil pressure was low. When the duty engineer started changing over to a second filter, lubricating oil pressure was lost; causing the engine to stop and the ship to black-out. The engine was restarted and the passage was resumed.

At 1805, the main engine low lubricating oil pressure alarm sounded again. At 2000, after further inspections had been undertaken, the chief engineer advised the master that the main engine could not be run due to probable bearing damage and that the ship would need to be towed to the nearest port for repairs. The main lubricating oil pump was also found, at this time, to have failed.

The ship was towed into Melbourne, arriving on 15 July, where all main and bottom end bearings were inspected. A large gouge mark was found on one bottom end bearing.

Further investigations revealed that the gudgeon pin in number five piston had failed when a pre-existing, undetected flaw led to fatigue cracking of the gudgeon pin. The engine manufacturer had not provided sufficient guidance for monitoring the fatigue life of gudgeon pins or for inspecting gudgeon pins for cracks.

The investigation also found that maintenance planning for the main lubricating oil pump was inadequate in that maintenance was not undertaken according to the manufacturer's instructions, despite the fact that the pump had failed previously.

The execution of routine maintenance on the lubricating oil filter was also inadequate in that the spare filter was not ready for use. The shipboard procedures did not identify the error and the procedures for operating and monitoring the filter were also ineffective.

The report makes three recommendations to address the identified safety issues with the aim of preventing other similar occurrences.

Marine Recommendations

[MR20070027] [MR20070028] [MR20070029]

Executive summary

On 16 June 2006, during Kota Pahlawan's voyage from Singapore to Australia, a foul odour was noted coming from two containers on board the ship. The containers were packed with xanthates, dangerous goods which produce carbon disulphide vapours and can spontaneously combust.

Later that day, the master informed the ship's charterer of the 'incident' and that the odour indicated that the packaging of the xanthates was not 'gas-tight', in accordance with international rules. He also asked for the containers to be discharged at Brisbane, the ship's next port of call.

At 0411 on 18 June, the master reported the incident as a defect to the Australian Maritime Safety Authority (AMSA). At 0720, the ship embarked a coastal pilot and started its transit of the Great Barrier Reef.

At 0907 on 19 June, AMSA issued a defect report and started collecting information about the incident. At 1252, the pilot disembarked from the ship after it had completed its transit of the northern part of the Great Barrier Reef Inner Route.

The ship berthed in Brisbane on 22 June after an 'emergency' was declared in the port. All eight xanthates containers on board the ship were discharged and purged with nitrogen gas to mitigate the risks posed by the foul smelling, highly flammable and toxic carbon disulphide vapours. On 24 June, the master was asked to reload the containers. He agreed on the condition that AMSA provide a written acceptance of the proposal with regard to 'compliance' with international rules.

By 0400 on 25 June, the xanthates containers had been reloaded onto the ship before it sailed from Brisbane. On 6 July, the ship discharged the last of the xanthates containers in Fremantle.

The report identifies several safety issues and the safety actions to address them.

Executive summary

At 1400 on 1 May 2006, Crimson Mars sailed from Bell Bay, northern Tasmania with a local pilot on board. The sky was cloudy and the visibility was clear with a light south-easterly wind. During the ship's turn to port around Garden Island, at about 1440, starboard instead of port helm was applied for approximately one minute. The error was not noticed initially and by the time maximum port helm was applied at 1441, grounding was inevitable. Soon after, the pilot ordered both anchors to be let go and the main engine to be run at emergency full astern in an attempt to reduce the effects of the impact. At 1442, the ship grounded on Long Tom Reef as the port anchor was let go and the main engine run astern.

The ship, with its main engine running astern, moved off the reef and refloated at 1446. An attempt to retrieve the anchor resulted in the failure of the port windlass. The ship remained anchored until 1605 when two tugs arrived to assist. The anchor cable was cut and left in the river with the port anchor. The ship then returned to the Bell Bay anchorage with the assistance of the tugs.

An inspection of the ship revealed that it was severely damaged and that temporary repairs could not be carried out in Bell Bay. The ship's departure was delayed until contingency arrangements could be put in place. Crimson Mars sailed from Bell Bay on 12 May for Hualien, Taiwan, to discharge its cargo and carry out permanent repairs.

The report identifies several safety factors and makes recommendations to address them.

At 0958 on 6 April 2006, the mooring hawser attaching Dampier Spirit to the CALM  buoy at the Stag oil platform off Dampier, Western Australia, parted and forced the ship to put to sea as a cyclone approached.

Dampier Spirit's master had delayed making the decision to disconnect from the CALM buoy when a cyclone, centred 200 miles from the ship, was declared. His decision may have been delayed because of ambiguities in the company's decision guidelines; the procedures did not accurately reflect the ship's ability to sail away from danger; the Stag platform was still discharging crude oil into the ship's cargo tanks; and the ship had safely remained at the buoy during a previous cyclone.

After the ship had separated from the buoy, it had difficulty in manoeuvring away from the area because the performance of the ship was reduced by the 'slow steaming' fuel injector nozzles fitted in the main engine and by the build-up of barnacle and coral growth on the hull.

The ship was tracking towards Tryal Rocks until the wind eased, allowing it to sail into safer water. If Dampier Spirit had grounded on Tryal Rocks, its 12 100 tonnes of crude oil cargo may have been spilled into the sea, resulting in significant damage to the environmentally sensitive mangroves and turtle nesting grounds in the area.

Executive summary

On the evening of 24 January 2006 Global Peace entered Gladstone harbour for the transit to the Clinton Coal Terminal. The plan was for the ship to berth at Clinton number three berth with the assistance of three harbour tugs.

As the ship was approaching the berth, the pilot ordered all three tugs to stop pushing and to lay alongside. The master of the aft tug, Tom Tough, laid the tug alongside the ship, with the tug at an angle of about 15 degrees to the ship's side. The tug's bow was in line with the front of the ship's accommodation.

At about 2354, Tom Tough's starboard main engine unexpectedly shutdown, and the tug's stern swung sharply to starboard. The tug's starboard quarter made heavy contact with the ship, puncturing the ship's shell plating in way of the port heavy fuel oil tank. Oil immediately began to flow into the harbour.

The investigation found that a crack in the tug's starboard main engine clutch oil discharge pipe resulted in the system being emptied of oil. The resultant loss of system pressure activated the engine shutdown.

The report identifies a number of contributing factors and makes recommendations to address them.

Executive summary

On 5 February 2006, Pacific Sun berthed at number eight wharf Darling Harbour, Sydney. The weather was fine with little wind. The twelve to four quartermaster was assigned to clean rust streaks from the outside of the port bridge wing windows. At 1205 the senior second officer checked the safety harness and completed a work permit, as required by the working aloft procedure, but no workplace risk assessment was used in planning the job.

The quartermaster, wearing the safety harness, then started work on a catwalk outside the port bridge wing. At about 1249 he fell approximately 24 metres onto the wharf below. He died as a result of the injuries sustained from the fall. He was an experienced seaman who had been inducted in the ship's safety management system and had done this task many times.

The ATSB's investigation report concludes that the quartermaster's harness was not properly attached to the grab rail when he probably lost his footing and fell. The contributing factors to the incident include an inadequate safety harness, the design of the catwalk, an inadequate workplace risk assessment and procedures, the ineffective use of personal protective equipment and that the quartermaster may have been distracted from the task at the time by non-work-related issues. There was no evidence to support a suggestion that he may have committed suicide.

The ATSB has made several safety recommendations with the aim of preventing further incidents of this type.

Executive summary

Desh Rakshak arrived off Port Phillip on the morning of 4 January 2006, with about 80 000 tonnes of crude oil cargo on board, and at 0800 a pilot boarded the ship for the transit from sea to the Melbourne outer anchorage.

The pilot planned to enter the port to the west of the track marked by the main leading lights, to keep the ship out of an opposing tidal flow for as long as possible. When the ship was almost abeam of Point Lonsdale Lighthouse, the pilot thought he could see the high and low main leading lights just open to the west. This indicated to him that the ship was on the edge of the Great Ship Channel. However, the ship was further to the west than the pilot thought.

The ship continued the transit and anchored at 1154. No one on board the ship observed anything that might have suggested that the ship had grounded during the pilotage.

At about 1245, the chief mate found the level in the lower fore peak water ballast tank rising. He told the master, and they decided to pump out the tank and inspect it. The inspection revealed that the tank's shell plating had been holed.

The ship berthed in Geelong on 5 January and temporary repairs were carried out before it sailed for Singapore on 19 January, where it was dry-docked for permanent repairs.

The investigation found that the ship probably grounded at about 0825, when it was almost abeam of Point Lonsdale, while transiting from sea to the Melbourne outer anchorage.

The report identifies a number of contributing factors and makes recommendations to address them.

Executive summary

On Thursday 30 September 2005 at about 0800 hours (Central Standard Time) steel plate, part of a load that had shifted on Pacific National freight train 5MA5, struck a TransAdelaide passenger train 206A at Eden Hills railway station platform. There were no injuries and only minor damage to both trains and track infrastructure.

Eden Hills is located in the Adelaide Hills region approximately 14 km from Adelaide on the Belair railway line which forms part of the Defined Interstate Rail Network corridor. Within the railway corridor there is a standard gauge line managed by the Australian Rail Track Corporation (ARTC) and an adjacent broad gauge line managed by TransAdelaide.

The investigation concluded that the collision occurred as a result of the movement of inadequately secured metal plates on a Transi-flat container located approximately 1250 m from the front of train 5MA5. Based on available evidence, the shifted load had been out-of-gauge from Murray Bridge, 85 km from the point of collision. In addition, the ARTC track at Eden Hills station platform was up to 140 mm closer to the TransAdelaide track than the design clearance. Given the inadequate load securing methods, and the forces to which the load had been subjected during its carriage, there was a relatively high risk of a load shift resulting in an out-of-gauge collision.

Executive summary

At about 0947 on 25 August 2005 a freight train travelling from Acacia Ridge¹ to Sydney, numbered as 5BS7, collided with a stationary track vehicle² at the take-off point³ within the Greenbank⁴ station yard limits. The impact speed was 21.9 km/h and the track vehicle was pushed back 25 metres. There were no injuries as a result of this accident and damage was limited to the front end of the track vehicle.

The track vehicle, with three track workers on board, had arrived on the main line at Greenbank moments before the arrival of the Sydney bound train and was going to the take-off point to be removed from the rail track for road operation. The approaching train was seen and heard by the track workers however they thought they would reach the take-off point and remove the track vehicle before the train arrived. When they realised that they could not, they escaped from the vehicle before the collision.

The two-man train crew of the Sydney bound train were travelling on a proceed signal and had made a routine brake application in preparedness for the mandatory stop at the Greenbank staff hut⁵. As the Greenbank staff station yard came into view they saw the track vehicle and made an emergency application of the train brakes 246 metres from the point of impact.

The train had departed Acacia Ridge under Rail Vehicle Detection authority to travel to Greenbank where the safeworking system changed to electric staff⁶.

The track vehicle was travelling from Bromelton to Greenbank on a routine track inspection on the authority of a Track Occupancy Authority (TOA). This TOA consisted of an electric staff and implied verbal authority to proceed within the Greenbank staff station yard limits to the take-off point.

The potential for simultaneous arrival at Greenbank had not been detected by the QR south-west train controller when developing the train graph. Distractions attributed to teaching a trainee controller and ambiguous communication regarding the departure time of train 5BS7 contributed to this oversight. This ambiguous communication resulted in the train controller believing that the train would not depart before 0945. However, it was intended that 0945 would be the latest departure time.

The investigation also found that longstanding inadequate safeworking practices between Acacia Ridge and Glenapp⁷ allowed the train controller’s oversight to result in this accident. These practices pertain to the operation of track vehicles that are not detected by track-circuitry⁸. The same system of safeworking exists between Glenapp and Casino⁹ with two versions of rules and procedures.

Safety actions recommended as a result of this investigation pertain to QR, Interail and ARTC ensuring that blocking facilities are applied where necessary, rule and procedure conformity on the electric staff territory between Greenbank and Casino, trainee train controller training program structure and enforcement, verbal communication protocols, and locomotive data logger accessibility.

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1. Acacia Ridge – A southern suburb of Brisbane, site of a major rail freight terminal.
2. Track vehicle – A vehicle, usually self propelled, used mainly for inspecting and maintaining infrastructure. In this instance able to operate on rail or road.
3. Take-off point - Staging beside the track for removing track mounted maintenance vehicles or equipment clear of train movements.
4. Greenbank – 17 Kilometres ‘south’ of Acacia Ridge.
5. Staff hut – location where tokens are kept.
6. Electric staff – A metal rod of prescribed design used as a token to authorise train movements into or through a block in electric staff territory.
7. Glenapp – The electric staff station/crossing loop 12 kilometres on the Queensland side of the border.
8. Track-circuitry – An electrical current that uses the rails of a railway track as conductors such that a train electrically connects them by its axles. The absence or presence of this rail to rail connection indicate the absence or presence of a train or item of rollingstock.
9. Casino – A provincial city on the Brisbane to Sydney rail line, about 169 kilometres from Acacia Ridge. Casino is an interface between electric staff working and rail vehicle detection (RVD) safeworking systems.

Executive summary

At approximately 1213 Eastern Standard Time on 11 August 2005, a small motor vehicle drove into the path of a Pacific National locomotive, G535, on the Edith Street level crossing at Horsham in Victoria. The crossing is protected by flashing lights a bell, approach warning signs and road markings. The driver of the motor vehicle was fatally injured as a result of the collision.

The investigation found that the driver of the motor vehicle did not to give way to the train as prescribed in 'Road Rules - Victoria'. Based on available evidence it is believed that the driver of the motor vehicle was distracted by the intersection immediately ahead, Dooen Road, and/or personal issues and was apparently unaware of the train's presence, even though the level crossing warning devices were operating at the time of the accident.