Summary

On 26 July 2002 Doric Chariot sailed from Hay Point, Queensland on a voyage to India via the Great Barrier Reef inner passage and Singapore. A pilot was engaged for the Reef passage.

The voyage initially proceeded normally and, on 29 July, as the ship approached Eel Reef light, the pilot requested a slight course alteration to allow more sea room for passing a south-bound ship. After passing this ship the pilot requested another course adjustment to bring the ship back toward the planned track. He then spoke with the OOW (Officer of the Watch) about the time he should next be called and sat on the daybed at the side of the wheelhouse to take a rest before the ship arrived at the next reporting position near Piper Reef.

The ship continued under the direction of the OOW until the pilot was next called. When the pilot stood up and looked at the ship's position with reference to the two beacons ahead at Piper and Inset Reefs, he immediately realised that the ship was to the west of the two-way route and approaching the southern end of Piper Reef. He ordered, 'hard-a-starboard' and, shortly afterwards 'full astern' but it was too late. The ship started to swing to starboard but, within about one and a half minutes, at about 0335, the ship ran aground to the south of Piper Reef light.

The ship was successfully refloated on 6 August 2002. No injuries or pollution resulted from the grounding.

The report concludes that the pilot:

1. sat down intending to rest but fell asleep, in an inappropriate area of the pilotage passage;
2. instructed that he should next be called in a position too close to the approaching dangers for any successful corrective action to be taken should it be required;
3. was likely to have been experiencing a significant level of fatigue, based on the FAID program measurement, that affected his performance. This was predominantly as a result of his personal fatigue strategies before and during the passage and;
4. did not provide the OOW with sufficient clear, unambiguous, instructions regarding the course between Eel Reef and Piper Reef and made assumptions as to the OOW's actions that were not justified.

The report also concludes that the OOW:

1. did not maintain an effective visual watch and allowed Doric Chariot to stray from the intended course;
2. did not adjust the ship's course to follow the route drawn on the chart;
3. did not fix the ship's positions at intervals that were consistent with safe navigation and;
4. did not fully understand the pilot's intentions.

Additionally,

1. The bridge resource management exercised by the pilot and the OOW was ineffective.

The report makes three recommendations involving clearer understanding between pilots and officers; a fatigue management policy by pilots; and a paper to the IMO.

Summary

At 0712 on 18 June 2002, the Panama flag bulk carrier Western Muse berthed at Port Kembla, NSW, to load a cargo of steel slabs and coils for Pohang in South Korea. The vessel had been chartered for the voyage by BHP Transport and Logistics.

The cargo was to be loaded using the ship's cranes. The master was advised to ensure that the cranes and wires were in good condition as they would be inspected by the stevedores before being used. Before the vessel's arrival at Port Kembla, after checking the cargo gear, both the master and mate were satisfied that the cranes and wires were in good condition.

The stevedore's inspection of the cargo gear started soon after the vessel had berthed, but unsuitable weather conditions led to only one crane being checked that day. The next morning the other cranes were inspected and, as a result, the mate was told to change the cargo wire of no. 2 crane.

During the remainder of that day, the crew carried out the task of changing the wire. Much of the work was carried out from the platform on top of the crane, requiring the use of safety belts.

By about 1745 the wire had been changed. The bosun, who was on the platform on top of the crane, gave the order for the operation of the crane to be checked. He then released the clip on the rope lanyard attached to his safety belt from railing on the platform. At the same time, the deck cadet, who had been operating the crane, raised the cargo hook, then the jib.

The lanyard on the bosun's safety belt was drawn into the sheaves for the jib, dragging the bosun in between the sheaves and the luffing wire. He screamed out and one of two seamen with him immediately shouted to the cadet, by handheld radio, to stop the crane.

By the time the bosun was freed, he was haemorrhaging severely from wounds to his leg and pelvis. The master asked for ambulance assistance and, by about 1830, paramedics and a police rescue squad were in attendance on the ship. Soon afterwards, one of the paramedics advised the master that the bosun was dead.

The police forensic squad arrived to carry out their work and, at about 2230, the bosun's body was removed from the top of the crane and taken to the mortuary. The interim post-mortem report stated that the cause of death of the bosun was massive traumatic injuries resulting in amputation of the left leg and the side of the pelvis.

The ATSB investigation concludes that, among other factors contributing to the incident:

• The task of changing the wire was physically and mentally demanding, possibly causing the bosun's concentration to lapse at the end of the day;
• It is probable that the bosun was concentrating on the cargo wire and that he was not watching the luffing wire after he released the lanyard on his safety belt. In addition, poor light would have made it difficult to see any detail on the platform.

This report recommends that:

• In accordance with the objectives of the ISM Code, companies, in addition to documenting preventive maintenance procedures, also develop, document and implement associated safety procedures;
• Procedures and precautions for personnel working aloft include warnings that loose clothing or personal safety equipment might become entangled in moving machinery.

Conclusions

These conclusions identify the different factors contributing to the incident and should not be read as apportioning blame or liability to any particular individual or organisation.

Based on the evidence available, the incident occurred due to a combination of the following factors:

1. After the bosun released the rope lanyard on his safety belt, the lanyard became entangled in the luffing wire or was drawn into the sheaves for that wire, dragging him in between the sheaves and the wire.
2. The task of changing the cargo wire, in addition to being arduous and lengthy, was physically and mentally demanding, possibly causing the bosun's concentration to lapse at the end of the day.
3. The conditions of lighting under which the crew were operating at the top of the crane would have made it difficult to see any detail on the platform.
4. It is likely that the bosun was concentrating on the movement of the cargo wire and that he omitted to watch for movement of the luffing wire.
5. Though the mate had signed a permit to work that morning, the conditions for the permit were not re-assessed once darkness had fallen.
6. While the company and the ship had the necessary ISM accreditation, the safety manual contained no precautions or procedures for the crew when working in close proximity to moving machinery on cranes.

In addition, although not a contributing factor, the Inspector concludes that the condition of the wire that was renewed did not meet the requirements of Marine Orders Part 32. The wire was not fit for use and, hence, did require replacing.

Summary

At 1148 on 15 April 2002, the Bahamas flag bulk carrier SA Fortius arrived off the New South Wales port of Port Kembla. The ship's deadweight was 88 674 tonnes at a mean draught of 10.655m and it was trimmed almost 3 metres by the stern.

At 1300 the pilot embarked, and the ship proceeded inwards to the number two coal loader, in the inner basin. The intention was for SA Fortius to enter the outer harbour, pass through the 'Cut' and turn to starboard through some 230 to berth, on a southerly heading, at the coal loader in the eastern basin. The wind speed was about ten knots from the south-southeast.

Approaching the breakwater, four tugs were made fast, one on a tow line through the forward centre Panama lead, two tugs alongside on the starboard side (one forward, the other aft) and a tug aft, on a line led through a stern Panama lead, on the port side.

The passage to the inner harbour apparently proceeded without incident. Once in the inner harbour the pilot initiated the turn to starboard utilising the ship's engine, rudder and the two forward tugs. The tug made fast through the forward Panama lead towed the bow to starboard, while the forward tug on the starboard side was used to slow the ship by coming astern.

After the ship had turned through some 90 it became apparent to the pilot that SA Fortius was experiencing a significant drift angle¹. The master of the stern tug became concerned as SA Fortius's stern was closing on the multi-purpose berth and the dolphin at the southern end of the grain berth. He anticipated that the next order from the pilot would be for his tug to take the stern to port and he positioned the tug forward of the beam, between the ship and the dolphin.

The ship maintained headway, contacting the third fender from the southern end of number two coal berth on a heading of about 078 (T).

At, or immediately after, the time of contact the pilot ordered the two stern tugs to take the ship's stern to starboard. The stern tug however, had become temporarily trapped between the grain berth dolphin and the ship and sustained damage to its fenders forward and aft. At this time the tug positioned on the starboard side aft parted its tow line. The ship maintained a reduced rate of turn and cleared both the grain berth dolphin and number two coal berth, which had sustained damage in the initial contact.

SA Fortius was directed to berth at number one coal berth, where it completed mooring at 1523.

This report concludes that:

1. SA Fortius developed a large drift angle, which resulted in the ship being too far to the north in the turning basin.
2. The drift angle was not detected by the pilot.
3. The engine was put to 'slow ahead' at about 1356, when the intended engine order was 'slow astern'.
4. The pilot did not take sufficient notice of the tachometer and rudder angle indicator.
5. The bridge team work was negligible, resulting in a breakdown of effective and safe communications between the pilot and the ship's staff on the bridge.
6. The master did not take sufficient steps to ensure that he was aware of the intended manoeuvre in the inner basin.
7. There was a lack of specific direction to the tugs by the pilot. He did not follow the 'Standard Orders to Tugs' issued by the Port Kembla Port Corporation in December 1999.

The report recommends that:

• Pilots use the procedures as laid out in 'Standard Orders to Tugs' issued by the Port Kembla Port Corporation in December 1999, when directing tug manoeuvres.
• Port authorities, where not otherwise equipped, should consider the introduction of an electronic aid, with track prediction capability, to assist pilots with the berthing of ships.
• All ports should consider publishing their general port entry and berthing manoeuvre plans on the Internet. This would provide port users with direct access to port information (or indirect access through ship's agents), permitting masters and officers to plan passages as recommended in the International Chamber of Shipping's 'Bridge Procedures Guide'.
• Periodic meetings between pilots and tug masters be reintroduced at an operational level.
• When piloting ships, pilots should consider means by which they can verify all orders given by them.

¹ With the bridge aft, drift angle is the angle between the ship's heading and the direction in which the ship's bridge is travelling. Rowe, R.W. (1996) The Shiphandler's Guide, Nautical Institute.

Summary

At about 0624 on 27 March 2002, the Panama flag bulk carrier La Pampa sailed from the Clinton Coal Terminal at Gladstone for Fos in France. A pilot was on board and three tugs assisted the ship off the berth. The vessel was loaded with 160 927 tonnes of coal and had a deepest draught of 17.825 m.

Both main steering pumps were tested satisfactorily before departure and were running when the vessel sailed. At about 0650, just before the tugs were released, a steering alarm sounded. The rudder was stopped at hard to port, but the problem quickly seemed to resolve itself. Then, at about 0710, by which time the tugs had been released and had returned to their berth, the steering alarm sounded again.

The steering continued to operate as the chief engineer went to the steering flat to investigate. There he found that both main hydraulic inlet and outlet lines on number one steering pump were leaking large quantities of oil under pressure. This pump was stopped and then restarted but at about 0712 the steering failed. The pilot asked for tug assistance, while the chief engineer tried, unsuccessfully, to operate the emergency steering system.

At 0714, before the tugs could assist the ship, La Pampa grounded on the northern side of the channel. At 0722 the vessel was refloated with the assistance of the tugs and was anchored at an emergency inner anchorage. Tank soundings established that number one double bottom ballast tank was taking in water and the ballast and stripping pumps were started to control the ingress of water. During this time the chief engineer was checking the steering gear and discovered pieces of piston seal from one of the hydraulic rams lodged in a control valve.

Later in the day the decision was made to shift the ship to the outer anchorage. At 1820, with number two steering pump operating, the anchor was weighed. La Pampa proceeded outward with three tugs in attendance but, at 1904, the steering failed once again. The vessel then had to be assisted by the tugs to the outer anchorage where it was anchored at 2345. Repairs to the hull and steering gear were then undertaken.

The Australian Maritime Safety Authority (AMSA) detained the vessel until 14 April when repairs to the steering gear were complete and they were satisfied that the vessel was seaworthy.

The report concludes that:

• the grounding was caused by a major failure of the steering gear.
• the steering gear failure was due to the disintegration of the piston seals in the starboard steering rams.
• the failure of the seals on the suction and discharge ports on number one steering pump was the result of an over pressurisation caused by debris from the failed piston seals being passed into the hydraulic system.
• the failure of the piston seals in the starboard steering rams meant that the steering system could not be operated using either the emergency pump or number two steering pump without isolating these rams.
• The master did not direct anybody to inspect the steering gear when the initial, transitory, malfunction occurred at 0650

The report recommends that:

• Port authorities consider the risks associated with the passage of deep draught vessels within their ports and have appropriate contingency plans in place to deal with foreseeable emergencies.

The collision

At 0401 on 11 April 2002, the fishing vessel Seabreeze II collided, bow on, with the starboard side of the general cargo ship Forum Samoa II. There were no injuries to any person on either vessel, but the collision resulted in damage to the bow of the fishing vessel, which returned to port for repairs.

Neither vessel was keeping an adequate lookout before the collision and this report, as do many previous reports of collisions, emphasises the need for all vessels to maintain a proper lookout at all times.

Summary

At 1800 on Sunday 17 February 2002, the bulk carrier CSL Pacific sailed from Melbourne after discharging a cargo of furnace slag. The ship was bound for Adelaide to load a cargo of powdered cement.

At 0750 on Monday morning, the chief engineer, deck mechanic and deck fitters met to discuss their major work for the day which was to repair some of the buckets on number one bucket elevator.

Prior to starting work, the deck mechanic went to number one control room and checked that the circuit breaker for the main electric motor on the bucket elevator was open. He did not place a danger tag on the circuit breaker.

The same morning, the boatswain and seamen had started to prepare cargo holds one and two to receive the powdered cement cargo in Adelaide. The seamen were sweeping the residue of the slag cargo from the bottom of the holds into the bucket elevators. This work was being performed under the supervision of the mate who was periodically running number two bucket elevator for short periods to provide the men with empty buckets to fill.

At about 1100, the boatswain, working in the bottom of number two hold, requested that the mate rotate number two bucket elevator. At this time a deck fitter was working inside the top of number one bucket elevator. He was lying with his torso inside the bucket with one foot resting on one of the drive chains as he was welding.

The mate went to number two control room and ran the bucket elevator for a couple of seconds. He then went to number one control room to check on the cleaning in number one hold. While there he decided to run the bucket elevator to provide an empty bucket for the man working there and went to the circuit breaker for the drive motor. Finding no danger tag, he closed the breaker and then ran the motor for 2-3 seconds. Although he had been told about it earlier, he had forgotten about the work being performed at the top of number one bucket elevator.

The fitter welding inside the bucket elevator sustained serious injuries when the bucket elevator moved. His right hip had been dislocated, his pelvis and a vertebrae had been fractured, two ribs were broken, and he had some ligament damage in the groin area.

Help was quickly at hand and the injured fitter was lifted out of the bucket elevator and taken on a stretcher to the ship's hospital where he was examined by the second mate. It was evident that the fitter's injuries were serious. The master organised a telephone consultation with a surgeon from the Royal Adelaide Hospital who advised him to land the fitter as soon as possible. After speaking to the ship's manager and the Adelaide agent the decision was made to divert the ship to Portland, Victoria.

CSL Pacific arrived off Portland at 1740. At 1800 the injured fitter was transferred to a pilot launch and then to Portland base hospital. The deck fitter spent the next six weeks in Portland base hospital recovering from his injuries before being repatriated on 2 April 2002.

Local safety action

The Sports Aircraft Association of Australia (SAAA) announced in July 2003 that it is scoping the development and implementation of a four-stage flight safety assistance program for members. The program adopts some of the existing programs run by the association and will develop into a broader program incorporating aspects not currently covered.

The intention is to encourage members to sign onto the total program while still giving them the choice under the experimental rules.

During July /August 2003, the Association's technical coordinator travelled overseas to meet with United States of America Experimental Aircraft Association officials to discuss that organisation's flight advisor program.

An outline of the SAAA intended program was introduced to SAAA members in October 2003.

The Association will also include a note and link to this report on its website www.saaa.com.

The engine manufacturer issued Service Bulletin SB72-E181 on 6 August 2003 to provide a long-term solution to the uneven blade root friction problem. That SB introduced a revised dry film lubricant (DFL) to be used as an alternate blade root lubrication coating. Incorporation of the SB is indicated by a change in blade part number.

The manufacturer has also revised the manufacturing process for the HPC blades, changing the blade root machining process from broaching to milling.

A new design HPC blade drum has been developed to prevent blade loading slot cracking. Service Bulletin SB72-E106 was issued on 7 March 2003 to include the application of the improved DFL to the first stage HPC blade root dovetails of those blade drums at manufacture.

As an interim measure, the manufacturer has revised the inspection limits for blade root damage and scores, and has instigated blade root DFL removal and replacement at each module overhaul. An ultrasonic, non-destructive-inspection procedure, that can detect blade root cracking without removing the engine from the aircraft, has also been developed.

The manufacturer reported that an update to these solutions would be supplied to all operators.

Civil Aviation Safety Authority (CASA)

• On 23 January 2003, CASA airworthiness directive AD/BAe 146/102 became effective, requiring all operators of BAe 146 aircraft to action the requirements of BAE Systems (Operations) Limited, Inspection Service Bulletin (ISB) 21-156. That ISB relates to inspections of air-conditioning ducts. It has been found that the sound attenuating material used in the air-conditioning ducts can absorb oil and become a source of persistent air contamination.
• On 10 July 2003, CASA airworthiness directive AD/BAe 146/105 became effective, requiring all operators of BAe 146 aircraft to carry out a modification in accordance with BAE Systems Service Bulletin SB. 49-036-36019E. That modification provides an improved seal at the aircraft - APU interface, reducing the likelihood of contamination of cabin air due to ingestion of oil from the APU bay.

Operator

The operator of the aircraft involved in this incident previously incorporated various modifications to the cabin air system, APU and engines and introduced improved maintenance practices in an effort to minimise the occurrence of cabin fumes events.

More recently, the operator has undertaken to go beyond the requirements listed in CASA AD/BAe 146/102, by fully replacing the sound attenuating ducts of their entire BAe 146 fleet. On 30 April 2003 the operator advised that during the period since August 2002, when the first duct replacement was completed, there has been a reduction in safety reports received. It has not stopped air quality events occurring but has removed the occurrence of lingering odours.

The operator has also:

• commenced trials of a new bearing seal that has realised positive results during recent bench testing by the engine manufacturer
• refined a flowchart for use by engineering personnel that ensures that every regulatory aspect is completed during the maintenance investigation and certification process
• developed a stand-alone Cabin Air Quality Safety Report, as an adjunct to the Safety Occurrence/Incident Report currently in use. This allows the operator to focus on the specifics of air quality and what symptoms crews are experiencing
• employed a coordinator to be the company's single point of contact for liaison with external agencies such as CASA and the ATSB, regarding all air quality matters.