Summary

On 7 March 1997, the Polish flag general cargo vessel Lodz 2 was lying at no. 24 berth, Victoria Dock, Melbourne. Using one of its own cranes, the ship was discharging a general cargo of steel products, including bundles of steel pipes, from no. 2 hold and tween deck.

At about 0740, the sixth load of steel pipes, for that morning, was being discharged onto the wharf by no.1 crane, a 12.5 tonne capacity crane situated on the aft end of the forecastle on the ship's centreline. The crane was being driven by one of the waterside workers.

The load, weighing approximately 8.6 tonnes, consisted of 18 lengths with diameters varying up to 273 mm. As the load reached the side of the ship, there was a violent jolt and a bang as the slew bearing failed, then the crane fell from its pedestal into the port tween deck of no. 2 hold. The jib struck the port bulwark, setting it down and out from the ship's side, while the body of the crane hit the inboard edge of the port hatch coaming, before rotating through 180 and finishing up, upside-down, in the tween deck.

The driver was able to climb out through one of the broken cab windows and up the ladders, out of the tween deck to the main deck, before the effects of shock caught up with him. He had fallen, in the cab of the crane, approximately 17 metres into the tween deck from the crane's position on its pedestal.

An ambulance was called and the crane driver and a waterside worker acting as the hatchman, also suffering from shock, were taken to a medical clinic but were not detained. The crane was severely damaged, and the badly twisted jib had to be cut up to remove it from the ship.

The incident was investigated by the Marine Incident Investigation Unit under the provisions of the Navigation (Marine Casualty) Regulations.

Conclusions

These conclusions identify the different factors which contributed to the circumstances and causes of the incident and should not be read as apportioning blame or liability to any particular organisation or individual.

1. No. 1 deck crane collapsed due to a catastrophic failure of the slew ring bearing. The crane was not overloaded at the time of the failure.
2. The slew ring bearing failed following a prolonged period of progressive wear which went undetected at any statutory survey or examination.
3. The extreme wear which led to the bearing failure was induced largely by an almost total absence of lubrication for the bearing.
4. The vessel had no established planned maintenance or lubrication schedules for the deck cranes.
5. There was no record relating specifically to a measurement of the bearing clearances at any time since the vessel was built, and there was no record on board of the initial bearing clearances, by which the wear rate could have been established. 6. Damage to the jib of the crane, as witnessed by repairs, may also indicate that damage to the slew ring bearing was initiated by some earlier incident. 7. The standard of record keeping and the absence of detail in certification, together with the condition of the slew bearing of no. 1 crane at the time of the incident, would suggest that the standard of survey over the last five years had not been of an acceptable quality.

Summary

On 22 February 1997 the Bahamas flag bulk carrier Clipper Kawa was lying at the outer anchorage off the port of Albany, Western Australia. The ship had just completed a voyage in ballast from Singapore and was preparing to load a cargo of Australian wheat for Inchon in South Korea.

At about 0815 on the morning of Saturday 22 February, the Bosun, with the two deck cadets and two seamen set to work transferring used dunnage lying on the hatch cover of No.3 hold to the space between the break of the forecastle and No.1 hatch. The plan was to partly deballast No.3 hold for maintenance.

The Bosun and the two cadets went to unlash the forward gantry crane. This done, the senior cadet remained in the starboard driving cab while the Bosun, the junior cadet and the two seamen slung the dunnage. On completion, the Bosun and the two seamen alighted from the port side of the hatch cover, while the junior cadet alighted on the starboard side. The two seamen then went forward, and the Bosun, having received an 'all clear' signal from the cadet on the starboard side, signalled the driver to move the gantry forward to No.1 hatch.

After the gantry crane arrived at No.1 hatch and lowered the dunnage, the Bosun noticed that the junior cadet had not arrived up forward. He walked aft on the starboard side and found the cadet, apparently unconscious, lying against the hatch coaming of No.2 hold. The crew carried him into the crew's recreation room in the accommodation and the Chief Officer started to apply CPR.

Shortly afterwards, on unzipping the overalls of the cadet, it was found that his abdomen had burst open and it was concluded that he was dead.

The postmortem revealed that he had died from shock and haemorrhage following multiple crush injuries.

The incident was investigated by the Marine Incident Investigation Unit under the provisions of the Navigation (Marine Casualty) Regulations.

Conclusions

These conclusions identify the different factors which contributed to the circumstances and causes of the incident and should not be read as apportioning blame or liability to any particular organisation or individual. It is concluded that:

1. The junior deck cadet on board Clipper Kawa died from shock and haemorrhage as a result of multiple crush injuries received after being caught between the power belt idler wheel, on the starboard leg of the forward gantry crane, and the after coaming and hatch cover guide on No.2 hold.
2. The cadet must have been aware that the crane was moving as he had, shortly before, given an 'all clear' signal to the Bosun and had walked forward to a position ahead of the moving crane.
3. There was no sound reason for the cadet to have been in that particular position at the same time as the moving gantry crane and it cannot be known what was in his mind immediately before the incident.
4. There is a possibility that the cadet, mistakenly thinking he had time to cross in front of the moving crane, attempted to cross the crane track to get to the space between the after end of No.2 hold and the deckhouse.
5. The audible alarms on the gantry cranes are not sufficiently loud or 'startling' as to hold a person's attention while the cranes are moving along the deck, particularly in a strong wind and against the background noise of the hydraulic machinery.
6. Although possibly not a significant factor in this incident, the gantry cranes have no warning notices to indicate that they may start moving at any time.
7. Neither fatigue nor alcohol are considered to have been contributing factors in the death of the cadet.

Summary

The Maltese flag general cargo/container vessel Cape Arnhem sailed from the port of Gladstone, Queensland just before midnight on 24 February 1997. As No.2 hatch was clear of containers, the Agent had informed the Master that the Pilot would be taken off by helicopter. The Master had queried this but was assured by the marine Pilot that there was ample room at No.2 hatch for safe helicopter operations.

At 0045, 25 February, the marine Pilot asked the Master to have all the deck lights switched on and for No.2 crane to be topped and swung out to port in readiness for the helicopter. These requests were complied with, No.2 crane being topped and slewed to maximum, the hook also being raised to 'cut-out' position. When this had been carried out, the Pilot informed the helicopter that it was safe to approach the vessel from the starboard side.

The helicopter landed on the starboard side of No.2 hatch at 0105, when the vessel was in the vicinity of S1 and S2 buoys. The marine Pilot went down to the deck and boarded the helicopter, fastening himself into the starboard front seat, next to the helicopter pilot.

The helicopter lifted off the hatch, hovered briefly, tilted and started to move forward, across the hatch, towards the port side. It then started to climb, accelerated and, according to those watching and to their concern, it banked to the left. There was then a loud bang as the main rotor blades struck the hook block of the topped No.2 crane. The helicopter started to rotate, the tail rotor also striking the hook block. The helicopter then flipped upside down and fell to the sea, about 20 m from the ship's side.

The Master immediately informed Gladstone Port Control, started to slow the vessel down and mustered the emergency lifeboat's crew. As soon as way was off the vessel, the lifeboat was launched and sent to the area of the accident.

A local fishing vessel was first on the scene, rescuing the helicopter pilot and recovering the body of the marine Pilot. A marine rescue boat from Gladstone was able to retrieve the upturned helicopter.

The helicopter/aviation aspects of the incident were investigated by the Bureau of Air Safety Investigation (BASI).

Conclusions

These conclusions should not be read as apportioning blame or liability to any particular organisation or individual.

The clear area available at no.2 hatch was in excess of the 16 m required for a Hughes 500 helicopter.

From the evidence provided by the master and officers:

• Cape Arnhem maintained a steady course and speed during the helicopter operation;
• the helicopter banked to the left as it climbed from the hatch.

Although it had no bearing on this incident, the crew were neither well versed nor drilled in helicopter operations, which raises the question of the advisability of utilising a helicopter when there is likely to be no emergency support procedure in place.

The helicopter/aviation aspects of the incident will be the subject of a report by the Bureau of Air Safety Investigation (BASI).

Summary

At 0500 on 10 January 1997, the 39,630 tonne Cypriot flag bulk carrier Tassos N departed the Alcoa wharf at Kwinana W.A., bound for Ferndale in the USA with a cargo of 37,775 tonnes of alumina. The weather was fine and calm and the visibility good. With a Fremantle Pilot on board, the ship safely negotiated the Calista Channel and then the Stirling Channel.

As it entered the Parmelia channel, however, a steering gear fault occurred which resulted in the ship not responding properly to the movements of the helm. The ship's head swung either side of the intended track. As the Pilot attempted to arrest the swing, the bows swung sharply to starboard. The Master switched from No.1 to No.2 steering systems but then, seeing no response from No.2, he immediately switched back to No.1. In spite of the Pilot's helm and engine orders, and dropping the port anchor, the ship grounded in the channel on a heading of 032 with 'L' beacon abeam and only 30 metres from the bridge.

The vessel had grounded only forward and was refloated later that day with the aid of tugs and a change of trim through ballasting by the stern. Damage was confined to the paintwork on the ship's bottom.

The incident was investigated by the Marine Incident Investigation Unit under the provisions of the Navigation (Marine Casualty) Regulations.

Conclusions

These conclusions identify the different factors which contributed to the circumstances and causes of the incident and should not be read as apportioning blame or liability to any particular organisation or individual.

1. Tassos N grounded as a direct result of the failure of the steering gear.
2. The steering gear failed following the perishing and breaking-up of the rubber dust seal within an actuating solenoid on the servo-control hydraulic power unit. As a consequence of this failure, small pieces of rubber jammed the movement of the solenoid causing the failure of No.1 steering system.
3. It is specifically mentioned in the manufacturer's manual, relating to the servo-control hydraulic power unit, that regular inspection or maintenance of the power unit, of which the solenoid was a component, is not necessary.
4. On account of the short time available following the steering gear failure, neither the Master nor the Pilot could have taken action, beyond the measures which were taken, to avoid the grounding.
5. Although the Master changed over steering systems to the No.2 (stand-by) system at the steering console and then changed back to the faulty system, the time available was such that the grounding was inevitable, even had he realised that No.2 system was operational.
6. The Master and other members of the ship's complement were showing signs of fatigue both before and after the grounding. It is not considered, however, that fatigue was a contributing factor in this incident.

The aircraft was observed to become airborne from runway 33 and then to lose altitude with the landing gear extended. The descent was continued, causing concern to the tower controller who activated the crash alarm. After the crew were asked and had confirmed that operations were normal the aircraft landing gear was retracted, and it began to climb.

The investigation found that the flaps had been retracted at the time when the landing gear is normally retracted. Neither pilot had any recollection of making the selection, nor were they aware that the flaps were retracting, until after the stall warning activated during the climb after take-off.

The helicopter operator was hired by a government organisation to assist with locust plague control. The helicopter pilot was required to fly at low level to assess locust numbers in areas identified by ground personnel. When the pilot or his observer reported adequate densities of locusts, the area locust plague controller would dispatch a fixed wing agricultural aircraft to spray the locusts with insecticide.

The accident occurred on the pilot's second day on task. Flying commenced at about 1000. The pilot ferried his helicopter from Quorn to Orroroo, a distance of 42 km, and landed. Then he flew a solo reconnaissance flight for approximately 35 minutes, before returning to Orroroo airstrip. There, an observer boarded for a flight expected to last about 10 minutes. When the helicopter had not returned to the airstrip after about 20 minutes and there was no radio contact, the pilot of an agricultural aeroplane commenced an airborne search. He soon found the helicopter, crashed and on fire in an oat crop.

Evidence at the crash site showed that the helicopter had been tracking approximately south when it collided at about 90 degrees with a single power line, 27 ft above the ground. The wire snagged on the forward crossbeam of the skid landing gear. The wire stretched but did not break as it pulled the helicopter to the ground in a nose low attitude. At impact the main rotors struck the ground, and the instrument console shattered the forward portion of the Perspex windshield. The still unbroken powerline then flipped the helicopter backwards along its flight path where it impacted the ground inverted. During the impact sequence the muffler was dislodged and the fuel system ruptured. A nearby farmer reported that she heard the helicopter's engine continue to run for a short time after the unexpected loss of her household electrical power. Aviation gasoline (AVGAS) was ignited, and the aircraft was consumed by fire. The three strand, high tensile, steel wire comprising the powerline did not break until it was weakened by the intense heat of the post impact fire.

The pilot was suitably qualified to conduct the flight. He was not considered to have been suffering from fatigue, nor was he subsequently found to have been suffering any medical problem which may have contributed to the accident.

No fault was subsequently found with the helicopter airframe or engine which may have contributed to the accident.

Personnel who arrived at the crash site within minutes of the accident reported that the weather was fine. Visibility was excellent, the wind was almost calm, the sun was high overhead, and there was no cloud. The absence of splattered locusts on recovered unburnt pieces of the Perspex windshield/canopy found near the first point of ground impact, indicated that the pilot's forward visibility was probably not significantly obstructed by the windshield immediately prior to the accident.

The power line struck by the aircraft was an east/west spur line spanning 400 m between poles. The nearest pole to the crash site was 186 m to the west. This pole was also supporting a prominent powerline parallelling a gravel road heading south-west. In contrast, the pole at the eastern end of the spurline was near a farmhouse and outbuildings, 214 m east of the accident site. The farmhouse was close to another gravel road heading south but there was no powerline associated with this road.

On the morning after the accident, investigators noticed many locusts within the oat crop and on the ground but few in the air. Later in the day the locusts became airborne, and the enormity of their numbers became obvious. To locate and assess the density of locusts the task often required the helicopter pilot to fly low. There may appear to be few if any locusts in a suspected plague area because they could be within the pasture or crop, or on the ground. When the helicopter collided with the powerline, the pilot was probably in the process of descending low over the crop, expecting the rotor downwash to disturb the locusts enough to prompt them to take flight.

The helicopter was not equipped with any form of wire strike protection system (WSPS) or warning device to detect a powerline. A WSPS was not a requirement in the contract. No known WSPS exists for the Hughes 300. In this occurrence, a WSPS fitted helicopter would probably have cut the wire and survived with little damage to the airframe and no injury to personnel. In previous years, helicopters contracted for the same work had been fitted with WSPS.

A WSPS does not eliminate the possibility of an accident or injury as a result of a wire strike by a helicopter, but it reduces the risk. The safety value of the WSPS has been recognised more in recent years; WSPS is now routinely fitted to military, firefighting, search and rescue, police and ambulance helicopters.

Electronic powerline detection devices are being developed for aircraft. They may enhance safety for future low level operations by providing pilots with warning of a powerline ahead of the aircraft. Some successful trials have already been conducted in Australia.

The pilot would probably have had difficulty detecting the powerline due to the long span of the single wire. It is possible that he either did not see the wire at all, or he may have seen it too late to successfully achieve avoiding action.

The Bureau of Air Safety Investigation is investigating a number of safety deficiencies relating to aircraft operations in non-controlled airspace with a view to reducing the reliance on the unalerted "see-and-avoid" principle as the primary means of separation for fare-paying passenger flights.

For example, the Bureau issued Interim Recommendation (IR) 970155 to the Civil Aviation Safety Authority on 30 January 1998, which resulted from the analysis of a similar occurrence.

The interim recommendation stated in part:

"The greater use of larger and faster aircraft for RPT flights in non-controlled airspace increases the need for the adoption and use of "separation assurance" techniques in conjunction with "alerted see-and-avoid" procedures by all flight crews.

"Although the inclusion of "separation assurance" techniques in airline flight operations manuals would address the deficiency to some extent, procedures for other IFR and the majority of visual flight rules (VFR) flights are also essential. Many pilots may require guidance and training on "separation assurance" techniques.

"Alerted see-and-avoid" procedures used in conjunction with "separation assurance" techniques provide a fail-safe method of self-separation which enhances safety.

"The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority in conjunction with Airservices Australia:

"Review aviation regulations and instructions, with the aim of maximising the use of "separation assurance" procedures in conjunction with "alerted see-and-avoid" procedures by pilots of flights in Class G airspace.

'The Bureau of Air Safety Investigation further recommends that the Civil Aviation Safety Authority:

"Implement an education program for pilots to promote the use of "separation assurance" procedures in Class G airspace".

The first part of the recommendation was sent to Airservices Australia as IR970175.

The crew were operating a de Havilland Canada DHC-6 Twin Otter aircraft in Exercise Highland Pursuit 2/97. The purpose of the exercise, which was conducted by No. 173 Surveillance Squadron, 1st Aviation Regiment, Australian Army, was to provide tropical mountainous flying training in Papua New Guinea. There were three trainees and one training pilot on board the aircraft.

On Sunday, 9 November 1997, the third day of flying operations in Papua New Guinea, the crew were conducting a flight from Madang and return via a number of airstrips in the central highlands. When haze and cloud prevented them flying the flight-planned direct track between the Koinambe and Simbai airstrips, they decided to fly north-west via the Jimi River valley and one of its tributaries. Two of the trainees were occupying the cockpit seats, one as flying pilot and the other as navigating pilot using a 1:1,000,000-scale chart. When the crew turned the aircraft to follow a tributary off the Jimi River, the training pilot was in the aircraft cabin.

A few minutes later, their discussion regarding the progress of the flight attracted the attention of the training pilot. By this time, however, the position of the aircraft in the valley, and its available performance, were such that an escape from the valley was not possible. The aircraft collided with trees before impacting steeply sloping ground.

It was subsequently established that when the crew turned from the Jimi River, they entered the wrong valley. Calculations based on the manufacturer's performance data showed that the aircraft did not have sufficient performance to outclimb the increase in terrain elevation from the Jimi River valley to cross the Bismarck Ranges via this valley. There was a low level of experience and corporate knowledge within the Army regarding the operations of fixed-wing aircraft such as the Twin Otter in tropical mountainous areas.

Against this background, deficiencies were identified in the planning and preparation for the exercise, including risk assessment and the selection and briefing of the training pilot.

In this occurrence, the crew of the aircraft was aware at the time of flight planning that a change in the direction and strength of the wind was expected before their arrival at Sydney. However, this change did not present problems for the crew at the flight planning stage, as the forecast conditions were still acceptable for a landing on runway 34L. During the flight, the changes in the wind direction and strength were still acceptable for the aircraft to use runway 34L until the change in wind velocity which was notified at 0426.

Until that time, the forecasts previously available to the crew contained errors of up to 70 degrees in wind direction. The only forecast which indicated a possibility that the wind would be southerly was the Sydney Airport Weather Briefing supplied to the operator on 14 October 1997.

The investigation was unable to determine why the crew did not act upon the change in wind information, or upon the implications of the resulting excessive downwind component for landing on runway 34L, before passing the DPA. By that stage little time remained in which to initiate a diversion to a suitable alternate airport. The crew did not request a diversion to Brisbane, and this, coupled with the ATC's delay in handling the aircraft after the DPA, eroded the time remaining in which a diversion was feasible.

At all times during the occurrence the aircraft had sufficient fuel to complete the flight to Sydney, and the aircraft landed with more than the minimum fuel reserves in accordance with company policy.