On 7 September 2003, two crew members on Pacific Wisdom were injured and one subsequently died. The two men fell about 12 metres to the bottom of an empty cargo hold after a scaffold on which they were working collapsed.

Summary

At 0400 on 21 August 2003, the Maltese flag bulk carrier Lancelot was off Diamond Head, on the New South Wales coast, heading south to Newcastle. The visibility was good and the second mate had earlier sighted the lights of a group of four fishing vessels to starboard. He used the automatic radar plotting aid (ARPA) to assess their movements. When the mate took over the watch, he too used the ARPA to plot the movements of the approaching fishing vessels.

The ARPA indicated that the nearest fishing vessel was on a reciprocal course and that its closest point of approach (CPA) was more than one and a half; miles¹ to starboard. Soon afterwards, however, the mate noticed that it was crossing from starboard to port. He altered the ship's course to starboard, clearing the other vessel, before ordering the original course resumed.

The mate then realised that the second fishing vessel was on a collision course, and he ordered the helm 'hard to port', attempting to steer away from it. However, the fishing vessel continued to close with the ship and, when the mate realised that a collision was imminent, he ordered full starboard rudder to minimise the angle of impact. At 0427 the two vessels collided.

The four fishing vessels had sailed from Forster earlier that night. At 0230, on board Jenabar, the second vessel in the group, the skipper, who had kept the initial watch, handed over to one of the deckhands. The watch changed again at 0330 when a second deckhand took over. The vessel, on autopilot on a north-easterly course, was heading for an area off Port Macquarie with the other fishing vessels. At 0425 the deckhand, who was seated at a table in the wheelhouse, said that he had checked the radar and had seen no sign of a ship. However, a minute or so later, when he looked out, he saw the dark shape of a ship, extremely close, on the starboard bow. Before he could get to the helm and disengage the autopilot, the fishing vessel had collided with the ship.

Though the fishing vessel was extensively damaged above the water line, none of its crew of four was injured. The ship turned to assist but, after being informed by Jenabar's skipper that assistance was not required, resumed its voyage to Newcastle. Jenabar returned to Forster to have the damage surveyed and to organise repairs.

This report concludes that:

• There was no evidence that Jenabar had made any significant change of course in the hour before the collision.
• The mate on Lancelot did not check compass bearings of the approaching fishing vessels to assess the risk of collision nor were his alterations of course to port to prevent the collision at about 0420, and again at 0423, appropriate.
• The moderate seas and the size and construction of Jenabar would have adversely affected its radar detectability.
• The bright deck lights on the fishing vessels obscured their navigation lights.
• The deckhand on watch on Jenabar at the time of the collision was not keeping an adequate or effective lookout and, as a result, only noticed the ship moments before the collision.

The report recommends that:

• Ship owners, operators, managers and masters, fishing vessel owners, operators and skippers should ensure that the requirements for watchkeepers to keep a proper lookout, visually and by radar are understood and complied with
• The National Marine Safety Committee (NMSC) and State and Territory marine authorities should review the minimum qualifications for watchkeepers on fishing vessels
• The NMSC and State and Territory marine authorities should ensure that guidance on procedures for watchkeeping and safety of navigation applies to all vessels
• Radar manufacturers' operating manuals should contain explicit instructions for setting up ARPAs for collision avoidance.

¹ Miles refers to nautical miles. One nautical mile = 1852 metres.

On 20 October 2003, a class society surveyor was conducting a safety equipment survey on board the Panamanian tanker Port Arthur at the bulk liquid berth at Port Botany, NSW. During the survey, the hooks of the starboard lifeboat released and the boat fell almost vertically, bow first, into the harbour. Its crew of four suffered various injuries.

Summary

At about 0001 on 29 May 2003 the 225 m long Panama flagged bulk carrier Asian Nova fouled the warps of the Australian fishing vessel Sassenach. The prawn trawler was dragged against the hull of the bulk carrier, damaging its port quarter and causing it to capsize and sink.

Sassenach's skipper lost his life as a result of the collision, his body was recovered from the sunken trawler on 5 June 2003. The deckhand was able to jump clear at impact and was rescued some five hours later by a searching fishing boat.

Immediately after the collision Asian Nova's master was called to the bridge, the vessel was stopped and the incident reported. Asian Nova remained on scene until released by Reefcentre.

The report concluded:

1. The third mate's course alteration to starboard just after 2330 was insufficient to provide an adequate passing distance astern of Sassenach.
2. The third mate's decision to make the relatively small alteration to starboard was made on the basis of information provided by the ARPA but was not in accordance with the company's instructions or good watchkeeping practice.
3. The third mate had sufficient sea room to make a bold alteration.
4. The proximity of the fishing vessel at the change of the watch meant that the third mate should not have handed over control of the watch until passed and clear of the fishing vessel.
5. Neither the second nor third mates followed the recommended practice, nor company requirements, or the ship's standing orders when handing over control of the navigational watch.
6. The second mate resumed the course marked on the chart before properly assessing whether it was safe to do so.
7. The second mate did not keep a proper lookout.
8. Inter-personal relations were possibly a factor in the deficient hand-over between the third and second mates.
9. The assessment by the fishing vessel crew that Asian Nova was passing clear was made on scanty information.

On 17 May 2003, three engineers were burned, one severely, while the Panama flag bulk carrier Medi Monaco was alongside in the port of Geelong, Victoria. The engineers were burned when the auxiliary boiler furnace 'flashed back' four times in succession during maintenance.

Executive summary

On 22 September 2002 the catastrophic failure of the main engine turbocharger disabled the cement carrier Goliath in Bass Strait. The replacement turbocharger failed in a similar manner on 12 February 2003, only four and a half months later, when Goliath was off Jervis Bay, again disabling the ship.

At 0107 on 22 September 2002, the Australian flag bulk cement carrier Goliath experienced a main engine turbocharger failure while the vessel was en route from Newcastle to Devonport when the turbocharger 'exploded' and disabled the ship's main engine.

At 1543 on 12 February 2003, while Goliath was en route from Devonport to Sydney, the turbocharger failed again. This time, the failure was witnessed by the second engineer who heard the rapid acceleration of the turbocharger before it exploded. Once again, the turbocharger had been damaged beyond repair and the ship was disabled.

The investigation report concludes that both turbocharger failures were similar and had occurred when the compressor discs burst due to overspeed. While it is not possible to state with certainty, the most likely mechanism leading to both overspeeds was a scavenge fire in the engine.

The ATSB delayed the release of these final investigation reports because of litigation involving the parties and because the investigations preceded and were not protected under the Transport Safety Investigation Act 2003.

Summary

On the morning of 26 February 2003, the Liberian flag bulk carrier, Pactrader, arrived at Thevenard from Lumut in Malaysia and embarked a pilot for berthing at Thevenard wharf. The ship entered the port and made fast, without incident, port-side-to the northern side of the wharf to load a cargo of gypsum for Auckland, New Zealand. The cargo was loaded as planned and completed during the early hours of 28 February. Pactrader remained alongside the wharf after completion of cargo operations waiting to sail on the high tide predicted for early the next morning, 1 March.

The pilot boarded Pactrader again at midnight, 28 February for the departure. The pilot and master discussed the outward pilotage and, at 0006 on 1 March, the ship commenced singling up the mooring lines as per the departure plan. A single tug was pushing up on the ship's starboard side at about midships. The wind was from about the south-south-west at 20 knots.¹ The tide was setting to the north (the last of the flood) at up to 0.5 knots.

At 0012 the last mooring line was let go and the ship started moving from the berth. As the ship moved ahead it was set to starboard by the tide and wind and, a short timelater, it ran aground along its starboard side when its stern was just clear of the end of the wharf. It had only moved about one ship length ahead.

At 0224 on 4 March, the ship was refloated with the assistance of a salvage tug despatched from Adelaide and returned alongside the wharf. Divers and a classification society surveyor inspected the ship and, when they indicated that there was no significant damage and that the ship was seaworthy, Pactrader was released by AMSA² to continue its voyage to New Zealand.

The report's conclusions include:

• The pilot did not make sufficient allowance for the significant forces acting on the beam of the ship at sailing time.
• The tug was not used to best advantage given the prevailing circumstances.
• The planning of the sailing operation was inadequate in that neither the master nor the pilot reviewed alternative strategies for unberthing, such as tug utilisation, engine movements and rudder usage.
• The 'soft nose' at the end of the wharf discouraged the pilot from remaining close to the wharf during his outward movement.

The report makes a recommendation that:

Flinders Ports should undertake a risk assessment of the Port of Thevenard, taking into account the variable environmental factors, together with infrastructure and pilotage ongoing training experience issues.

¹ 1 knot = 1 nautical mile (1852 metres) per hour.
² AMSA is the Australian Maritime Safety Authority.

Summary

At 1612 on 21 March 2003, the Australian flag roll-on/roll-off cargo vessel Searoad Mersey departed from Melbourne on a scheduled service to Devonport in Tasmania. By 1924 the vessel had cleared Point Lonsdale, at the entrance to Port Phillip and was en route to Devonport.

At 2118:50 the engine room alarm sounded in the duty engineer's cabin, followed shortly after by the fire alarm. During his subsequent inspection of the engine room the duty engineer found a main engine connecting rod lying on the deck on the inboard side of the port main engine. The port main engine had stopped. There was oil lying all over the floor plates, on and around the engine, and on the deck head above the engine. It was apparent that there had been a catastrophic failure of the number one piston assembly, cylinder liner and cylinder cover.

A short time later the port main generator overheated and shut down which caused the ship to black out. The port generator had stopped as a result of the damage to the port main engine which had caused a large loss of cooling water from the common cooling system.

By about 2215 the various engine room systems had been stabilised and checked by the engineers. The decision was made to return the ship to Melbourne and by 2230 the starboard main engine had been started and the vessel was proceeding under its own power. Searoad Mersey arrived alongside Webb Dock in Melbourne at 0715 on 22 March 2003 where repairs to the damaged port main engine commenced.

The report makes the following conclusions relating to the failure of Searoad Mersey's port main engine:

• A casting flaw found in the piston skirt fitted to number one unit initiated a fatigue crack which eventually caused the piston to fail in service.
• The vessel's maintenance system did not include a system for tracking the total operating hours of the main engine piston assemblies.
• The vessel's maintenance system did not include a procedure for crack testing the piston skirts in the areas stipulated by the manufacturer in their service bulletin Piston overhaul of VASA 32 engines after 24 000 running hours and later overhauls.
• The critical manufacturer's Main Components maintenance intervals for VASA 32, 32LN and 32GD bulletin had not been provided to the vessel or its technical manager.
• The evidence strongly suggests that Wartsila Vasa 32 engines have had a history of piston skirt failures similar to that experienced by Searoad Mersey.

The report makes recommendations to the operators of Wartsila Vasa 32 engines and to Wartsila NSD in relation to the servicing of piston assemblies and the distribution of engine service bulletins.

Accident sequence

On 11 November 2003, a Piper Seneca, registered VH-CTT, was seen to diverge right during a go around from runway 11 Right at Bankstown Airport, NSW. It maintained a constant height above the ground and; when about halfway along the runway, the aircraft's nose lifted and it banked steeply to the right before impacting the ground in a near vertical nose-down attitude. A student pilot in the left seat and an instructor pilot in the right seat were the only occupants.

A fire commenced when the aircraft impacted the ground or shortly after the impact. The fire intensified after the aircraft came to rest. The main cabin door, located over the right wing, separated from the aircraft during the accident. The instructor pilot vacated the aircraft through that opening about 30 seconds after the aircraft came to rest. The student pilot was fatally injured. The instructor pilot received severe burns and was treated in hospital for three and a half weeks before succumbing to those injuries.

Effectiveness of fire fighting services

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 fire fighting arrangements for Bankstown Airport, as they affected transport safety at Bankstown Airport on 11 November 2003'. Effectiveness is defined as 'serving to effect the purpose; producing the intended or expected result'.¹ The instrument was issued to the ATSB on 15 December 2003.

¹ Macquarie Dictionary (revised third edition), The Macquarie Library, NSW, 2003.

On 02 April 2003, a Bangladesh registered McDonnell Douglas DC-10-30, S2-ACR, was climbing through 2,700 ft following departure from Chittagong - Patenga Airport, Bangladesh when the No. 1 engine failed. The EGT exceeded 1,000ºC and the engine was shutdown. The aircraft returned for an uneventful landing.

The flight data recorder (FDR) was recovered from the aircraft in April 2003. The Civil Aviation Authority of Bangladesh (CAAB) was responsible for investigating this accident and appointed an investigation committee which included the aircraft operator. The CAAB requested ATSB assistance in the recovery of data from the FDR. The Executive Director of the ATSB approved the request. The CAAB also requested that some of the investigation committee be present during the download and recovery procedure. To protect the information supplied by the ATSB to the CAAB, the operator and investigation work undertaken to assist these agencies, the ATSB initiated an investigation under theTransport Safety Investigation Act 2003.

In 2007, due to the continuing uncertainty of attendance by the Bangladesh representatives, the ATSB downloaded the FDR to enable its return to the operator. A factual report describing the recorded data found on the FDR was prepared and provided to the CAAB.

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Released in accordance with section 25 of the Transport Safety Investigation Act 2003.