Summary

At 0155 on 9 October 1999, the prawn trawler May Bell II was about 50 miles east of Newcastle, NSW, heading slowly west. The skipper and the deckhand were recovering their nets when the deckhand heard the sound of a ship's wash just forward of the trawler. He ran to the wheelhouse where he put the engine full astern but, a few seconds later, the two vessels came into contact.

The deckhand sounded the trawler's horn, leaving it on, but there was no answering signal from the ship. He was unable to make out a stern light or the ship's name on the stern as the ship continued on towards the northeast.

The bow of the trawler was holed by the impact, but there was no ingress of water. The skipper called Sydney Radio on VHF (very high frequency radio) to say that the trawler had been struck by a ship, informing the station of the position and time of the collision and adding that he was returning to Sydney.

The trawler returned to Sydney that afternoon, whereupon the Australian Transport Safety Bureau (ATSB) interviewed the crew and obtained samples of paint deposited, as a result of the collision, on the stem of the trawler.

AusSAR, the Australian search and rescue organisation, provided the ATSB with a surface picture (surpic) of ships in the area at the time of the collision. Positions were obtained from certain ships on the surpic and a woodchip carrier, Craig The Pioneer, was close enough to the position of the collision to warrant further investigation.

When Craig The Pioneer arrived at Bell Bay in Tasmania in November 1999, interviews were conducted with the master, deck officers and the AB (able-bodied seaman) who had been on watch with the 2nd mate. The 2nd mate and AB, who had been on the navigation watch at the time, denied all knowledge of the incident stating that they had not seen the trawler either visually or by radar.

The ATSB also obtained paint samples from the ship. Paint samples from both vessels were analysed by the Scientific Unit, Forensic Services, of the Australian Federal Police at Canberra, the report concluding that there was strong evidence that the ship and fishing vessel had come into contact.

Conclusions

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

• On the basis of the positions of both vessels and the analysis of paint samples from the fishing vessel and the ship, the Inspector is satisfied that Craig The Pioneer collided with May Bell II.
• Those on watch on the bridge of Craig The Pioneer did not maintain a proper lookout either by sight or by radar. Under the conditions of optimum visibility at the time of the incident, the lookout being maintained on board the ship would have to be considered seriously deficient to miss seeing the trawler prior to the collision.
• The skipper and deckhand of the trawler were on deck, concentrating on retrieving nets, when the collision occurred and were not keeping a proper lookout.
• The vision of both the skipper and deckhand of the trawler was significantly impaired from working under bright lights.

It is also considered that the fitting of a radar reflector or similar device to the fishing vessel to enhance its radar returns would have increased the likelihood of it being detected by a ship.

Summary

The Panamanian flag general cargo vessel Sun Breeze berthed at the West Australian port of Bunbury on 16 August 1999 to load a cargo of sawn timber.

The vessel loaded packs of timber of various sizes, most of which had no weights marked on them. During loading, the master estimated weights of cargo loaded in each of the vessel's two hatches by draught survey. When the hatches were full, the weight of cargo loaded on the hatch tops and deck was limited by the master's requirement to maintain a minimum metacentric height (GM) of 50 cm.

After loading was completed on 21 August, the vessel's GM, after allowing for free surface effects in certain tanks, was calculated to be 47 cm.

After lashing of the deck cargo was completed, Sun Breeze sailed at 1800 the same day for China. The vessel was upright when the harbour master piloted it from the port. After the harbour master disembarked, the engine revolutions were increased to sea speed at 1830.

When the master left the bridge, the 3rd mate changed the steering from manual to autopilot, at which time the ship started turning to starboard on its own accord. He changed back to manual steering, ordering helm to bring the vessel back on course. The vessel then seemed to him to list initially to port before listing to starboard.

The master returned to the bridge, by which time the list was about 15° or 20° to starboard. He stopped the engine and the list increased before settling at about 25°. The vessel lost some packs of timber from no. 1 hatch top over the side at this time. A distress message was sent out at about 1848 before the master anchored the vessel at 1900. The harbour master went out to the ship and non-essential crewmembers were disembarked by a tug.

The master corrected the list by ballasting side tanks. He advised the owner of the ship of the situation and obtained permission from the harbour master to re-enter the port after a surveyor had verified the vessel's stability.

The vessel berthed at Bunbury once more at 1310 on the 22nd August. The cargo was restowed and secured and the amount of deck cargo was reduced, after which the vessel sailed for the discharge port in China, where it arrived safely on 10 September 1999.

Conclusions

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

Based on all the evidence available, the following factors are considered to have contributed to the incident:

1. All fuel, diesel, fresh water and some ballast tanks were slack, reducing the vessel's stability.
2. The cargo in the holds and tween decks was not secured to prevent movement in a seaway in accordance with the approved cargo securing manual.
3. The ship's stability was based on an inclining experiment that did not meet IMO approved standards. As a result, the position of the lightship centre of gravity is in question.
4. The stability information supplied to the ship contained incorrect data on free surface moments.
5. Packages of timber were not marked with their weights and the master had to estimate weights in each compartment by draught survey.
6. The lashings at hatch no. 1 were incorrectly set up, opening to permit the cargo to be lost overboard after the vessel listed.
7. The voyage instructions mentioned lashings for the deck cargo. It made no mention of securing arrangements for cargo in the hatches.
8. The master did not have a copy of the charter party, neither was he informed of correct stowage factors or weights of the type of cargo to load. He did not have sufficient information with which to prepare a proper loading plan and exercise proper oversight of loading.
9. The owner, master and the vessel's agent did not inform the Australian Maritime Safety Authority that the vessel would be loading timber deck cargo.
10. The master did not have a copy of the code of safe practice for the carriage of timber deck cargoes, neither did the ship's approved cargo securing manual include timber deck cargoes.
11. The stability calculations did not allow for absorption of water by the deck cargo or for consumption of fuel from low tanks once the vessel was at sea.

In addition, the Inspector considers that the master would have been justified in delaying loading of the cargo until he was given all information necessary to ensure the ship's safety.

Summary

The Italian flag tanker Laura D'Amato berthed at the Shell Terminal Gore Bay Sydney, at 1224 on 3 August 1999, with about 90,957 tonnes of Murban Crude Oil. The loading arms were connected to the ship, the tank ullages measured and the quantity of oil on board checked. The mate and the Shell shore officer conferred and signed the 'Ship/Shore Safety' checklist. The checklist was also counter signed by a Sydney Ports inspector.

At 1412, the ship commenced discharging using no. 2 cargo pump. Initially, the water bottoms were removed at a slow rate of pumping. At 1430, all the cargo tanks were opened to lower their levels and the discharge rate was increased to 1000 m/h. At 1650, some cargo tanks were shut, the rate was further increased to 1500 m/h, and the suction valves for the two slop tanks (six wings port and starboard) opened.

By about 1815, the mate decided the level of the slop tanks was falling too slowly. To draw more directly from these two tanks and to increase the rate of discharge, the mate decided to open no. 3 cargo line to no. 2 pump by opening two 'crossover' valves on the main sea line in the pumproom. At about 1820, he ordered the cadet to open the two valves.

At 1825, the Shell wharf watchkeeper was returning from a routine check of the loading arms and moorings, when he suddenly smelled a strong odour of hydrogen sulphide. He immediately contacted the shore officer reporting the smell and asking whether the ship was venting its tanks for any reason. It was established that this was not the case.

The wharf watchkeeper went back to the shore manifold but detected no sign of a leak. The smell of hydrogen sulphide was still strong and, as he checked the water between the ship and the shore, he detected a slick of oil, which he traced to the ship's port side. He reported to the shore officer, who immediately ordered the ship to stop pumping.

The ship's pumps were stopped at 1836. The Shell emergency plan was implemented immediately.

The mate, who had already ordered the cadet to close the two valves that he had just opened, then ordered the 3rd mate to stop the cargo pump. He went ashore to see if he could locate the source of the oil spill. The wharf watchkeeper showed him the position on the port side, of the vessel, where oil was seen to be welling to the surface of the water. The mate and the pumpman then went to the pumproom and checked all the valves. They found the two sea-chest valves on the sea suction line were fully open.

When the two men attempted to close the sea-chest valves, they found the large, manual, butterfly valves 'back-seated' open. To close the valves, both men had to use a large wheel key to break the seat. In closing the valves, any security seals placed between the two adjacent valve handles were broken.

At this point, the flow of Murban crude oil from Laura D'Amato into Gore Bay ceased.

Conclusions

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

The factors which lead to the escape of crude oil cargo from Laura D'Amato into Sydney Harbour include but are not limited to:

1. The sea-chest valves on the sea suction line adjacent to the port sea chest in the vessel's cargo pumproom were open.
2. The use of the sea suction line as a cargo pump suction crossover line led to cargo filling the line and escaping through the open sea-chest valves overboard.
3. The ship's cargo system did not provide for a separate designated cargo pump suction crossover line or some means of isolating the cargo system from direct connection to the sea chest.
4. The presence, at various times, of seals placed between the sea-chest valves lead to a false assumption on the part of the ship's staff that the sea-chest valves must therefore be shut.
5. The false assumption contributed to the fact that the ship's staff did not properly check the sea-chest valves, as required by the ISM Code procedure, the ISGOTT Guide and normal tanker operations, before loading in Jebel Dhanna and discharging in Sydney.
6. There was no remote monitoring, on the cargo control console, of the positioning of the two sea-chest valves.
7. The vessel's Safety Management System did not adequately detail the pressure test procedures to be carried out on the sea-chest valves each time they were to be checked for tightness.
8. The independent cargo surveyor in Jebel Dhanna did not recognise that the sea-chest valves were, in fact, open.
9. The Ship/Shore Checklist procedures, in Jebel Dhanna and Sydney, did not physically check and identify that the sea-chest valves were in a closed position.
10. The probability is that the sea-chest valves were opened some time after leaving Zhanjiang and before arriving at Jebel Dhanna. There was no operational reason for opening these valves.

Summary

Between 17 and 23 July 1999, the Singapore flag bulk carrier Padang Hawk loaded a full cargo of nickel ore from barges at Kouaoua, New Caledonia. Late on 23 July, the ship sailed for Townsville, Australia. During the passage, Padang Hawk was subjected to rough seas and rolled heavily. At about 2200 on 26 July, the ship developed a 15 list to port.

A quick examination of the holds showed that the cargo in four of the five holds had settled and appeared to have liquefied.

Some water was pooling on the surface of the cargo in number 1 hold. The cargo in the forward holds appeared to be 'flowing' with the movement of the ship.

The master reduced speed and altered course to put the wind and seas on the ship's port quarter. Ballast was then pumped to correct the list. The ship's course was maintained so that it entered the inner route of the Great Barrier Reef by Grafton Passage rather than the more southerly Palm Passage.

The ship finally arrived safely in Townsville at 2000 on the evening of 28 July.

Summary

The Panama flag general cargo ship New Reach sailed from Cairns, Queensland, at 0654 on 16 May 1999 bound for Penang, Malaysia, with a full cargo of sugar. A licensed pilot was embarked to take charge of the navigation through the inner route of the Great Barrier Reef.

At about 1020 on 16 May, New Reach passed Low Isles, the southern limit of the compulsory pilotage area.

The pilotage proceeded routinely until about 0311 on 17 May, when, after making a routine mandatory report to the Reef Reporting Centre, the pilot realised that the light on Heath Reef was in the wrong position relative to the ship's heading. He altered course to port to bring New Reach to the west of Heath Reef. At about 0320, the ship grounded in shallow waters about 220 m south of the reef edge on a heading of 327, about one hour before low water.

Nobody was hurt as a result of the grounding and no oil or other pollutant escaped from the ship.

At about 0920 on 17 May, New Reach was refloated under its own power and, after reporting to the Reef Centre, went to anchor south of Night Island, 17 nautical miles to the north. The Australian authorities issued detention orders. At 1314 the vessel was given permission to move to Lloyd Bay, close to the Lockhart River Settlement and its airstrip.

On 18 May, divers, surveyors and other officials boarded the vessel. A new pilot also joined New Reach to relieve the pilot on board.

After an underwater inspection by the divers and an examination of the fore peak tank by the class society surveyor, the ship was cleared to resume its voyage. The vessel cleared Booby Island at 0530 on 19 May.

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 following factors are considered to have contributed to the incident:

• When the pilot realised that the ship was out of position, he did not establish the ship's true position to allow him to take appropriate action based on full and correct information.
• The pilot's navigation of the ship in proximity to Heath Reef was based on insufficient information, faulty analysis and inexperience.
• The pilot made an error of judgement, and his overall performance was affected by fatigue.
• The pilot did not have any effective strategy to manage or counteract inevitable fatigue levels.
• Neither the master nor pilot briefed the watchkeeping officers on the passage through the inner route. Communications regarding navigation between the pilot and the officers on watch was minimal.
• The 2nd mate did not fulfil his duties and obligations to maintain the ship on course by bringing the pilot's attention to the plotted position of 0249 or the plotted position of 0307.
• Approaching Heath Reef, the 2nd mate established that the ship was to the east of the intended course line but did not alert the pilot to the ship's position.
• With the pilot on the bridge for the passage from Fife Reef, the 2nd mate was unconcerned at the relative position of Heath Reef light.
• There was a marked lack of bridge resource management, which led to New Reach grounding through over- reliance on a single person.
• The fishing vessel Shanendale was well clear of New Reach and did not in any way restrict the cargo ship's sea room.

Summary

On the morning of 28 April 1999, the Greek tanker Olympic Symphony, loaded with crude oil, was inbound to the BP wharf at Luggage Point in the Brisbane River. A pilot was conducting the navigation and the master and 2nd mate were on the bridge. The vessel was on hand steering and, after clearing East Channel, was steadied on a course of 245°. At about 0755, the vessel approached the Entrance Channel and the pilot ordered port rudder.

Olympic Symphony was steadied briefly on a course of 230° when the helmsman noticed that the rudder angle indicator did not indicate any rudder movement to port. At about 0757, the helmsman reported that the vessel was not responding to the helm and that the steering was stuck to starboard.

The pilot ordered the helm hard over each way but there seemed to be no response. He noticed from the rudder angle indicator that the rudder was at 5° to starboard. He ordered the speed reduced and asked the master for emergency steering. The master told the chief engineer to check the steering.

The pilot intended passing ahead of an anchored ship, but Olympic Symphony continued to swing to starboard. He realised that they would have to pass astern of the anchored vessel, which was now less than 3 cables off. He ordered the wheel put hard to starboard. The rudder angle indicator went to starboard, and he ordered full ahead on the engine. By this time, the stern of the anchored vessel was almost ahead, probably less than a cable* from the bow of Olympic Symphony.

Olympic Symphony passed astern of the anchored vessel, clearing it by about 6-10 m.

The pilot informed port control (Brisbane Harbour) of the steering failure, stating that the vessel was likely to anchor. However, subsequent tests of the steering system showed that it was operating satisfactorily. The master told the pilot that the chief engineer had found no problem with the steering.

The pilot then notified port control that the vessel was operational and that it would be at the entrance beacons in about 12 minutes. The vessel resumed passage to the berth without further incident and, at 1014, was secured alongside.

* 1 Cable = 0.1 nautical miles = 185.2 m

Conclusions

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

Based on all the evidence available, the following factors are considered to have contributed to the incident:

1. The micro-switch roller for the 'helm off midships' alarm was liable to obstruct the helm indicator slide.
2. The 'helm off midships alarm' was not approved by the manufacturers of the steering console and had been installed without reference to them.
3. The communication by the bridge team to the pilot was deficient, in that the master and the helmsman were aware that there was a response to the movements of the helm to starboard of 5° starboard only, but the pilot was not informed of this.
4. The master did not try the other steering system or change to the non-follow-up mode.
5. It is possible that the pilot, asking for emergency steering, prompted the master to think of the emergency steering position in the steering flat rather than to consider other alternatives available on the bridge.
6. The procedures available to the bridge team did not specify action to be taken following failure of both steering systems.
7. The ship's bridge team was not familiar with the steering systems and modes available to it.
8. Given the unknown cause of the temporary steering failure, insufficient consideration was given to the risks and possible consequences of transiting the Entrance Channel.
9. Neither the master nor the pilot offered port control sufficient explanation of the incident to allow those on duty to make a judgement as to whether or not the harbour master should be informed, and conditions imposed on an entry into port by Olympic Symphony.

Taken as promptly as they were, the actions of the pilot averted a collision.

Summary

On 13 February 1999, the motor vessel Waddens was berthed, port side to, at No. 8 wharf in the port of Cairns. The vessel had been on a voyage from Lihir, Papua New Guinea, to Tauranga, New Zealand, but had diverted to Cairns after it experienced problems with the main engine turbocharger.

The master and mate decided that the opportunity should be taken to run the starboard lifeboat. Permission was obtained on 14 February from Cairns Harbour Control to lower the boat and run it in the harbour. The boat was lowered to the water at 0830, manned by the 2nd mate and an able-bodied seaman (AB) and tested for about an hour.

At 0930, the lifeboat was positioned under the falls for hoisting and connected to the lifting hooks. There was some difficulty experienced in positioning the boat under the falls because of a strong tidal flow. The mate, bosun and an AB were standing by on the ship while the falls were being connected and the boat was hoisted.

When the boat was ready for hoisting, the 2nd mate returned to the aft end of the boat while the AB remained forward. The boat was hoisted to a position where the tricing pendants were to be attached and the winch stopped. At that moment, the falls suddenly disengaged and the lifeboat fell to the water, landing upright.

The 2nd mate was observed lying on the aft deck just outside the cabin. The AB, who had been at the fore end of the boat, was in the water. The AB who had been standing by on board the ship dived overboard to assist him. Both AB's then climbed aboard the lifeboat and, while one of them assisted the 2nd mate, the other manoeuvred the boat to the wharf and made it fast.

Having informed the master of the incident, the mate called Cairns Harbour Control to request assistance and an ambulance. The ambulance arrived at about 0945 whereupon paramedics attended to the 2nd mate. The lifeboat was towed by a coastguard craft to a marina pier from where the 2nd mate was taken ashore and transported by ambulance to Cairns Base Hospital.

At about 1015 the lifeboat was returned to Waddens. It appeared to be undamaged and was later hoisted and stowed on board without further incident.

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 available evidence, the Inspector concludes that:

1. Mechanical failure was not a factor.
2. The locking devices securing the release lever were not engaged.
3. The release mechanism was operated inadvertently, possibly by the boat's painter fouling the release lever.

Contributing to the accident were issues of poor ergonomic design:

1. The release lever was fitted at a position in the boat where it could interfere with free access to and from the fore deck through the cabin window.
2. The location of the release lever meant that, if unlocked, it might be moved accidentally to a position at which the hoisting hooks could release.
3. Although there is no evidence that release lever was mistaken for the gear lever for the engine in this instance, the proximity of the lever to the engine controls, in the Inspector's opinion, increased the possibility of accidental release.

Summary

At 0600 on 14 January 1999, the Australian Antarctic research and supply vessel Aurora Australis was on passage from Fremantle to the Antarctic, making good a speed of 11.5 knots on a south-westerly heading. After a 'non-critical' engine room alarm at 0614, a fire alarm occurred. The master, who had just relieved the mate on watch, glimpsed flames on an engine room CCTV monitor. The master sounded the general alarm and stopped the main engine. The ship's staff and the expeditioners went to their fire muster stations, while the duty engineer made for the engine control room. He encountered thick smoke as he entered the engine room but was able to reach the control room, from where he shut down all the running fuel pumps and engine room ventilation supply fans.

At 0627, after receiving reports that all vent flaps were shut, all remote fuel shut off valves operated and all fans stopped, the chief engineer discharged the Halon 1301 fixed fire-extinguishing system. The ship's position was 32º 57.7´ South, 114º 09.7´ East. Seven minutes later, the vessel transmitted a PAN PAN call which, after a number of repeats on different frequencies, was acknowledged by Brisbane Radio.

At 0700, to conserve fuel, the emergency generator was shut down, rendering the vessel 'dead ship'. The master convened a meeting on the bridge to discuss the best method by which to effect a re-entry into the engine room and at 0907, after re-starting the emergency generator, the chief engineer and an IR, backed up by a second team standing by, entered the engine room via the shaft tunnel to assess the situation. They reported that the fire was out then attempted to use a fire hose to cool down the area around the forward end of the starboard main engine, where the fire appeared to have been centred. On pressurising the hose, however, it parted from the coupling. A second hose brought into the engine room also parted from its coupling.

The engine room was vacated while other hoses were tested on deck before another attempt was made to cool down the seat of the fire. It was planned that, because of the heat, teams would enter in 10 minute relays. At 1100 another team entered, cooled the area and checked for hot spots. A bin of smouldering rags was found near the control room and eventually extinguished.

Checking of the engine room for hot spots was continued for the next two hours before the engine room was opened up and venting commenced at 1302. When attempting to start an air compressor, the emergency generator stopped and it was found that a short circuit appeared to have damaged its automatic voltage regulator. The master, concerned about the vessel's situation, with no electrical power and no starting air for the generators or main engines, called P&O Polar and requested that a tug stand by. Soon afterwards, a tug was despatched from Fremantle.

After fitting a spare AVR, which was found also not to work, the engineers supplied excitation for the generator by tapping off the generator's starting batteries and eventually restored power to the vessel. At 2345, the port main engine was started and Aurora Australis, escorted from 0300 by the tug Wambiri, proceeded back to Fremantle at 8 knots, arriving alongside at 1305 on the following day (15 January).

Conclusions

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

Based on all the evidence available, the following factors are considered to have contributed to the fire:

1. The fire was caused by the failure of a flanged joint on the starboard main engine fuel supply pipework, the resulting spray of diesel fuel igniting on the turbochargers or exhaust pipework.
2. The flanged joint failed after two of the four screws failed in fatigue, and the other two had worked loose.
3. A sheet metal cover, manufactured by local contractors and which left a gap down the side, failed to provide the necessary screening of the failed flanged joint, hence allowing the escaping fuel to reach a source of ignition.
4. In the absence of all the physical evidence, the inspector could not reconcile conflicting evidence, given by the engine-builders and ETRS, on whether or not the 8 mm allen screws had, or had not, been overtightened upon last assembly of the pipework.
5. The design of the pipework adjacent to the failed flanged joint is such that a torque wrench cannot be applied to all the screws in order to tighten them to the correct torque specified in the Wärtsilä manual.
6. Vibration and misalignment of the pipework were factors which contributed to the failure of the allen screws.
7. The use of allen screws, having no locking arrangement, in the LP fuel system was a further contributing factor.

It is also considered that:

1. In general, the response to the fire by the ship's crew and the expeditioners on board was measured, effective, and demonstrated initiative.
2. Following an earlier fire on the same vessel, in July 1998, P&O had taken all reasonable measures to reduce the risk of another such engine room fire.
3. The use of allen screws without any locking arrangement is becoming an increasingly common contributing factor in fires caused by failures in the LP fuel systems of medium speed diesel engines.
4. The maritime industry should note the inspector's concern about the practice of individuals entering a fire zone in the engine room in order to reach the engine control room during the early stages of a fire.

Summary

At noon on 2 February 1999, the fishing vessel Tina was at anchor about 30 miles east of Noosa Head. The skipper and two crew on board were asleep in the forecastle space when, at about 1240, the skipper was awakened by the sound of a ship's whistle.

The skipper and both crew members hurriedly left the forecastle and went to the wheelhouse, from where they saw the bow of a ship going past. Immediately after this, the hull of the ship made contact with the starboard boom of Tina. The boom was damaged, and the crew of Tina saw a figure on the bridge of the ship emerge from the wheelhouse and watch them through binoculars.

The skipper read the name of the ship as the stern went past and advised Brisbane Harbour of the incident, but he was not able to contact the ship, the Cemtex General, registered in Keelung. Cemtex General was on a voyage from Newcastle to Hualien in Taiwan. The ship had been experiencing moderately rough seas and poor visibility in heavy rain showers. The duty officer was using radar to assist with keeping a lookout. The anchored vessel was not seen on the radar and was only seen visually about a ship length away, fine on the port bow. After the collision, Cemtex General continued on its voyage without stopping. The master did not advise the Australian Search and Rescue organisation, AusSAR, of the incident, or report the matter to the owners of the ship in Taiwan.

There was no other damage to the trawler apart from damage to the boom and Tina returned to Mooloolaba the same day, arriving there at about 1800.

The master, duty officer and the lookout of Cemtex General were interviewed after the vessel returned to Australia to load at Weipa on 13 March 1999.

Conclusions

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

• The speed of Cemtex General was not safe given the factors that should have been taken into account under Rule 6 of the Collision Regulations.
• There were no whistle signals being sounded aboard Cemtex General as required by the Collision Regulations, despite the rain and restricted visibility prior to, and at the time of, the collision.
• Those navigating Cemtex General placed too great a reliance on radar navigation without appreciating the limitations of radar.
• The lookout on Cemtex General was inadequate.
• No lookout was being kept aboard Tina.
• Tina was anchored in busy shipping lanes.
• Tina was not displaying the signals required by the Collision Regulations for a vessel at anchor. The absence of such signals contributed to the master's immediate impression that Tina was making way.

Executive summary

On 26 November 1999, a Freight Victoria Ltd (Freight Victoria) employee moved the points at the Adelaide end of the Ararat yard shortly before a grain train was due to pass through Ararat on the main line. The employee's duties did not require him to move points, nor was he qualified or authorised to do so.

As a result of the employee's actions, the grain train was diverted into the Ararat yard, where it collided with a stationary ballast train. The employee subsequently reported that he had moved the points in order to be helpful. There was no evidence to suggest otherwise. The two crew members of the stationary ballast train saw that a collision was imminent and escaped from the locomotive shortly before the impact. They were not injured.

The two crew members on board the moving grain train applied emergency braking when they saw that the points were not set for the main line. They remained on board the locomotive and sustained serious injuries as a result of the collision.

The investigation determined that the system in operation at Ararat was fragile in the face of human error.

The device used to unlock the points and permit their movement, was stored in a metal box near the points. This box was secured with a padlock of a type widely used on the Victorian non-urban rail network. The employee who moved the points had been issued with a key of this type in order to perform his normal duties, even though it was generally considered that personnel with his limited qualifications would not normally be issued with such a key.

There was no system in place to prevent the points from being moved in front of an oncoming train. Such systems are in place at other locations on the Adelaide-Melbourne main line.

Additionally, there was no provision to inform Drivers on the main line or Train Control, of the movement or position of the points.

Although this accident was triggered by the unsafe and unauthorised actions of an employee, the accident had its origins in a number of organisational and system deficiencies.

The primary deficiencies identified in the course of this investigation were related to:

• hazard identification and the management of risk;
• safety training;
• interface management;
• system design;
• standardisation of procedures and safety systems;
• the control of safety-critical equipment;
• oversight of the activities of rail organisations; and
• safety promotion.

Both the Australian Rail Track Corporation (ARTC) and Freight Victoria have undertaken a review of their networks and have identified locations where they have concerns about the integrity of main lines. The two organisations are applying risk assessment methodologies to determine whether further measures are required to improve the error tolerance of the system at those locations. Any progress on those reviews has been acknowledged in Section 10.1 Local safety action.