River Embley arrived at the anchorage off Gladstone at 0902 on the morning of 14 October. After 'finished with engines', the diesel alternator was put online and the steam plant was shut down to allow for repairs on the number two turbo alternator exhaust steam valve.
At about 1010, after checking that the exhaust steam system had drained, the chief engineer and third engineer started working on the valve. A short time later, while they were dismantling the valve a thousand litres of pressurised hot water unexpectedly started to spray from the valve and onto the chief engineer standing on staging below.
In an effort to escape the hot water spray the chief engineer tried to jump clear of the staging but became entangled in the securing rope which had formed a barrier.
The ship's crew mounted an immediate first aid response and the master organised a helicopter evacuation. The chief engineer was transported to Gladstone Hospital and later transferred to the Royal Brisbane Hospital intensive care unit.
The report concludes that the engineers did not fully assess the exhaust steam piping system and its drainage arrangements, or allow sufficient time for the exhaust steam system to completely drain before starting to work on the valve.
The ship's work permit system and job safety analysis procedures were not utilised by the engineering crew and deficiencies in safety management were not identified in two audits prior to the accident.
It is also considered that a sizable experience gradient between the chief engineer and the other engineers along with a lack of team training allowed a series of 'single person' errors to go unchecked and unquestioned.
The ATSB has made several safety recommendations aimed at preventing further accidents.
Safe Concordia is a dynamic positioning, self-propelled, semi-submersible accommodation platform that uses four electrically driven thrusters to maintain its position. The platform's construction was completed, and its delivery trials were carried out, in March 2005.
During its voyage from Singapore to Bass Strait, Australia, the platform experienced two electrical fires in its thruster power system. On 12 September 2005, after it had entered Bass Strait a fire started in the platform's number four thruster transformer. On 18 September, a fire occurred in an electrical cabinet that was providing power to the number one thruster motor.
The investigation found that the transformer fire was probably the result of an internal short circuit that occurred when the insulation failed due to overheating. The cabinet fire was the result of an electrical arc that occurred because the work bridging out of some electrical equipment was not adequately undertaken.
It was also considered that Safe Concordia was not fit to fulfil its charter obligations in view of the unresolved faults in the thrusters' electrical power systems and the design of the platform did not allow for effective and safe fire fighting in the thruster rooms.
The report makes several recommendations to address these issues.
At about 1600 on 22 July 2005 Leeuwin II grounded on an uncharted shoal during a voyage under motor from Careening Bay to Hunter River in the Kimberly region of Western Australia.
Less than two months later, on 16 September, Leeuwin II again grounded on an uncharted shoal. On this occasion in Shark Bay, Western Australia, during a passage from Denham to Monkey Mia.
Both groundings were investigated by the ATSB, and because of the similarities in the key factors which led to both incidents, the reports have been combined.
At about 1630 on 15 September 2005, a fire broke out in the engine room workshop on board the bulk carrier Opal Naree.
A fitter had been allocated the task of weld repairing the sewage system save-all base, while the duty oiler was assigned to standby in the workshop below and keep a fire watch. The oiler left the workshop to answer the telephone, and then attended to a ballast pump fault that the second mate had alerted him to.
During this time the fitter continued to work, and it appears that molten metal from the welding process fell into the workshop, landing on coiled electrical cables, causing them to ignite.
The fire was detected by the fitter and the emergency alarm was raised.. The crew mustered and the master contacted the port authority, who, in turn contacted the fire and emergency services.
The crew closed all the engine room doors and fire dampers while the master and chief engineer assessed the situation. They decided to use the fixed fire extinguishing system, and at 1700 carbon dioxide was released into the engine room.
By 1800 two fire fighting tugs were standing by the ship and the fire and emergency services authority (FESA) were on board.
At 2153 the ship's crew and FESA commenced the first of two inspections of the engine room.
There was no sign of fire and by 2310 the ship's crew had begun ventilating the engine room.
At about 1600 on 22 July 2005 Leeuwin II grounded on an uncharted shoal during a voyage under motor from Careening Bay to Hunter River in the Kimberly region of Western Australia.
Less than two months later, on 16 September, Leeuwin II again grounded on an uncharted shoal. On this occasion in Shark Bay, Western Australia, during a passage from Denham to Monkey Mia.
Both groundings were investigated by the ATSB, and because of the similarities in the key factors which led to both incidents, the reports have been combined.
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. During the anchor retrieval process 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 then made contact a second time before Pilsum finally made its way clear.
At about 0540 on 24 May 2005, a fire started on board the Singapore registered general cargo ship Java Sea while it was berthed in Cairns. The fire started in the engine room adjacent to the oil-fired thermal fluid heater, at deck level, under the poop in way of the aft peak bulkhead.
Initial attempts by the ship's crew to fight the fire using a fire hose were unsuccessful and the decision was taken to use the engine room Halon 1301 fixed fire extinguishing system. The release of the Halon 1301 proved ineffective, primarily because of the inability of the crew to close the dampers on the ventilation openings at the top of the funnel casing.
The fire was finally extinguished by the Queensland Fire Service, using high expansion foam injected through a hole cut in the base of the funnel at poop deck level directly above the seat of the fire.
The engine room and accommodation were significantly damaged by the fire and the associated firefighting activities, to such an extent that Java Sea had to be towed to Singapore for permanent repairs.
The report found that it is probable a leakage of hot pressurised thermal fluid (mineral oil), possibly in the form of a spray, ignited when it came into contact with an un-lagged section of the oil-fired thermal fluid heater exhaust piping; and once started, the fire was fuelled by the contents of the thermal fluid expansion tank, the main engine cylinder oil service tank and the stern tube lubricating oil tank.
The report identifies a number of contributing factors and makes recommendations to address them.
Just after 0920 (ship's time) on 16 May 2005, the engineer cadet on the bulk carrier Golden Bell fell through an open section of deck grating while working in the ship's engine room. He landed on the bottom deck plates, approximately seven metres below, suffering severe head and internal injuries. The ship was at anchor off the Western Australian port of Dampier.
The cadet died as a result of his head injuries a short time after being evacuated by helicopter to the Nickol Bay Hospital in Karratha, about 20 km from Dampier.
Shipping companies, managers and ship's masters should ensure that shipboard safety management systems include procedures for working on electrical equipment that are adequate and not ambiguous. It is essential that these procedures are backed up by sufficient onboard training and auditing to ensure personnel involved in performing or supervising electrical work understand and fully implement these procedures.
MR20050024
Regulatory authorities, shipping companies and ship managers should consider the feasibility of widening the requirement for medical examinations and certificates to include more stringent testing for, and monitoring of, chronic conditions such as heart disease and diabetes.
Significant Factors
Based on the evidence available, the following factors are considered to have contributed to the death of the electrician aboard Probo Panda on 11 May 2005.
The electrician had a pre-existing heart condition, coronary artery atheroma.
Current medical examination standards for seafarers are inadequate in terms of detecting conditions such as coronary heart disease.
Working on live electrical equipment and not implementing the measures outlined in the ship's SMS increased the likelihood of the electrician receiving an electric shock.
The electrician may have suffered an electric shock, causing him to fall between the deep frame and a parallel pipe.
The subsequent exertions, attempting to climb free, probably induced the heart attack.
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.
Rendering the earth leakage detector inoperable removed a safety device that may have drawn attention to the electrician's plight earlier.
Comments and Analysis
COMMENTS AND ANALYSIS
On 13 May 2005 investigators from the ATSB conducted interviews with the master and chief engineer on board Probo Panda. Discussions were held with local police, the ship's agent and legal representative.
A postmortem examination of the electrician was conducted by the coroner in Rockhampton. The coroner's report was provided to the ATSB and cited the cause of death as coronary artery occlusion (heart attack) attributable to coronary artery atheroma (a build up of fatty patches inside the lining of the coronary arteries).
The contents of the electrician's pockets, which included tools, insulating tape, starters and old tube end fittings, and the fact that a new tube end fitting was found hanging from the light fitting (Figure 3) indicate the electrician had been in the process of changing this item.
The light fitting was situated directly above a transverse deep frame outboard of the main engine charge air cooler cleaning filter, starboard aft at the bottom plate level.
The light fitting was still live, with its circuit breaker closed and no danger tags fitted. Prior to the ATSB's arrival, the ship had organised for a shore based electrician to render the equipment safe while preserving the evidence to the greatest extent possible.
It is likely the electrician was crouching on the deep frame so he could reach the light fitting. It seems that he received an electric shock which knocked him off balance, causing him to fall between the deep frame and the parallel pipe. The subsequent exertions, attempting to climb free probably induced the heart attack.
Figure 3: Light fitting
The electrician's health
The ship's medical log listed the only medication that had been issued to the electrician during his time on the ship was an expectorant cough medicine.
The master and chief engineer both commented that the electrician appeared to be in good health.
Prior to joining Probo Panda the electrician had undertaken a seaman's medical examination. The medical certificate, issued on 19 July 2004, indicated he was in good health, with no indications of coronary heart disease.
While a number of studies into coronary heart disease amongst seafarers have been undertaken, their findings have generally been inconclusive.
In one such study published by Dr. H.D. Wickramatillake, it was found that of 68 deaths due to natural causes amongst British seafarers in the period 1986 to 1995, 62 were attributable to coronary heart disease.
In another study completed by Offer-Ohlsen in 1981, it was observed that.
… out of 2,646 seamen 8% suffered from cardio-vascular disease and they had previous experience of pre-cardial pain…
Currently there are no international standards that require seafarers to be subjected to rigorous medical examinations that would highlight conditions such as coronary heart disease. It is possible that had the company or the statutory authority required the electrician to undergo such an examination, he may have been alerted to his condition at the time of his last medical examination.
Seafarers, particularly those completing long contracts on international trading ships, are required to spend extended periods away from adequate medical supervision. Statutory authority and company medical policies should ensure that seamen suffering from chronic medical conditions are identified and adequately monitored.
Working unsupervised
The electrician was probably alive for some time after he fell; however, he was not discovered in time to save his life.
The fact that he was missing for approximately three hours without notice is of concern.
It is the responsibility of all crew to ensure that those working alone have their whereabouts and wellbeing regularly monitored.
Electrical isolation
The ship's SMS contained procedures for carrying out work on electrical equipment. These procedures required completion of an electrical work permit (check list), electrical isolation, and, where electrical isolation was not possible, allowed work on live circuits where 'adequate precautions' were taken.
The permit system was in use on board Probo Panda for complex jobs; however, it was evident that the system was not used when undertaking what were described as 'simple' tasks. The procedures and associated check list did not differentiate between simple and complex tasks.
It is possible that a qualified and experienced electrician would not see the need to complete an electrical work permit for a task such as repairing a light fitting. The ship's procedures, however, did not allow him to make such a judgment. Notwithstanding this, it is fair to expect that the electrician should have isolated and tagged the power supply prior to commencing work on the light fitting.
There were no alarms recorded during the day that may have indicated an earth on the 220 volt electrical system. Such an alarm may have prompted the duty engineer to investigate what caused it and possibly led to an earlier discovery of the electrician.
When inspected, the earth leakage detector was not operable as the fuses had been removed. The ship's staff were not aware that these fuses had been removed and indicated that the alarm had recently been working.
While the fuses were not found with the electrician, he may have removed them to prevent nuisance alarms from interrupting the duty engineer while the light fittings were being repaired.
Rendering safety monitoring devices such as earth leakage detectors inoperative should be avoided wherever possible.
Final report
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.
The electrician died while working on one of the ship's engine room light fittings.
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.
He had been missing for several hours and was only found after a search of the vessel was instigated by the master.
At 0535 on 15 April 2005, the Greek registered bulk carrier Spartia collided with the Australian rock lobster fishing vessel Hannah Lee, 17 nautical miles off Cape Bouvard, in position 32 43.8'S, 115 16.9'E, on Western Australia’s south-west coast. Spartia was in ballast and making for the port of Bunbury to load alumina. Hannah Lee had departed the small port of Mandurah at 0345 to work it’s rock lobster pots located approximately 37 nautical miles south-west of the port.
Hannah Lee’s skipper failed to observe Spartia in the time leading up to the collision as he was preoccupied with keeping his vessel on course. The bridge team on Spartia had identified the fishing vessel about 20 minutes prior to the collision. They had assessed that a risk of collision existed but, as Hannah Lee was on their port side, they maintained the vessel's course and speed, in accordance with the international collision regulations. When it became obvious to the bridge team that Hannah Lee was not going to give way, the master ordered avoiding action, consisting of a change in course and turn to starboard.
This action was ineffective in preventing the collision and Hannah Lee impacted Spartia’s port side, in way of number six hold a short time later. No one was injured in the collision and no pollution resulted.
After the collision, Spartia continued its voyage to Bunbury, where it anchored at 0900. Hannah Lee made for the port of Fremantle where it berthed at a repair yard at about 0910.
The report concludes that:
The visual lookout being maintained on board Hannah Lee was inadequate, ineffective and in the minutes prior to the collision, non-existent.
The VHF on board Hannah Lee was not tuned to the internationally accepted distress and calling frequency, channel 16.
Engine noise emanating from the rear of the wheelhouse prevented Hannah Lee’s skipper hearing any sound signal from Spartia’s forward whistle.
A non-operational radar prevented Hannah Lee’s skipper from detecting Spartia by this means in the time leading up to the collision.
Hannah Lee’s skipper did not have the required knowledge of the COLREGS and his obligations under them.
It is probable that Hannah Lee’s skipper’s judgement, actions and situational awareness were affected by fatigue as a result of his work routine and waking time activities over the previous week.
The decision by Spartia’s master to take avoiding action when Hannah Lee was one nautical mile away was too little and made too late.
It is also considered that:
VHF recordings from the Fremantle Port Authority indicate that it is probable that Spartia’s bridge team did not attempt to use VHF channel 16 to alert Hannah Lee to the presence of the ship in the period of time leading up to the collision, despite their claims to the contrary.
Both vessels should have stopped and established contact as soon as possible after the collision.
The report recommends that:
All State and Territory registered commercial vessels operating offshore should be required to carry an operational VHF radio which is capable of maintaining a continuous watch on channel 16 (156.8 MHz) and, if required for vessel operations, another channel.
Skippers of commercial State and Territory registered vessels should ensure that they have a full understanding of the COLREGS and their obligation under those regulations, with particular regard to keeping a lookout and actions to avoid a collision.
State and Territory marine regulatory authorities should consider amending their policy and regulations with regard to perpetual certificates of competency with a view to implementing a revalidation process consistent with the requirements of the National Standard for Commercial Vessels.
State and Territory marine regulatory authorities, through the National Marine Safety Committee, and in consultation with the Australian Seafood Industry Council, should ensure the safety and welfare of fishing vessel crews by reviewing work practices on Australian fishing vessels with a view to establishing guidelines for the management of crew fatigue.
