Abstract

At about 1932¹ on 30 March 2008, freight train 1MA6Q, travelling from Melbourne to Adelaide, derailed on the Mt Emu Creek bridge near Pura Pura, Victoria. Twenty-one wagons derailed, coming to rest on the track past the bridge abutment. As a result of the derailment, some containers burst spilling their contents onto the rail corridor and the adjacent public road.

The investigation determined that the derailment occurred as a result of a failed rail due to fatigue cracking emanating from an unused bolt-hole.

Rail safety recommendations

[ RO-2008-004-SR-011] [ RO-2008-004-SR-012]

1. The 24-hour clock is used in this report to describe the local time of day, Eastern Daylight Tme (EDT), as particular events occurred.

Abstract

At 0750 on 11 March 2008 a northbound freight train, numbered 2WB3, passed the outer home signal at red without authority at Gloucester, NSW. Gloucester is located about 140 km north of Broadmeadow (suburb of Newcastle) on the main Sydney to Brisbane rail line. There were no injuries or damage as a result of this incident.

Executive summary

At about 1815 on 24 December 2008, the Australian registered floating storage and offloading tanker, Karratha Spirit, began disconnecting from its mooring buoy at the Legendre Oil Field, about 60 miles north of Dampier, Western Australia, because of an approaching tropical cyclone.

The master was on the forecastle, directly controlling the operation. Before the mooring hawsers could be released from the ship, the import hose drifted under the hawsers and he ordered the main engine to be run astern for about 1 minute in an attempt to pull the hose clear. At about 1954, after the wire suspending the oil import hose parted suddenly, the master ordered the crew to finish letting go the hawser pickup lines so that the ship could depart the mooring buoy.

An integrated rating applied the port winch drum's brake to stop the drum moving and then stepped between the cheeks of the drum to cut the lashing that held the end of the heavy hawser pick line on the drum. At about 1958, when the lashing parted, the last three turns of heavy line rapidly unwound from the drum, striking the rating on the head and throwing him under the winch drum. He died as a result of his injuries.

The ATSB investigation found the procedures for connecting and disconnecting from the mooring buoy had not always been followed and that the difference between the procedures and shipboard practice had not been identified during any shipboard review and the risks associated with this amended practice had not been assessed.

The investigation also found that it is possible, under some circumstances, that facilities like Karratha Spirit can fall outside the jurisdiction of the safety regulators. The report issues one recommendation and one safety advisory notice to address these safety issues.

Abstract

At about 14151 on 10 March 2008, train 6MP9 was carrying containerised general freight from Melbourne to Perth when it derailed 11 wagons near Hines Hill in Western Australia. Although there were dangerous goods on the train, they were not involved in the derailment.

The investigation determined that wagon ABFY2797U derailed due to a 'screwed journal' as a result of a wheel bearing failure.

Executive summary

At 1428 on 13 December 2008, the Hong Kong registered container ship APL Sydney's starboard anchor was let go in Melbourne anchorage. Four minutes later, the pilot left the bridge and by 1436, he had disembarked the ship. The 35-knot south-southwest wind was gusting to 48 knots. A submarine gas pipeline lay 6 cables (1.1 km) downwind.

By 1501, after dragging its anchor, the ship was outside the anchorage boundary. The master advised harbour control he intended to weigh anchor and was instructed to maintain position and wait for a pilot. At 1527, when weighing anchor was started after receiving permission from harbour control, the ship was within 50 m of the pipeline. While weighing anchor, the anchor dragged across the pipeline, snagged it at about 1544 and, subsequently, the anchor windlass failed.

At 1603, the pilot returned to the ship and, after discussions with the master and harbour control, he decided to dredge the anchor clear. At 1621, less than 1 minute after APL Sydney's main engine was run ahead, the pipeline ruptured. There were no injuries, and the pipeline was isolated.

The investigation found that the rupture was the result of attempting to dredge the anchor instead of slipping it. The anchor had also been let go too close to the pipeline in the poor weather conditions. The report identifies safety issues in relation to the port's risk management with respect to the pipeline and anchorage boundaries and its shipping control procedures; the ship's safety management system with respect to passage planning, the master's authority, crew familiarisation and the working language; the pilotage company's procedures for anchoring and mobile telephone use; and the windlass failure. Safety actions to address all the issues have been taken or proposed by the relevant parties.

Executive summary

At about 2117 on 24 November 2008, while preparing the ship to sail from Townsville, Queensland, a crew member on board the Maltese registered container ship Spirit of Esperance was injured after falling about 4 m during an operation to stow the number three cargo crane hook.

Immediately following the fall, the crew member was treated by the ship's crew and, shortly afterwards, by ambulance officers. He was then transferred to hospital where he later died as a result of the injuries he had sustained.

The Australian Transport Safety Bureau (ATSB) investigation found that the design of the cargo crane hook cradle did not allow for unassisted stowage of the hook when the ship had a stern trim in excess of 2.1 m; there were no guidelines or procedures available on board the ship to assist the crew with the task of stowing the cargo crane hook when it was misaligned from its cradle; the crane operations job safety analysis did not identify the risks associated with stowing the hook in these circumstances; and when the ship's stern trim was in excess of 2.1 m, the ship's crew routinely violated the working aloft procedure by climbing the emergency ladder adjacent to the hook's cradle without a permit or appropriate personal protective equipment.

The investigation also found that the deceased crew member was probably under the influence of alcohol at the time of the accident, and this may have adversely affected his reaction time, balance and cognitive ability. The ATSB acknowledges the safety actions taken by ASP Ship Management to address these safety issues and, in addition, has issued three safety advisory notices.

Executive summary

At 2142 on 31 July 2008, the fully laden cape-sized bulk carrier Iron King departed from its berth in Port Hedland, Western Australia, with a harbour pilot on board.

Iron King made its way through the harbour and while the assisting tugs had been let go by 2217, just before the ship reached Hunt Point, they continued to escort it. Shortly afterwards, at 2219 and again at 2221¼, the ship's rudder failed to respond to port helm orders as the pilot attempted to steady the ship's heading on the Spoil Lead.

The master switched the steering control switch between the two follow-up control systems and informed the pilot that steering control had been restored. The ship was still turning to starboard, so the pilot ordered full ahead and hard-to-port in an attempt to keep the ship in the channel and thus avoid grounding. He also directed the tugs to make fast to the ship as soon as possible. However, the tugs were unable to provide much assistance and by 2225, the ship had collided with Beacon 44 and grounded.

The ship remained aground until the next high tide, when it was successfully refloated.

The investigation found that the steering gear failed to respond to the helm orders because a leaking actuator relief valve was limiting the steering system hydraulic pressure. It was also found that; it was normal practice for assisting tugs to be let go before departing ships reached Hunt Point; the pilot directed the tugs to make fast to the ship again, but they were unable to do so before it grounded; the master was not aware of the appropriate emergency steering system change-over procedure; and the pilot had not been provided with training in the implementation of a suite of 'risk analysed' responses to predictable emergency scenarios in a simulated environment.

A number of safety actions have already been taken by relevant parties to address these safety issues. In addition, the Australian Transport Safety Bureau has issued one Safety Advisory Notice.

Abstract

At about 1745 on 27 October 2008, during cargo discharge operations whilst alongside in Port Kembla, New South Wales, the chief mate of Great Majesty remotely opened two ballast valves adjacent to the number two water ballast pump (No. 2 WB P/P) to gravitate2 seawater into the number one water ballast tank (No. 1 WBTK).

About 10 minutes later, the engine room bilge alarm sounded and the duty motorman found seawater flooding into the space through the open casing of No. 2 WB P/P. Repair work had been started on No. 2 WB P/P but the suction line had not been blanked off.

The inflow of water was stopped after the alarm was raised. About 390 m3 of seawater had entered the engine room and a total of 22 electric motors located on the lower levels of the engine room were damaged by the water ingress.

The investigation found that the ballast operation procedure did not provide sufficient guidance to the crew. The investigation also found that the work permit system onboard had not been effectively implemented. Consequently, most maintenance and repair work being carried out by the ship's crew was without a work permit.

Abstract

On 18 November 2008, while the Maltese registered bulk carrier Saldanha was anchored off Newcastle, NSW, a ship's engineer was burned when the auxiliary boiler furnace 'flashed back' during a routine boiler oil firing unit burner exchange.

The ATSB investigation into the incident found that the ship's crew were not aware of all of the hazards associated with maintaining the boiler burner; were not aware of previous flashbacks involving similar burners; and were not aware of the appropriate first aid treatment required for burn injuries.

The investigation also found that the safety bulletin that had been previously issued by the manufacturer did not inform operators that the oil firing unit could be modified.

Executive summary

At 0710 on 15 July 2008, the Greek registered bulk carrier Atlantic Eagle sailed from Albany, Western Australia, partly loaded with a cargo of grain. At 0815, the ship was just outside port limits and its speed had been increased to 14 knots for the voyage to Fremantle, Western Australia.

During the next 10 minutes, the master made two significant course alterations and then set the ship on a heading of 235º, an allowance of five degrees to port of the ship's planned course. At 0835, he left the bridge, instructing the second mate to keep the ship on the set heading and clear of islands.

The second mate maintained the ship on a heading of 235º but did not monitor the ship's progress or establish its position. At 0856½, Atlantic Eagle grounded on Maude Reef, seriously damaging its hull, rudder and steering gear before moving clear of the reef. The grounding did not result in any pollution.

On 24 August, after completing temporary repairs, the ship was towed from Albany, bound for Jakarta, Indonesia, to discharge its cargo in preparation for undergoing permanent repairs in Vietnam.

The investigation found that Atlantic Eagle's safety management system procedures for navigation and record keeping had not been effectively implemented on board the ship. The report issues two recommendations to address these safety issues.