On 10 December 2002, the third engineer aboard the bulk carrier Golden Bridge was killed whilst engaged in maintenance work in the engine room. A perspex sightglass exploded into his face when the fresh water generator he was working on was accidentally pressurised. The explosion blew the engineer backwards and he struck his head causing a fatal injury.

On 14 September 2002, two men were found drifting in a liferaft 30 miles east of Moreton Island, Queensland. The two men had been in the liferaft since their vessel, Tamara, had sunk some 14 days previously.

Summary

On 28 July 2002, the Netherlands flag general purpose cargo vessel Marion Green, of 11 894 gross tonnes, carrying 6000 tonnes of cocoa beans, was off the coast of Western Australia on passage from Fremantle to Adelaide.

At 1130 that morning a fire alarm was activated by the smoke detection system in No. 2 cargo hold. After a brief inspection through the open hold access by the mate and second mate, during which they saw some flames on top of the cargo, all openings were closed and the discharge of CO2 from the fixed firefighting installation was started. By 1715 that afternoon, 86 bottles of CO2 had been released into the hold.

At 0700 on the following day, a slight increase in hatch cover temperature was recorded. The master was advised by the vessel's managers to discharge the remaining 11 bottles of hold CO2 and to divert to Albany as a port of refuge.

Marion Green berthed in Albany at 1615 on 29 July. Additional bulk CO2 was delivered to the ship from Perth and this, too, was discharged into the hold over the next few days. On the morning of 31 July, the after panels of No. 2 hatch were opened for an inspection. Flames were seen on the top layers of cargo, and these were doused by the fire brigade after which the hatches were again closed, and more CO2 discharged into the hold. At 1400 the following day, 1 August, the hatch covers were once more opened and, after further flare-ups had been doused by the fire brigade, stevedores began discharging the cargo into sand bungs on the wharf. By 10 August all the cocoa bean cargo had been discharged and Marion Green sailed for Adelaide.

The report concludes that the investigation was unable to determine, exactly, the cause of the fire, but four distinct possibilities were examined. These were:

• Self-heating of the cargo due to fungal growth
• Ignition caused by the flammable characteristics of the phosphine used for fumigating the cargo
• Cigarette ends discarded in the hold during loading of the cargo in Makassar
• A cargo light that had been left in the hold on sailing from Makassar

It also concludes that:

• the vessel's 'no smoking' policy was not properly enforced during cargo loading
• insufficient CO2 was released into the hold in the early stages of the fire
• inadequate information on the hazards of shipping cocoa beans was provided to the ship's staff and
• the response to the fire, once the vessel was alongside, lacked co-ordination and a clear understanding of who had the responsibility and authority for dealing with it.

The report recommends that:

• the shipowners enforce a strict 'no smoking' policy in the vicinity of cargo operations
• the shipowners ensure that ship's masters are provided with all relevant information on the hazards of carrying organic cargoes and their fumigation
• shippers, stevedores and ship's officers ensure that adequate ventilation channels are provided when stowing such cargoes and
• deck watchkeeping officers log the isolation and stowage of all electrical equipment from the holds on completion of cargo operations.

Summary

At 1032 on 25 August 2002, the Korean flag bulk carrier Hanjin Dampier departed from the Hamersley Iron wharf at East Intercourse Island in the port of Dampier, Western Australia. A pilot was conducting the navigation of the ship which was loaded with iron ore and had a displacement of 233 158 tonnes with draughts of 17.94 m forward and 18.10 m aft.

At 1127, just after Hanjin Dampier passed number four Hamersley Channel beacons, two of the ship's three main generators stopped, leaving only one generator running and connected to the main switchboard.

At 1152, with the ship 1.3 miles east of Courtenay Head and making headway at a little over eight knots, the third generator's circuit breaker tripped open. With the total loss of power to the main switchboard the main engine stopped, and the ship lost steering. The rudder had stopped at 10 to starboard. As the ship slowed, it started to turn to starboard towards shallow water. The emergency generator failed to start automatically and, as a result, steering was not restored for some four minutes.

At 1202, Hanjin Dampier touched bottom. By about 1203 the ship had come to a stop on a heading of 047(T) in a position between the charted deep draught track and the Woodside Channel (20 29.7 degrees, 116 43.3 degrees).

Hanjin Dampier was refloated on the next spring tide, on 8 September, using five tugs and after 5000-6000 tonnes of cargo had been discharged. The ship had suffered only minor damage to the bottom shell plating and the ship was cleared by the classification society to continue trading until the next scheduled drydocking.

The report's conclusions include:

• The ship grounded as a direct result of the loss of steering;
• Steering was lost when the ship's three main generators tripped off the main switchboard due to water contamination of their fuel supply;
• The emergency generator failed to start automatically due to a fault in one of its starting batteries;
• The crew took no action nor instigated any contingency plan in the time leading up to the blackout when they could have reduced the risk to the ship; and
• Lack of effective communication between the chief engineer and master contributed to the crew's failure to take any pre-emptive action.

The report makes three recommendations involving the testing of emergency power arrangements, bridge resource management training for engineers and the use of tugs in the port of Dampier.

Summary

At 0318 on 19 July 2002, the Liberian flag container ship ANL Excellence embarked a pilot off Point Cartwright, Queensland, for the passage to Fisherman Islands container terminal in the Port of Brisbane. After arriving on the bridge, the pilot set up a portable electronic chart display equipped with a differential global positioning system, to allow him to independently monitor the passage to the berth.

The pilotage proceeded routinely. There were no other movements within the port or the approach channels during this time. The weather was reasonable, though visibility was reduced at times by passing rain showers.

At 0518, ANL Excellence passed beacon E1 and entered the East Channel. Rain was falling at this time and the bridge window wipers were operating. Ahead, the starboard lateral beacon E3 and the port lateral beacons E2 and E4 could be seen. A temporary, starboard lateral buoy was marking the position of the cardinal beacon E5 which had been destroyed by a ship some 15 months previously. This temporary buoy was not seen by anyone on the bridge.

As the vessel passed starboard lateral beacon E3, the pilot ordered starboard rudder to bring the ship to a heading of 240 and then called Brisbane Port Control to advise that the ship would be at the entrance channel at 0600.

The master, sitting in front of one of the two radars, realised that the relative bearings of beacons E4 and E2 were changing and went to the helmsman to see what was happening. The pilot went to his electronic chart system, which had reverted to a blank screen stand-by mode. He tapped a key and when the chart was restored, he suddenly realised that he had ordered the course alteration too soon.

The main engine was stopped and put astern, but ANL Excellence grounded before the ship had begun to slow.

The ship was refloated on the high tide of the afternoon of 19 July 2002, using its main engine and with the aid of tugs. Following an inspection of the hull, both internally and externally on 20 July, the vessel was cleared by the Australian Maritime Safety Authority, and its classification society to continue in service.

The report conclusions include:

• The pilot did not follow his normal procedure of checking the position of the course alteration using his portable electronic chart system.
• The temporary buoy marking the original position of the original east cardinal beacon E5 (the turning mark) was obscured by rain.
• The green light on the temporary buoy was not as conspicuous as a white light, which would normally be associated with a cardinal navigation mark.
• Although not suffering from chronic fatigue, the pilot's performance was probably affected by the trough in his circadian rhythm associated with the hours between 0400 and 0600.
• The pilot's electronic chart system was placed at a significant distance from where he was standing, with its display in power saving mode at a critical moment.
• The bridge team did not detect the erroneous helm order and failed to challenge the pilot.

The report recommends that:

• Where port authorities use a buoy or other temporary aid to replace an established navigation aid, the shape and the light characteristics of the temporary aid should be consistent with those of the aid it replaces.
• Brisbane Marine Pilots should review the power management settings and placement of a pilot's portable electronic chart system to ensure that the information displayed remains easily visible from the pilot's conning position at all times during a pilotage.

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, ANL Excellence grounded on Middle Banks on 19 July 2002 as a result of the pilot erroneously ordering an alteration of course at the starboard lateral beacon E3 instead of at the temporary starboard lateral buoy marking the position of the original east cardinal beacon E5. The following are considered to be factors in the incident:

1. The pilot did not follow his normal procedure of checking the position of the course alteration using his portable electronic chart system.
2. The temporary buoy marking the original position of the original east cardinal beacon E5 (the turning mark) was obscured by rain.
3. The green light on the temporary buoy was not as conspicuous as a white light, which would normally be associated with a cardinal navigation mark.
4. Although not suffering from chronic fatigue, the pilot's performance was probably affected by the trough in his circadian rhythm associated with the hours between 0400 and 0600.
5. The pilot's electronic chart system was placed at a significant distance from where he was standing, with its display in power saving mode at a critical moment.
6. The bridge team did not detect the erroneous helm order as a result of:
   1. Both the master and mate were probably fatigued as a result of their hours of work during the passage through the Great Barrier Reef, which was exacerbated by the 'time of day' effect.
   2. Neither the master nor the mate were sufficiently aware of the ship's situation, at the time, to challenge the pilot's premature order for the course alteration.
   3. Insufficient attention was paid to the ship's radar display.
   4. The navigation chart in use by the ship did not show the temporary replacement of E5 cardinal beacon with a temporary starboard lateral buoy marking the southeast extremity of Middle Bank.
   5. The interpersonal tension between the master and mate effectively nullified the active participation of one qualified navigator in the bridge team.

Taharoa Express

Taharoa Express is a Panama flag bulk carrier of 145 842 tonnes deadweight at a summer draught of 17.42 m. The vessel, owned by Pacific Transport Trading SA and managed by Hachiuma Steamship Company, was on charter to NYK Line, Tokyo.

Classed with Nippon Kaiji Kyokai, the vessel was built in 1990 by Hyundai Heavy Industries in South Korea. It is of standard bulk carrier design with 9 cargo holds located forward of the accommodation superstructure. It has an overall length of 269 m, a moulded breadth of 43 m and a moulded depth of 23.8 m. Propulsive power is provided by a 5-cylinder B&W 5S70MC diesel engine of 11 974 kW driving a single fixed pitch propeller which gives the ship a service speed of 14 knots.

At the time of the incident, Taharoa Express had a complement of 25. The master, mate and the chief engineer were Japanese and the other officers and crew were Filipinos. The master and other officers all held appropriate qualifications.

Conclusions

The following factors are considered to have contributed to the incident:

• The seaman was standing almost directly over the fairlead roller for the mooring rope and was not warned that he should have been in a safer position;
• It is likely that the bosun, thinking that the breastlines had been released, operated the winch to recover the lines, resulting in tightening of the line that was still attached to the mooring hook.

In addition, although tests on the hook were not conclusive, one or more of the following possibly occurred:

• The initial attempt to release the hook partially altered the position of the release system resulting in a release of the hook under tension;
• Dirt or rust had prevented the mooring hook from being correctly reset;
• The mooring hook was not correctly reset.

It is possible that modifications to the remote release mechanism might also have been a factor in the hook releasing.

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.