A Saab 340B aircraft, registered VH-EKN, was being operated on a scheduled flight from Orange to Sydney, NSW. The crew reported that, shortly after take-off, as they were setting climb power, they heard a `bang' similar to the sound of a compressor stall. The left engine gauges indicated zero torque and excessive inter-turbine temperature (ITT). The left over temperature and ignition lights illuminated, followed by a master warning annunciation. The crew carried out the engine failure procedure and, having shut down the left engine, returned to Orange and landed.

Eight days later, the crew of another Saab 340B, registered VH-OLM, operated by the same company, reported that shortly after take-off from Orange, the right engine displayed characteristics consistent with a compressor stall (ATSB Occurrence 200300078). On that occasion, after the crew carried out the appropriate checklist procedures, normal engine operation and indications were restored and the flight continued to Sydney without further incident.

The affected engines from both aircraft were removed for examination at the manufacturer's overhaul facility. The engine manufacturer, after reviewing the recorded engine data, identified that a number of similar conditions, that may have affected the engines, had existed during both flights. Both events had occurred on the first flight of the day. On both occasions a significant temperature inversion existed at approximately 1,000 ft above ground level, and the compressor stalls occurred when the crews were adjusting the power setting from take-off power to climb power. The engine manufacturer's assessment concluded that a combination of environmental conditions and engine operating procedures had led to both events and made several recommendations to the operator.

Those recommendations included changes to both the maintenance program and to the operation of the engines. They called for compressor washes to be conducted every 200 hours, or more frequently as determined by the operating environment. In the weeks prior to the occurrences there had been significant airborne particles in smoke from bushfires. That may have contributed to contamination of the compressor blades and consequently the engine's susceptibility to compressor stalling. The engine manufacturer also recommended that the operator consider amending the take-off configuration to include selecting the Environmental Control System (ECS) to ON for the first flight of the day. Use of the ECS opens the bleed air valves and reduces the likelihood of compressor stalls. Its use on the first flight of the day would counteract the conditions of temperature inversions that were usually more pronounced in the early morning.

Additionally, the engine manufacturer issued an alert service bulletin, SB CT7-TP S/B 72-A0328, Revision 1, dated 8 April 2003, which required checking that the correct rigging schedule of the engine variable inlet guide vanes (VIGV) had been implemented. Rigging of the VIGV to the specified schedule was used to reduce engine susceptibility to compressor stalls in the range of environmental conditions encountered during routine operations. The operator reported that, although the requirements of the service bulletin had been incorporated into its engine maintenance program, the rigging schedule check had not been completed on the occurrence engines. The service bulletin was subsequently incorporated into the USA Federal Aviation Administration Emergency Airworthiness Directive 2003-08-52, dated 15 April 2003 and subsequently mandated in Australia by the Civil Aviation Safety Authority as Airworthiness Directive AD/CT7/9 on 16 April 2003.

The operator reported that its maintenance program and standard operating procedures had been changed in accordance with the engine manufacturer's recommendations and that all engines in its fleet had been inspected in accordance with the requirements of the engine manufacturers service bulletin. Subsequently, there have been no further reports of compressor stalls in the climb after take-off.

On 16 January 2003, while conducting pre-flight checks during passenger boarding, the flight crew of a Boeing 737-700 aircraft, registered VH-VBS, detected a pungent burning smell. The pilot in command contacted the company by radio and requested that an aircraft engineer attend the aircraft.

The cabin supervisor advised the pilot in command that she could smell fumes near the forward door. The pilot in command then instructed her to disembark the passengers.

The first officer reported feeling faint and the pilot in command felt dizzy and weak at the knees as he stood to leave the flight deck. The pilot in command also reported experiencing shaking hands, watering eyes and tingling fingers. He opened the windows in the flight deck for ventilation and contacted air traffic control to request paramedic assistance. The cabin supervisor administered oxygen to the pilot in command and the first officer, but when the pilot in command attempted to stand, his legs collapsed from under him.

Airport Rescue and Fire Fighting services attended the aircraft to assist the pilot in command and requested an ambulance. The pilot in command was transported to hospital for observation and was advised by medical personnel that he showed signs similar to mild carbon dioxide poisoning.

A subsequent engineering examination of the aircraft found a burned diode on the master dim and test module circuit board on the P6 panel, located behind the first officer's seat. The plastic cased diode was the only component damaged on the circuit board. Failure analysis conducted by the aircraft manufacturer determined that the diode failure mode was due to excessive heating while under electrical load.

An examination of the circuit board conducted by the ATSB determined that the diode used on the master dim and test module circuit board was a plastic cased component which differed from the diode outlined by silk screening on the circuit board of the master dim and test module. The original diode specified for use was a hermetically sealed, metal cased, glass diode with heat dissipation properties superior to the plastic cased diode, however both diodes were approved by the aircraft manufacturer for use in this application.

The aircraft manufacturer conducted further testing on a diode with the same part number from the event master dim and test module to identify major components of combustion and reported the following:

`The plastic cased diode was manufactured of Bisphenol-A epoxy resin, which decomposed to form Phenol (C6H5OH) and variations of Phenol, eg. Methyl phenol (C6H4CH3OH). The mass loss at 427 degrees C was approximately 12 percent, as measured by thermal gravimetric analysis (TGA).'

The flight crew were physically affected as a result of exposure to the fumes produced from the combustion of the failed diode on the master dim and test module.

Local safety action

The operator has amended the company's operations manual to correctly reflect the types of fire buckets used on the company's individual helicopter types.

The operator has standardised the position of the external load jettison switch on the different helicopter types used by the company in fire fighting operations.

The company's operations manual now details the type of safety clothing to be worn by pilots when engaged in water-bombing operations in company helicopters. The clothing specified includes the wearing of cotton or better, flying suits, approved helmets and comfortable fitting life jackets. Inflatable life jackets have been positioned in each helicopter for that purpose.

The operator has introduced a system for tracking the fitment and maintenance history of cargo hooks fitted to company helicopters.

ATSB safety action

In a briefing to the Civil Aviation Safety Authority, the ATSB drew attention to the fact that the occurrence bucket was not of standard manufacture, and highlighted the possible effects of the use of non-standard buckets by helicopters during fire fighting operations.

As a result of this occurrence, the Australian Transport Safety Bureau issues the following safety recommendations:

Recommendation R20030219

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority, in conjunction with the relevant industry associations, highlight the safety benefits to helicopter pilots and crew of the wearing of personal protective equipment, such as helmets and personal flotation devices when carrying out water-bombing in support of fire fighting operations, through safety promotion initiatives.

Recommendation R20030220

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority, in conjunction with the relevant industry associations, assess the desirability of a requirement for Helicopter Underwater Escape Training for specialist aerial work operations, such as water-bombing in support of fire fighting operations.

Recommendation R20030221

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority, in conjunction with the relevant industry associations, consider advising Australian helicopter operators involved in water-bombing in support of fire fighting operations, of the need to review the type of fire-buckets used to ensure that they comply with the bucket manufacturer's guidance for use on helicopter types and to ensure that the fire-buckets are appropriately maintained.

¹ Issue Date: January 2003.
² Issue Date: May 2002.

Related Documents: | Media Alert |

Local safety action

As a result of its investigation, the operator has:

• increased the frequency of maintenance inspections of the wiring on the main landing gear, including the junction boxes, and introduced a detailed inspection that includes removal of the junction box cover, inspection of the connections and resealing of the cover, and
• amended the 'Loss of Cabin Pressure (Decompression)' section of the flight operations manual to require cabin crew to use portable oxygen for at least 30 seconds to one minute after flight crew advise that an aircraft has reached a safe altitude.

Executive summary

The Victorian Minister for Transport, the Hon Peter Batchelor, MP requested the Australian Transport Safety Bureau (ATSB) to undertake an independent investigation into the collision between steam locomotive K183,and its consist, and a loaded 'B-double' truck at the Saleyards Road level crossing, Benalla.

The investigation was conducted in accordance with the provisions of the Transport Act 1983 (Victoria) as amended.

The Terms of Reference for the investigation were:

The Investigation will examine all relevant matters including:

1. The immediate events leading to the collision, including determination of the relative contribution of rolling stock, infrastructure and operating procedures.
2. Train maintenance systems.
3. The track authority.
4. Qualification,training and re-training procedures for relevant staff.
5. Scheduling of train staff to heritage and special interest.
6. Operating procedures and effectiveness of such procedures.
7. Medical condition of the rail safety workers involved in the collision.
8. Post collision emergency management arrangements and procedures.
9. Conspicuity of the engine and tender.
10. Any specific issues relating to the Saleyards Road crossing and its approaches.
11. Final report format to follow the model Draft AS Guidelines for rail safety investigations.

At about 1250 on Sunday 13 October 2002 an historic steam passenger train, 8382 carrying a wedding party, collided with a fully loaded B-double flour truck on a railway level crossing at Benalla, Victoria.

The B-double truck did not give way and crossed the level crossing in the path of train 8382. The evidence to the investigation was that the B-double driver did not see the train until he was actually crossing the rail track. The train was so close that he did not have time to accelerate his vehicle clear. The probability is that the train crew had no reason to suppose that the B-double would not stop at the crossing and as the B-double started to cross the train crew could do nothing to avoid or mitigate the collision.

The train driver, fireman, and one footplate¹ visitor on the locomotive were fatally injured. Another footplate visitor was seriously injured as a result of the collision. No other injuries were reported.

The collision occurred on the Saleyards Road railway level crossing located approximately 1.1 kilometres from Benalla township on the Benalla - Yarrawonga/Oaklands branch line. The level crossing was a passive crossing protected by 'give way' and other warning signs on the road approaches. As a result of the collision, locomotive K183 and tender, carriage DT319 (power supply van) and the leading bogie of carriage BK712 derailed.

The B-double truck was owned and operated by Greenfreight Pty Ltd based in Wodonga. The train was operated by West Coast Railway. The train locomotive was owned by the Victorian Government and managed by Steam Rail Victoria Inc based in Newport. The carriages from the train were owned and maintained by West Coast Railway.

After impact, the train locomotive left the tracks and ploughed into soft earth next to the railway line. The locomotive was tipped onto its side and the tender was pushed into the locomotive cabin. The tender also distorted the crew compartment roof shearing the bolts holding the boiler safety valve assembly. High pressure steam vented into the atmosphere and into the crew compartment.

In accordance with the Terms of Reference, the investigation was limited to factors directly affecting safe rail operation. Other factors directly involving the B-double truck do not form part of this report.

The train and track infrastructure and maintenance systems were found to be in operational condition and conducted in accordance with accepted procedures. The train was running on an appropriate track authority. The qualifications, training and re-training procedures were appropriate and had been followed. The scheduling of train staff was not a factor in the collision, though the report recommends a review of rostering for special trains by the Rail Tram and Bus Union, particularly crews in secondary employment. The medical condition of the rail safety workers involved met the required standard and no medical factors were implicated in the cause of the collision. Post collision emergency management and response procedures were effective and efficient.

The locomotive was displaying its headlight on high beam. The train was so close to the truck as they both approached the crossing, and was also sounding its whistle, it is not possible to determine what level of conspicuity, if any, would have alerted the B-double driver.

A number of factors were identified as being critical to safe railway operation at Saleyards level crossing. The level of protection at the Saleyards Road level crossing could be improved for heavy goods vehicles accessing Saleyards Road from the east. The sighting distance, based on a train speed of 80 kph, may be insufficient to allow a heavy goods vehicle to cross and clear the level crossing in safety.

Additionally, the risk assessment process used by VicRoads and the Benalla Rural City Council to determine the level of protection used at railway level crossings on approved B-double routes could be improved.

The investigation makes several safety recommendations to the Victorian Department of Infrastructure, VicRoads, Benalla Rural City Council, Freight Australia, West Coast Railway, Rail Tram and Bus Union, Standards Association of Australia, and the Victorian Level Crossing Committee. The recommendations relate to reviewing railway level crossings on B-double routes, footplate visitors, fatigue management, and Australian Standards. One review should encompass level crossing protection treatments and include any significant changes such as traffic flow and type, speed and vegetation. The active involvement of the rail industry in level crossing issues is also recommended. A community education programme is recommended to address the dangers of railway level crossings to road and pedestrian users.

Additional recommendations include consideration of the type of road and rail traffic as part of the Australian Standard for level crossing protection.

For copies and enquiries of the report please contact the Victorian Department of Infrastructure, Public Affairs Division. Telephone (03) 9655 6263.

1. Footplate refers to the locomotive cabin of a steam locomotive.

Executive summary

At 15:33:01 on 24 October 2002 passenger train 5AL8 collided with a car and scheduled bus on the Salisbury Interchange controlled level crossing on Park Terrace. As a result of the accident four people were killed and 26 injured. A small sedan car and the bus were effectively destroyed. In addition two other road vehicles were damaged. The locomotive and the first vehicle of the consist sustained minor damage. There was no derailment of any rail vehicles.

The standard gauge track owned and operated by ARTC, runs parallel to two broad gauge tracks operated by TransAdelaide. These three tracks share the northern rail corridor, which runs through Salisbury.

As train 5AL8 approached the level crossing on Park Terrace from Adelaide, the driver and co-driver saw stationary road vehicles across the standard gauge track. The driver of the locomotive acted promptly in sounding a sustained warning on the horn, applying the emergency brakes and putting the throttle to idle. Two cars reversed clear of the track to a position between the standard gauge and the TransAdelaide tracks. The small sedan and the bus were unable to move because of other vehicles, though the driver of the sedan managed to jump out of her car and run clear.

The sighting distance from the train cab to the standard gauge crossing was approximately 250 m. The train could not stop in time to prevent the collision and came to a halt 183 m to the north of the Park Terrace level crossing.

The report concludes that the locomotive, rolling stock, rail, signalling infrastructure and the boom gate barriers at the crossing, up to the time of the collision, were in good condition and operated as designed.

Prima facie the road vehicles stationary on the rail tracks had entered the crossing when the drivers could not drive through the crossing because the crossing, or road beyond the crossing, was blocked. On this view the immediate causal factor was the non-observance of the Australian Road Rules 1999. From a systemic point of view, however, the accident was more complex with a number of causal factors relating to:

• road design (the number of entry/exit points);
   
• road traffic lights and the inter-link with the level crossing warning system;
   
• the width of the crossing;
   
• probable lack of awareness by road vehicle drivers of the road traffic rules as they relate to level crossings;
   
• the lack of 'near hit safety' reporting at level crossings;
   
• the lack of a focused body to oversight and undertake risk based assessments of level crossing safety.

The investigation found little evidence from records that Park Terrace level crossing was of public concern from a rail safety perspective. There were recorded concerns and direct observation that, when the traffic lights at the Salisbury Highway intersection were red, traffic did, on occasions, queue over the Park Terrace crossing. On the basis of direct observation, such an accident at Park Terrace was foreseeable.

The response to the accident by the emergency services and railway companies was timely. The first emergency persons to respond crawled beneath train 5AL8, a dangerous but understandable reaction to reach the injured. Police established tight control at the level crossing, but commuters and onlookers were able to access the adjacent lengths of track although the TransAdelaide passenger service continued running.

The report details 13 key conclusions:

1. The immediate cause of the collision between train 5AL8, the white Nova Holden WOJ 601 and Serco bus number 246 (VYV 786) was that the drivers of the road vehicles entered the level crossing, in contravention of the Australian Road Rules, at a time when they were unable to drive through the crossing and were blocked by other vehicles.
    
2. The driver and co-driver of locomotive NR 34, reacted promptly in sounding a warning of train 5AL8, applying emergency brakes and returning the throttle to idle. Neither the driver nor the co-driver could have taken any action that would have prevented the collision with the white Holden Nova or Serco bus number 246 (VYV 786) operating the 401 service.
    
3. Locomotive NR 34 and the 25 vehicles of the consist comprising train 5AL8 were in working order, were properly maintained and were fit for purpose. There were no deficiencies in the consist that contributed to the collision.
    
4. The railway infrastructure (track circuitry, signals, level crossing warning signals and the boom barrier) worked as designed within standard time limits.
    
5. Following the collision, the on train staff servicing the passenger vehicles of train 5AL8 acted promptly to assist the injured at the scene of the accident until they were able to relinquish care to the emergency services.
    
6. The response of the emergency services was timely.
    
7. The road traffic lights at the junction of Park Terrace, Gawler Street, North Lane and the Bus Interchange and the link with the level crossing warning signals worked as designed.
    
8. The road traffic signals at the Salisbury Highway/Park terrace intersection did not work as designed or as recommended by Australian Standard AS1742.14, in that the link with the railway crossing had been broken at some time and the special queue-clearing phase was not operational. There was no effective maintenance or checking system in place to monitor the continuing operation of the queuing phase of the lights and the links with the traffic Control Centre. The non-operation of the special queuing phase was probably not a significant factor in the collision of 24 October.
    
9. The road traffic on the western side of the level crossing for traffic crossing Salisbury Highway or turning onto Salisbury Highway was halted at the traffic signals causing traffic to back-up over the level crossing.
    
10. The backing up of westbound traffic across some part of the level crossing was not unusual and had become an accepted factor of driving in Park Terrace.
     
11. The complexity of the Park Terrace road system over a distance of 175 m from the bus interchange turning just east of the level crossing to the stop line at Salisbury Highway, increased the probability of road vehicles backing up to the level crossing in that:
    
    - Road vehicles exiting or entering the Station car park and crossing or from the outside westbound lane, right turn lane, or attempting to enter the eastbound lane potentially restrict traffic flow.
    
    - Road vehicles exiting or entering the Eureka Tavern car park across the traffic.
    
    - Heavy traffic southbound on the Salisbury Highway restricts the opportunity for traffic in the left turn lane to join the Salisbury Highway.
     
12. Based on observed behaviour of road vehicle drivers, a collision between traffic queued at Park Terrace and a train was foreseeable. However, the absence of any specific reports of near miss incidents or accidents between trains and vehicles at Park Terrace had led to a belief that there was no significant risk.
     
13. The lack of initial site control following the collision and during the immediate emergency phase increased the risk of pedestrian onlookers being struck by trains, either through any possible movement of train 5AL8 or the TransAdelaide services.

The Salisbury level crossing review report by Mr Vince Graham of January 2003 made a number of recommendations (attachment 2), which are endorsed by this report. Mr Graham also made interim recommendations in early November that the track speed 500 m on either side of Park Terrace should be limited to 50 km/h. This report recommends that train speed restrictions introduced as a safety measure in the vicinity of level crossings should be further reviewed taking into account the new traffic arrangements and safety measures and the different types and characteristics of trains on the standard and broad gauge tracks.

In addition the report recommends:

RR20030001
Road traffic signals adjacent to level crossings be regularly monitored to ensure that all links and functions within the system are operational.

RR20030002
Traffic flows through Park Terrace should be measured to assess the practicality of extending the timing on a link to force westbound traffic from Park Terrace to take account of the worst case timing scenario, while maintaining the existing timing of the boom barrier closing.

RR20030004
The rail industry should attempt to devise a confidential hazard reporting system that embraces the whole industry in the one system.

RR20030005
ARTC and TransAdelaide review their notification and communication procedures when responding to accidents on the shared rail corridor, particularly between the train control centres and the accident site.

RR20030006
The rail companies and emergency services examine ways in which early effective site control and control of public access might be further improved.

RR.20030007
Standards Australia develop a standard for the marking of a 'do not enter unless clear' area across level crossings, with a view to providing appropriate cues to help road vehicle drivers assess the space available on the other side of the crossing.

RR20030008
Transport SA should review the provisions of the Road Traffic Regulations 1996 to determine whether or not any existing penalty
covering the drivers of vehicles that stop or park within the boundary of rail level crossings is appropriate.

Note: This investigation was undertaken by the ATSB on behalf of the State Government of South Australia. Media enquiries should be directed to the SA Government's media contact, Emma Brown (08) 8204 8261.

Executive summary

At about 0914 on Tuesday 18 June 2002 a scheduled suburban electric passenger train number 1648, on an up journey, collided with an approaching scheduled suburban electric empty train number 1025, on a down journey, on a section of single line, 772.3 metres south of Epping Railway station. Passenger train 1648 had a driver and 16 passengers on board, while the empty train 1025 had a driver and two other drivers travelling as passengers with the train. Train 1025 was traversing a single line section and crossing into Epping Yard at the time of the collision. The leading cab on train 1025 had just traversed a set of points and passed the fouling point for both the main line and the crossover line into Epping Yard, moments prior to the collision. Train 1648 had departed Epping platform and was advanced into the single line section on a restricted indication, and had subsequently passed signal EPP121 that was indicating stop. Both trains and infrastructure, including signalling and tracks, were operated by Melbourne Transport Enterprises, through Connex Trains Melbourne (CTM) and Alstom Melbourne Transport Limited (AMTL).

Emergency services, including the Police, Fire and Ambulance services attended the scene. The driver of the passenger train suffered bruising to his right upper arm, but was discharged from hospital on the day of the collision. Minor injuries to passengers were reported. No passengers were hospitalised.

The evidence available, including an expert medical assessment, suggests that the driver of train 1648's performance was impaired by his physically 'unwell' condition. He could not recall events between the departure from Epping station on the up journey and the point that the train passed signal EPP121 at stop, a period of about one minute. As a result, signal EPP121 was passed at stop and a collision occurred. Train 1648 was travelling at about 60 km/h and train 1025 at about 12 km/h, at the point of initial impact.

Signal distances at Epping

There are safeguards or defences to protect against such an accident. On this occasion the defences in place failed to prevent the accident. A number of defences were identified as being inadequate in terms of design or application.

The investigation established that train maintenance was not a factor in the accident. In addition, the signalling system, which incorporates automatic train stops, operated within its design criteria. However, the design criteria of the signalling system was such that it could not maintain a minimum safety margin to prevent the collision, given the speed of the passenger train involved.

Trains are fitted with pilot valves (including a dead man's handle), so that in the event that a driver becomes incapacitated the train should be brought to a halt. On this occasion the driver of train 1648 had become incapacitated but the pilot valve did not activate by applying the train's emergency brakes.

The performance of the driver of train 1648 was impaired by migraine symptoms, and possibly treatment, and the effect of stressful personal circumstances. The driver's history of migraine had been declared during regular medical assessments but the medical guidelines did not address the symptoms or treatment for a potentially incapacitating illness. The report also addresses factors that contribute to the driver working when he was unwell.

The Investigation Team has also reviewed the factors surrounding the Footscray collision on 5 June 2001 (ATSB rail investigation report no. 11-01) and considers this event to contain some similar safety issues.

A number of safety actions have been taken or are underway through the Victorian Department of Infrastructure.

The report's recommendations on pages 41 and 42 relate to:

• the design of the signalling system;
• the train working procedures for trains operating on single line sections of track;
• the medical fitness/assessment guidelines;
• the medical conditions that can impair or incapacitate a train driver;
• driver sign-on procedures;
• sick leave policy;
• emergency procedures; and
• recommendations contained in the ATSB Footscray investigation report.

Copies of the report are available from the Director Public Transport Safety, Victorian Department of Infrastructure, Plaza Level, 80 Collins Street, Melbourne or by telephoning (03) 9655 6402.

Summary

On 8 December 2002, Ma Cho arrived in Devonport, Tasmania, to discharge a part cargo of fertiliser at number four berth on the western side of the river.

On 9 December, the master made the decision to conduct an abandon ship drill before the vessel was due to depart for Geelong. The drill commenced at about 1540 and the starboard lifeboat was prepared for lowering to the water.

At approximately 1548 the mate reported that the crew inside the lifeboat were seated and had fastened their safety belts. Lowering of the boat then commenced with one of the crew operating the davit winch brake from the deck. When the boat had been lowered approximately two metres from the davit head the after on-load release hook suddenly opened, releasing the after fall. The lifeboat's stern fell to leave the boat suspended vertically by the remaining forward fall with its stern swinging approximately five metres above the water. The boat crew were shaken by the incident but remained secured in their seats inside the now vertical lifeboat. The second mate had sustained a small cut over his left eye.

After the crew had disembarked, the lifeboat was lowered to the water to allow the on-load release system to be inspected. It was found that the cable operating the after hook was not properly secured by the saddle clamp under the operating unit. Each time the actuating handle was operated, lost motion was induced by the cable sliding through the clamp and this meant that the after hook was not resetting fully. The cable clamp was temporary repaired and then the lifeboat was housed in its davit. Ma Cho was subsequently cleared to complete the voyage to Geelong.

The report conclusions include:

• The cable clamp securing the aft hook's operating cable adjacent to the operating mechanism had been modified which resulted in lost motion within the cable.
• As a result of the lost motion in its operating cable, the after hook had not been fully reset when the previous lifeboat drill was conducted on 2 November 2002.
• The design of the on-load release system was flawed with respect to the hook locking mechanism.
• The ship's safety management system was deficient with respect to both the operating and maintenance instructions and to crew training on the on-load release system.

The report makes a general recommendation to ISM Code accreditation authorities regarding ship safety management systems as they relate to on-load release systems. The report also recommends that the lifeboat manufacturer and classification societies review the design of the on-load release system.

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.