Grounding of the bulk carrier Fitzroy River

Final report

Summary

The Australian steam turbine bulk carrier Fitzroy River sailed from the Lorim Point bauxite berth, Weipa, at about 1800 on 24 August 1998. The Master, who held a pilotage exemption certificate for the port, conducted the outward pilotage.

The outward passage proceeded routinely between Lorim Point jetty and Gonbung Point. After executing the turn to starboard off Gonbung Point, the Master found that the ship was south of the intended course line and he steered a course into the 'Bellmouth' to compensate.

With the ship steering a course of about 285, and when the bridge was on the line of leads marking the centre of the South Channel, the Master ordered port rudder to turn the ship into the South Channel. Very soon afterwards, the Master realised that the ship was not turning fast enough and he ordered full port rudder.

The ship's heading had reached 240 when the bow grounded on a spit of shoal water extending about 200 m east-north-east from Bn.18, which marks the north bank of the inner eastern end of South Channel. Immediately the engine was put to about 70 rpm astern, but the ship proved to be securely aground with the bow about 130 m from Bn.18 on a heading of 243.

The Master reported the grounding to the ship's managers and the ASP Ship Management emergency plan was activated.

The ship was refloated the following morning with the assistance of tugs. Nobody was injured as a result of the grounding and no pollution resulted.

An inspection of the ship showed that it had sustained no material damage, and the vessel was able to continue in service.

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 following factors are considered to have contributed to the grounding:

1. The intended use of Bn.25 and Bn.33 in transit was inappropriate and impracticable given that:

  • they were astern of the ship;
  • Fitzroy River has limited visibility astern;
  • Bn.33 would be over 1.4 miles away and difficult to see;
  • there were insufficient people on the bridge to monitor the transit from the port side of the ship;
  • there were adequate cues and prompts for conning Fitzroy River ahead of the ship; and
  • looking for the transit was a distraction.

2. Reduced underkeel clearance affected the rate of turn between Bn.28 and Bn.20.

3. Given Fitzroy River's distance from Bn.20 and the ship's heading when the Master ordered the rudder to port to turn into South Channel, the order was given too late.

4. At the time of the order to put the rudder to port, there was a residual swing to starboard, which built in a critical delay in the turn.

5. The Master's relative inexperience resulted in his not detecting a reduced set to the north between Bn.30 and Bn.32, which should have alerted him to a possibly reduced tidal flow in the Embley River.

6. Although there is some evidence of a slightly reduced tidal flow in the Embley River, it was the series of small errors of judgement, rather than the reduced rate of the tidal stream that were the main contributors to the grounding.

7. The reduced manning on the bridge did not allow for full use to be made of the electronic navigation aids, particularly the radars.

8. Deficiencies in the training of exempt masters.

  • Written advice to masters seeking exemption is based on notes made by past pilots. These notes have no official standing and do not include tidal data provided to the port authority.
  • The ad hoc nature in the training of exempt Masters for the Port of Weipa, resulted in a lack of structure in training and the Master not receiving critical information.

9. Although a number of bulk carriers at maximum draught have grounded on the outward passage in the port of Weipa, none of the reports are made available to masters seeking pilotage exemption and no overall analysis is available from which lessons can be It is further considered that:

10. The Helmsman steered the ship proficiently, in accordance with the Master's orders.

11. After the grounding, the Master and crew followed all the correct procedures. These actions, combined with the ASP Ship Management Emergency Plan and the operation of the tugs, contributed to the safe refloating of the ship.

Occurrence summary

Investigation number 136
Occurrence date 25/08/1998
Location Weipa
State Queensland
Report release date 15/06/1999
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Marine
Marine occurrence category Grounding
Occurrence class Incident
Highest injury level None

Ship details

Name Fitzroy River
IMO number 8019019
Ship type Bulk carrier
Flag Australia
Departure point Weipa, Qld
Destination Gladstone, Qld

Contact between MSC Katie and P&O Nedlloyd Sydney

Final report

Summary

On the evening of 18 June 1998, the Panamanian flag container ship MSC Katie embarked a Port Phillip Sea Pilot off Port Phillip Heads to proceed to Swanson Dock, Melbourne. The vessel crossed Port Phillip Bay at full sea speed and reduced to slow speed for passage up the Yarra River. Three tugs were made fast when the vessel was in the vicinity of the Westgate bridge and the vessel arrived at the swinging basin, off the entrance to Swanson Dock at 2338.

The tugs swung the vessel to starboard so that it was positioned to enter Swanson Dock stern first and the Pilot manoeuvred the vessel slowly up the dock towards the allocated berth, No. 3 East. No vessels were berthed at Nos. 1 and 2 East. As the vessel's bridge cleared No. 2 berth, the aft tug eased the stern in, to angle the vessel towards the berth.

The Pilot ordered dead slow ahead, to bring the vessel to a stop, but the engine failed to start. The starboard anchor was let go and the tugs took the weight to stop the vessel and to pull it away from the berth, but the port quarter of MSC Katie made contact with the stem of P&O Nedlloyd Sydney, berthed at No. 4 East. Both vessels sustained relatively minor damage.

After MSC Katie was safely moored alongside, the reason for the engine failure was traced to a blocked pipe to the main bearing lubricating oil pressure gauge/safety switch. This had created a spurious lubricating oil low pressure reading, which had initiated an emergency trip of the main engine, causing the fuel pumps to lift and preventing the supply of fuel to the engine.

Conclusions

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

  • The engine failure was caused by a blockage in the lubricating oil piping to a pressure safety switch. The blockage caused a 'low pressure' alarm, which initiated a main engine emergency trip mode, which in turn prevented the engine being started. There are no engine manufacturer's instructions or recommendations on periodic checking of such piping, and it is not standard practice on board ships for such checking to be carried out.
  • The lack of communications, between the bridge and engine room teams, resulted in the bridge team not keeping the engine room team informed of progress; and the engine room team not immediately informing the bridge team about possible ramifications of the engine 'emergency trip' alarm.
  • The lack of Bridge Resource Management principles on board, resulted in the members of the ship's bridge team not informing the Pilot about the main engine emergency trip and not keeping the Pilot informed about engine response.
  • There was an absence of a safety assessment of, and contingency planning for, the berthing operation. In addition, there was an absence of sufficiently detailed discussion of the berthing operation under Bridge Resource Management principles. As a result, no suitable lines were ashore to check the movement astern and, during the final approach to the berth, the bow tug was not in the optimum position to stop the vessel's movement astern, thus there were no safety barriers in place.

Occurrence summary

Investigation number 134
Occurrence date 18/06/1998
Location Melbourne
State Victoria
Report release date 22/12/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Marine
Marine occurrence category Engine Failure
Occurrence class Incident
Highest injury level None

Ship details

Name MSC Katie
IMO number 7434444
Ship type Container ship
Flag Panama
Destination Swanson Dock, Melbourne

Engine room fire on board the Aurora Australis

Final report

Summary

At about 0230 on 22 July 1998 a fire broke out in the engine room of the Antarctic research and supply vessel Aurora Australis. The ship was about 1300 miles south of Tasmania with 54 special purpose personnel (or expeditioners), 24 crew and an ice pilot on board.

About 25 minutes before the outbreak of the fire, the duty engineer had been woken by an alarm on the unmanned machinery space monitoring panel in his cabin. He went to the machinery control room and inspected the engine room. He cancelled the alarm and returned to his cabin at 0213. At that time, everything in the engine room appeared to be normal.

The duty engineer was roused again at 0225 by another alarm and, returning to the engine room, he discovered a fire at the forward end of the port main engine, around the turbocharger. The engine was stopped and the fire alarms sounded.

The fire at the turbochargers was attacked by engineers using portable extinguishers and apparently extinguished. A few moments later, however, at about 0236, a fireball erupted and the engineers were forced to evacuate the engine room. The expeditioners and crew were mustered on the helicopter deck and the fire teams deployed. Preparations were made for the operation of the fixed fire fighting system protecting the engine room.

The Halon 1301 fixed smothering system was released at 0252.Following the release of the halon gas, a MAYDAY message was transmitted and communications were established through Sydney Maritime Communications Centre.

From 0340 onwards, the engine room was re-entered on a number of occasions using self-contained breathing apparatus.

After consultation with the Tasmanian Fire Service by facsimile, ventilation of the engine room commenced at 1444. At about 1540 the engine room could be entered without breathing apparatus for a full inspection.

Although there was some damage to the port engine and turbochargers, the critical damage was to the electrical wiring of power and control circuits carried in cable trays affected by the fire. There was also some water damage, the result of water freezing in pipes in the Antarctic conditions.

Over the next three days, the ship's crew carried out repairs and 'jury rigged' electrical wiring to restore propulsive power to the starboard engine and electrical power to ancillary equipment.

Aurora Australis arrived back in Hobart on 31 July 1998, under its own power.

Investigation of the fire scene showed that the fuel source was from a split flexible hose between the port engine fuel filters and a length of rigid pipe on the fuel spill line.

It was also found that out of ten halon gas bottles, four had failed to discharge.

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:

  • The fire was caused by diesel fuel from a split in the flexible fuel hose in the spill line from the main engine coming into contact with a component of the port engine turbo-chargers, the temperature of which was in excess of the auto-ignition temperature of the fuel.
  • Failure of the hose was due to its age and to 'wear and tear'.
  • Although recommendations relating to fixed pipework on the engines, contained in the Wrtsil Technical Bulletin 'Safety aspects on and maintenance of fuel supply system of VASA 32' issued three years earlier, were implemented by the company, the recommendations in the same bulletin relating to the fitting, care and maintenance of sheathed hoses in the low pressure fuel system, were not followed.
  • When fitting the flexible fuel hoses at some time between 1991 and 1992, the ship's drawings were not altered to show the modification to the system.
  • Consultations between the company and Lloyd's Register, and the company and Wrtsil, on the use of flexible hoses were 'ad hoc' and no record of consultation or approval concerning their fitting was made by any party.
  • No approval was sought from the Australian Maritime Safety Authority for the fitting of flexible hoses.
  • Knowledge that the flexible hoses had been fitted under the floor plates was lost with the turn-over of engineers.
  • The fact that other flexible hoses were fitted to the engines was well evident, but this did not alert either class or AMSA surveyors to the fact that the modifications were not approved.

It is also considered that:

  • In general the response to the fire by the ship's crew and the expeditioners on board was measured, effective, demonstrated initiative and reflects great credit to all on board. Entry into any area adjacent to a fire, however, alone and without breathing apparatus or backup, is extremely hazardous and could compromise an entire firefighting effort.
  • The poor design of the electrical operating system for the Halon 1301 fixed smothering system led to its unreliable operation and to the partial discharge, only, of the halon.
  • The maintenance of the halon system involved at least three contractors and ship's staff, leading to a lack of continuity in maintenance and probably to the fitting of inappropriate fuses in the 24 volt supplies to the main control units.
  • Those involved in restoring propulsion to the ship showed considerable ingenuity, skill and initiative.

Occurrence summary

Investigation number 135
Occurrence date 22/07/1998
Location Antartica
State International
Report release date 28/06/1999
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Marine
Marine occurrence category Engine Room Fire
Occurrence class Incident
Highest injury level None

Ship details

Name Aurora Australis
IMO number 8717283
Ship type Research and Antarctic supply vessel (Ice Class)
Flag Australia
Departure point Hobart, Tasmania
Destination Macquarie Island

Collision between Barrington and the tug Austral Salvor

Final report

Summary

On the afternoon of 27 April 1998, the Australian flag tanker Barrington was inbound to the Ampol Wharf in the Brisbane River. A pilot was conducting navigation of the vessel. The vessel was in ballast and was to load a cargo of petroleum products. Barrington negotiated Pelican Banks Reach and entered Lytton Rocks Reach where she was to make fast the tug Austral Salvor, prior to turning and berthing starboard side alongside.

Austral Salvor left her berth at Whyte Island Tug Base at 1635 and waited off Clara Rock for Barrington to approach. A trainee tugmaster was at the controls of the tug with a supervising Tugmaster close at hand. When Barrington was off Clara Rock, the tug approached the vessel from astern on the port side.

'The tug approached within ten metres of the ship close to where she was to secure a line to the ship. The trainee tugmaster adjusted the tug's speed to enable him to position the tug correctly off Barrington.

While the tug was closing with the ship, the trainee tugmaster was in the process of reducing the speed further, when he noticed the bow of the tug sheering to starboard towards the ship.

The Tugmaster took control of the tug and attempted to arrest the sheer. The sheer of the bow was halted, but the stern swung in and the tug rolled, making contact with the ship just above the waterline. The shell plating on Barrington was holed at the point of contact, in way of a fuel oil storage tank, spilling fuel into the river.

The tug made fast to the ship at 1650, and Barrington was secured to the berth at 1736. Meanwhile, ship's staff had reacted promptly, transferring oil from the ruptured tank and were informed by the tug, at 1730, that the leak had stopped. The Port authorities had been alerted and initiated the Port of Brisbane Oil Spill Contingency Plan.

Permanent repairs were carried out to the damaged area at a repair berth in Brisbane and the vessel was able to load its cargo and proceed on its next voyage shortly after the 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 organisation or individual. Based on all the evidence available, the following factors are considered to have contributed to the incident:

  1. In handling the unilever to adjust the speed of the tug, the Trainee left on a component of starboard thrust, causing the bow to sheer to starboard.
  2. The Tugmaster corrected the sheer of the bow to starboard. However, as the stern of the tug closed within four metres, interaction forces contributed to the tug's momentum towards the ship causing the stern of the tug to make contact with the ship's side.
  3. On balance, the probability is that only the tug's stern made contact with Barrington.
  4. No action by Barrington contributed to the collision. It is also noted that:
  5. The collision caused indentation and penetration of Barrington's hull in way of the port heavy oil storage tank. Both the indentation and penetration of the shell plating were caused by contact with a steel bracket on the tug which was used to attach the after fender to the stern of the tug.
  6. The training regime, training manual and instructions provided for prospective Tugmasters would seem to be comprehensive and were not contributing factors in this incident.

Occurrence summary

Investigation number 132
Occurrence date 27/04/1998
Location Brisbane River
State Queensland
Report release date 27/01/1999
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Marine
Marine occurrence category Collision
Occurrence class Serious Incident
Highest injury level None

Ship details

Name Barrington
IMO number 8716356
Ship type Oil Tanker
Flag Australia
Departure point Mackay, Qld
Destination Ampol Wharf, Brisbane River

Ship details

Name Austral Salvor
Ship type Stern drive omni-directional tug
Flag Australia
Departure point Whyte Island Tug Base
Destination Clara Rocks

Fire in the engine room aboard Leonardo Da Vinci

Final report

Summary

On 11 June 1998, the Netherlands flag dredger Leonardo da Vinci was engaged in widening the approach channel to the Parker Point Terminal at Dampier, Western Australia.

At approximately 1750, the fire alarm sounded and crew members in the engine control room saw a fire on No. 1 diesel engine. The engines were stopped, the fuel supply shut off and the engine room battened down. A fire party attacked the seat of the fire with portable dry powder extinguishers, but as the party could not be certain the fire was fully extinguished, the Halon system was activated.

Two harbour tugs provided assistance in boundary cooling until a shore fire brigade party arrived on board. Members of the shore fire brigade party entered the engine room and, after a careful inspection, declared the fire to be fully extinguished.

The fire was caused by diesel fuel oil spraying onto the hot exhaust trunking of the engine. The source of the diesel fuel oil leak was traced to the shut-off cock to the pressure differential indicator on the No. 1 engine fuel oil filter. The bonnet of the cock had become dislodged, permitting diesel oil, under 8 bar pressure, to be sprayed upwards onto the exhaust trunking.

The fire caused extensive damage to electrical wiring and fittings, resulting in Leonardo da Vinci being out of commission for three weeks. One person was injured in the incident, receiving burns to the face and left forearm.

Conclusions

These conclusions identify the factors contributing to the incident and should not be taken as apportioning either blame or liability.

  • The fire occurred when diesel oil sprayed from a shut-off cock on No. 1 engine fuel filter on to the hot exhaust trunking of No. 1 diesel engine.
  • Over an undetermined period, the spindle bonnet of the shut-off cock had vibrated loose, had unscrewed and had been blown off, permitting the escape of diesel oil under 8 bar pressure.
  • At some undetermined time, the handle of the shut-off cock had been removed, to allow access to the square head of the spindle and had not been replaced. This action removed the locking, or keep-safe, portion of the valve.
  • Although five spare shut-off cock assemblies were held on board, missing handles had not been replaced on two shut-off cocks, indicating a laxity towards maintenance.

The following factors are considered to have contributed to the Technician sustaining burn injuries:

  • When leading the way out, the Electrician chose a route that took them into the engine room, the compartment in which the fire was burning, and he did not maintain physical contact with the Technician, so that they became separated in the dark/smoke.
  • On first boarding, the Technician had not been given a formal induction session, to ensure he understood the emergency signals and was familiar with the escape routes from the areas in which he was to be working.
  • The exits and emergency exits from the engine room and workshop areas were not clearly marked.

Occurrence summary

Investigation number 133
Occurrence date 11/06/1998
Location Dampier
State Western Australia
Report release date 20/01/1999
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Marine
Marine occurrence category Engine Room Fire
Occurrence class Incident
Highest injury level None

Ship details

Name Leonardo da Vinci
IMO number 8411592
Ship type Self-propelled cutter suction Dredger
Flag Netherlands
Departure point Parker Point Terminal, Dampier WA

Lifeboat incident and injury to crew aboard City of Burnie

Final report

Summary

After clearing its berth at Burnie, Tasmania on the morning of Sunday 15 March 1998, the ro-ro vessel City of Burnie stopped within the harbour to conduct a lifeboat drill. The drill involved the launching of the port lifeboat with a crew of eight.

The lifeboat was duly launched and coxswained by the Mate, it cruised around the harbour for about ten minutes. After the lifeboat had returned and the boat's crew had hooked on the falls, the recovery party, under the charge of the 2nd Mate, found that the electric motor for the falls winch would not start. The Chief Engineer went to the motor contactor panel, located in the funnel, where he operated the falls winch motor by manually pushing in the contactor. He used a portable radio to maintain contact with the 2nd Mate.

The lifeboat was hoisted by this method to deck level, where it was necessary to stop the hoisting while the boat's crew aligned the fall hooks with the davit heads. Hoisting was then resumed, in similar fashion, with all the eight men still in the boat. Despite a warning shout, the winch motor was not stopped before the davits brought up hard against the stops and the wire falls parted. The lifeboat fell to the water, turning over as it did so, spilling out most of the crew.

A number of small leisure craft rushed to the scene, rescued all eight crew members from the water and took them to the yacht club launching ramp. From there, ambulances took the crew members to Burnie hospital.

All eight crew members suffered some form of injury, two suffered major bone fractures, but fortunately no one was killed. The lifeboat was extensively damaged.

Conclusions

These conclusions identify the various factors that contributed to the incident and should not be read as apportioning blame or liability to any particular organisation or individual. The fall wires parted when the davits were hauled hard home under electrical power, the force exerted on the wires exceeding their breaking strain. The following factors are considered to have combined to cause the incident:

  • The fracture, at some earlier date, of the winch safety switch cover plate, which had allowed the entry of salt water, causing corrosion within the switch and an electrical open circuit.
  • The instructions for routine checks of the winch safety switch and davit cut-out switches at lifeboat drills, contained in the manufacturer's Instructional Manual, were not followed.
  • The use of the winch motor to turn-in the lifeboat by means of manually holding in the electrical contactor.
  • Although intermittent faults had been experienced with the operation of the electrical winch motors over a number of years and lifeboats had been raised by holding in the electrical contactors on other occasions, the ship's Safety Committee had not developed a written procedure to be followed under such circumstances.
  • The on-board practice for boat drills which resulted in the 2nd Mate not knowing the procedures followed for restowing the lifeboats, although he had served on City of Burnie for six years.
  • Neither the Mate nor the 2nd Mate was aware that the limit switches were by- passed and so would not operate when the electrical contactor was manually held in to operate the winch motor.
  • The absence of a company organisational mandatory reporting procedure, to keep shore management informed of operational malfunctions.
  • The design and positioning of the guideways, which prohibit safe, unimpeded transfer of persons from the lifeboat to the deck, resulting in the full boat's crew remaining in the lifeboat until it is fully housed.
  • The hook twisting problems experienced with the single wire fall, which resulted in the 2nd Mate's concentration, from habit, being on the davit heads and hooks.

Occurrence summary

Investigation number 130
Occurrence date 15/03/1998
Location Burnie
State Tasmania
Report release date 22/09/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Marine
Marine occurrence category Equipment
Occurrence class Serious Incident
Highest injury level Serious

Ship details

Name City of Burnie
IMO number 8009038
Ship type RoRo Cargo
Flag United Kingdom
Departure point Burnie, Tasmania

Collision between Eternal Wind and FV Melina T

Final report

Summary

On the morning of 5 April 1998, the fishing vessel Melina T was proceeding on a westerly course at full speed, about 7 knots, headed back to its base at Mooloolaba. One of the deckhands was on watch in the wheelhouse and the steering was in the automatic mode.

The Panamanian bulk carrier Eternal Wind was proceeding due north at 13 knots, on passage from Port Kembla to Niihama, Japan, with a cargo of coal. At 0800, the 3rd Mate took over the watch from the Mate, who had instructed the AB watchkeeper to take temperature and atmosphere readings of the cargo hold. The wind was from the south-east at force 5, which was generating a moderate to rough sea on a low swell, and the visibility was good.

At 0815, the two vessels collided, the bow planks of the fishing vessel being sprung by the impact, causing the fishing vessel to flood. Eternal Wind turned about to stand by Melina T, and took the four-man crew aboard when they had to abandon their vessel.

Melina T sank at 1027 and Eternal Wind diverted from its passage to land the four fishermen off Point Cartwright, where the men were disembarked to a water police launch. Eternal Wind then continued on its voyage to Japan.

The Master, officers and crew of Eternal Wind were interviewed when the vessel loaded at Hay point, Queensland on the subsequent voyage.

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 lookout being kept aboard Eternal Wind was ineffective in that Melina T was not seen in sufficient time to prevent collision.
  • The watch officer aboard Eternal Wind ceased to keep a lookout when he set about checking the error on the compass.
  • The 8-12 seaman watchkeeper aboard Eternal Wind had been assigned duties on the main deck and was not available to keep a lookout while the watch-officer was engaged in other navigational duties.
  • The officers aboard Eternal Wind placed an over-reliance on radar for lookout purposes in open waters.
  • The lookout being kept aboard Melina T was ineffective in that Eternal Wind was not seen until it had closed to two miles distance and a watch on the vessel was not then maintained to ascertain whether risk of collision existed.
  • The Skipper of Melina T had not reacquainted the relief deckhand with his standing instructions that he was to be told whenever another vessel was sighted.

It is further considered that the positioning of the nails securing the hull planking to the athwartship bulkhead, being close to the engine room side of the bulkhead, prevented effective plugging of the gaps and contributed to the foundering of Melina T.

Occurrence summary

Investigation number 131
Occurrence date 05/04/1998
Location SE of Fraser Is
State Queensland
Report release date 22/12/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Marine
Marine occurrence category Collision
Occurrence class Incident
Highest injury level None

Ship details

Name Melina T 875995
IMO number N/A
Ship type Fishing vessel
Flag Australia
Destination Mooloolaba, Qld

Ship details

Name Eternal Wind
IMO number 9162019
Ship type Bulk Carrier
Flag Panama
Departure point Port Kembla, NSW
Destination Niihama, Japan

Lifeboat injury to a crew member aboard Maersk Pomor

Final report

Summary

On 2 January 1998, the Bahamas flag geared bulk carrier Maersk Pomor was undergoing a Port State Control inspection, by a surveyor of the Australian Maritime Safety Authority, at the port of Gladstone, Queensland.

As part of the inspection, the Surveyor requested that the engine of the free-fall lifeboat be started and the movement ahead and astern tested. The 3rd Engineer boarded the lifeboat, started the engine, operated it in the ahead and astern modes and, the test satisfactory, stopped the engine. The Surveyor then requested that the lifeboat's rudder be operated, to port and to starboard.

Standing on the lifeboat boarding platform, from where he could see into the lifeboat, the Surveyor observed the 3rd Engineer unsuccessfully try to turn a spoked wheel, aligned fore and aft adjacent to the coxswain's seat. The 3rd Engineer then restarted the lifeboat engine, after which he again tried to turn the spoked wheel, this time with success. However, instead of the rudder turning, the lifeboat was launched, the 3rd Engineer being thrown to the bottom boards of the lifeboat.

The ship's rescue boat was launched, the lifeboat retrieved and taken alongside the wharf, where the 3rd Engineer was transferred to an ambulance. At Gladstone Hospital it was ascertained the 3rd Engineer had suffered a crush fracture of the first lumbar vertebra and concussion.

Conclusions

These conclusions identify the factors contributing to the incident and should not be taken as apportioning either blame or liability. The main contributing factors are considered to be:

  1. The 3rd Engineer's lack of knowledge about the free-fall lifeboat controls.
  2. The 2nd Mate's and Electrical Engineer Officer's lack of knowledge about the free-fall lifeboat controls.
  3. The training regimen on board, in that it had not ensured that the three officers were fully conversant with the free-fall lifeboat controls.
  4. The labelling and instructions for the lifeboat release gear, although clear, were not in the language of the crew.

Occurrence summary

Investigation number 128
Occurrence date 02/01/1998
Location Gladstone
State Queensland
Report release date 19/08/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Marine
Marine occurrence category Equipment
Occurrence class Serious Incident
Highest injury level Serious

Ship details

Name Maresk Pomor
IMO number 9102045
Ship type Bulk Carrier
Flag Bahamas
Destination Gladstone, Qld

Caraboa 1 contact with jetty and four moored vessels

Final report

Summary

On 8 January 1998, the Singapore registered livestock carrier Carabao 1 anchored with 3 shackles of cable about 240 m off the outer berth of the jetty, in the port of Broome in the north-west of Western Australia. The holding ground was considered to be good, and the vessel lay securely at anchor to the tides and westerly winds that predominated over the next six days.

On 14 January, westerly winds of between 10 and 15 knots were experienced, dropping in the early evening to a gentle 5 knot westerly breeze. At about 2225, about one and half-hours before high water and with the ship lying to the tidal stream and heading north-east, a sudden squall was experienced at Broome generating storm force easterly winds. Within seconds, Carabao 1 started to drag anchor directly toward the outer berth.

The Master, who was on watch, informed the engine room that he required the engine immediately, and called out the crew. The Chief Mate and Boatswain went forward to stand by the windlass.

At about 2228, the vessel's starboard bow, just aft of the anchor, came into contact with the eastern corner of the jetty. The vessel, drifting rapidly in a westerly direction, was then driven through the moorings of local fishing vessels. Four vessels were damaged, one of which broke from its moorings and was driven beneath the jetty by the wind and tide.

Between 2230 and 2235, the anchor held once more and Carabao 1 came to a stop close to the shore. Soundings at the ship's stern showed that there was about one metre of water under the keel.

By 2245 the wind had dropped below 20 knots, and the ship was able to recover its anchor at 2318 and move clear of the small craft moorings. By this time the wind had dropped completely away and Carabao 1 anchored once more, 440 m off the outer berth.

No one was injured as a result of this incident. In addition to the four smaller vessels damaged, Broome jetty suffered some damage and Carabao 1 sustained an isolated indentation to its hull plating forward and some superficial paint damage.

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 following factors are considered to have contributed to Carabao 1 dragging anchor and making contact with the jetty and fishing vessels:

  1. The proximity of the ship's anchor position to the jetty in the event that Carabao 1 was driven toward the west.
  2. There was no information available to the Master to warn him of the possibility of squalls developing and causing strong easterly winds.
  3. The delay, however minimal, of starting the ship's engine It is also considered that:
  4. The likelihood of occurrence of such squalls should have been known to the local harbour authority and the pilot.
  5. Even if, with the engine available, contact with the jetty could not be prevented, there was the possibility that dragging of the anchor further west through moored small craft, could have been avoided.

Occurrence summary

Investigation number 129
Occurrence date 14/01/1998
Location Broome
State Western Australia
Report release date 26/06/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Marine
Marine occurrence category Collision
Occurrence class Incident
Highest injury level None

Ship details

Name Carabao 1
IMO number 7368736
Ship type Livestock Carrier
Flag Singapore
Departure point General Santos, Philippines
Destination Broome, WA

Lockheed P-3C, A9-665

Summary

During a search mission, the crew of the P3 Orion aircraft, operating at 1,200 ft, sighted a Cessna 402 on a reciprocal track at 1,000 ft. The Orion crew took avoiding action. The incident occurred near the boundary of the designated search areas of the two aircraft.

Occurrence summary

Investigation number 199805874
Occurrence date 28/12/1998
Location Tasman Sea
Report release date 17/07/2001
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Near collision
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Lockheed Aircraft Corp
Model P-3
Registration A9-665
Sector Turboprop
Operation type Military
Departure point Unknown
Destination Unknown
Damage Nil

Aircraft details

Manufacturer Cessna Aircraft Company
Model 402
Registration VH-PEH
Serial number 402B0913
Sector Piston
Operation type Aerial Work
Departure point Unknown
Destination Unknown
Damage Nil