Summary

Ester J, a steel hulled fishing vessel, based in San Remo, Victoria, had been fishing for shark about 50 miles south of Port Phillip during the 25 November 1997, with a crew of three aboard.

At about 0100 Eastern Australian Standard Time on 26 November, the Skipper anchored the vessel in about 75 m of water in position 39 7.88' South 145 19.25' East, about 33 miles south of Phillip Island. The vessel switched on its anchor light and the Skipper and one of the deck hands went to bed, leaving one deck hand on watch.

At or a little after 0200, the deck hand noticed the lights of a ship approaching from an easterly direction. He realised that the vessel was bearing down towards Ester J and he immediately called the Skipper. The Skipper started the fishing vessel's engine and called the unidentified vessel on channel 16 VHF, with no response. There was no time to weigh anchor or cut the cable, so he put the engine full astern, but the two vessels collided at about 0215.

The fishing vessel sustained damage to the port side. The large vessel did not stop or make any attempt to call Ester J. A quick inspection of the damage showed the vessel was not in immediate danger of sinking.

Ester J's Skipper called Melbourne Maritime Communications Centre on the radio frequency 4125 kHz, reporting the incident. He then called his home by mobile telephone.

Nobody was injured and no pollution resulted from the collision.

The hull remained watertight and the engine was operational, so the Skipper set course for San Remo, where the vessel arrived safely at 0800 on 26 November.

Foreign paint samples found on Ester J, apparently as a result of the collision, were collected into glass jars and sealed, to assist in identifying the other vessel.

Conclusions

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

The evidence of the paint samples taken from Ester J, together with the circumstantial evidence of the ship's position at 0215 and absence of any evidence indicating any other ship in the area, satisfies the Inspector that the overwhelming probability is that Pacific Premier collided with Ester J.

Prima facie, the lookout maintained by the officer of the watch and any lookout aboard Pacific Premier was not effective in detecting the presence of Ester J by either direct visual means or by radar.

There was nothing to prevent Ester J anchoring in Bass Strait, however, the position of the anchorage was on the direct track from the eastern seaboard to South and Western Australia and hence in a position of greatest hazard.

Summary

In the afternoon of 26 November 1996, the Australian fishing vessel Nimbus was on passage from Cairns to Thursday Island in company with the fishing vessel Anniki, after both vessels had completed a refit. Each vessel was towing a string of aluminium dories or dinghies in line astern - Nimbus was towing five. The Singapore flag bulk carrier Maersk Tapah was on passage from Gladstone to India with a full cargo of coal. The navigation was under the control of a licensed pilot.

Both vessels were making for a point to the east of Low Isles, about 30 miles north of Cairns. At about 1522, while Maersk Tapah was overtaking Nimbus the two vessels collided. Nimbus sustained damage to its bow and wooden hull. Nobody was hurt and no pollution resulted from the collision.

The Pilot on Maersk Tapah ensured that Nimbus required no assistance and the two vessels exchanged details. Maersk Tapah continued on its voyage to India and Nimbus resumed passage for Thursday Island.

Conclusion

These conclusions identify the different factors contributing to the collision between Maersk Tapah and Nimbus and should not be read as apportioning liability or blame to any particular individual or organisation.

The factors leading to the collision centre on the watchkeeping aboard both vessels and the disregard of the International Regulations for preventing Collisions at Sea.

1. Neither the Pilot or Second Mate of Maersk Tapah made a full appraisal of the overtaking situation and risk of collision; their use of objective means to assess whether or not the bearing of the fishing vessel was appreciably changing was not effective.
2. Maersk Tapah's Pilot accepted an unnecessarily close quarter situation in the overtaking manoeuvre, resulting in contact between the two vessels.
3. With Maersk Tapah's automatic radar plotting aid giving inconsistent data for the vessels being overtaken, the Second Mate did not use compass bearings to establish whether the bearings of the vessels being overtaken were altering appreciably.
4. Maersk Tapah's Second Mate having voiced a concern about the overtaking situation did not inform the Master of his concern.
5. The lack of a lookout or any proper watchkeeping aboard Nimbus meant that the Skipper was not in a position to take action within the requirements of the Collision Regulations to take any necessary avoiding manoeuvre.

Summary

Early on 5 November 1996, the 140,086 tonnes deadweight Malaysian flag bulk carrier Giga 2 was nearing completion of discharge of a cargo of iron ore at No. 2 discharge berth, Port Kembla. Due to the vessel's light condition, the unloader could not be positioned over No. 1 hold, to remove the 1080 tonnes of cargo remaining in that particular hold. At the suggestion of the shift supervisor, ballast was pumped into No. 4 hold, which was permissible under the vessel's operations manual. Pumping of ballast into No. 4 hold commenced at 0530.

After the lunch break, two terminal workers descended into No. 5 hold, where the unloader was working, to clear iron ore from around the bottom of the forward spiral access ladder. The spiral ladder terminated at the top of the lower stool, six metres above the tank top. They had just completed this task and were about to climb the ladder when the bulkhead to the starboard side of the centre line, between No. 5 hold and the ballasted No. 4 hold, collapsed. Both workers were immediately engulfed by the deluge and, although one was able to haul himself clear, the other remained submerged.

The shift supervisor was working in his office ashore and, alerted by calls over the radio from the Hatchman, dashed on board and immediately descended the ladder into No. 5 hold. Up to his neck in the swirling water and guided by the Hatchman above, he was able to grab hold of the submerged worker. Assisted by another terminal worker, who had followed him into the hold, he was able to haul the unconscious and apparently lifeless worker clear of the water. The shift supervisor then administered cardio-pulmonary resuscitation (CPR), which was successful in restoring breathing in the worker. Very shortly afterwards an ambulance officer arrived on the scene and administered oxygen, before the worker was lifted from the hold and taken to hospital.

To identify the circumstances which led to the collapse of the bulkhead, the ship's procedures and documentation were examined. Also, a detailed examination of the bulkhead between holds 4 and 5 was undertaken, which included a metallurgical examination and a finite element analysis of the failed bulkhead.

Conclusions

These conclusions identify the different factors contributing to the collapse of the starboard side of the bulkhead at frame 193 aboard Giga 2 on 5 November 1996 and should not be read as apportioning liability or blame to any particular individual or organisation.

1. No. 4 hold was overfilled beyond its maximum allowable depth of water of 14 m.
2. The Mate relied totally on the remote gauging system for filling No. 4 hold, without physically checking on its accuracy.
3. An inaccurate reading was displayed in the ballast control room by the remote gauging system.
4. As the "high level" alarm was not independent of the gauging system, there were no effective defences, other than physical/visual checks, to ensure that the depth of water in No. 4 hold did not exceed the safe level.
5. There was no clear explanation as to the critical nature of the limit placed on the depth of ballast water in No. 4 hold. This was compounded by a lack of clear operating instructions, either in the native language of the ship's personnel or the working language of the ship.
6. The increase in depth of water from 14 m to 18 m resulted in more than doubling the maximum stresses within the bulkhead structure.
7. The specified size of the welds joining the lower stool shelf plate to the structure beneath it was insufficient to withstand the membrane forces developed at the bottom of the bulkhead with the excess water level in the hold.
8. The design and spacing of the webs within the lower stool, in relation to the corrugations of the bulkhead (and depending on the contribution made by the shedder plates), can result in high stress concentrations being formed within the area of failure at the stool shelf plate.
9. Buckling of the bulkhead, due to extensive wastage by corrosion, if not already started at the moment of failure of the welds, was imminent.
10. Extensive corrosion of the webs in the upper stool resulted in the bulkhead and the stool bottom plate being virtually detached from the upper stool. This would have facilitated detachment of the bulkhead along its upper edge during the failure but did not contribute to initiation of the collapse.
11. The quality of structural surveys of this vessel, over a period of time, was not effective in addressing the problem of substantial corrosion as defined and detailed in the International Association of Classification Societies requirements for enhanced surveys, or as recommended in the International Maritime Organisation's Assembly Resolution A.744(18).

It is further considered that:

1. detection of any deficiencies in the structure of the bulkhead was beyond the scope of Port State control inspections; and
2. based on the system for assessing applications for single voyage permits, there was no reason to refuse the application.

Summary

At 2300 hours on 16 November, the German flag container ship Columbus Victoria anchored in Port Phillip Bay with Point Gellibrand bearing 353 x 1.75 miles. The vessel anchored to the port anchor with 5 shackles on deck in about 12 m of water. The ship's draught was 6.3 m forward and 7.25 m aft. Sea watches were maintained on the bridge and the engine was put on 20 minutes notice. The ship was due to berth at about 0600 on 18 November.

At 1220 on 17 November, the chemical tanker Sampet Hope anchored with Point Gellibrand bearing 346 x 1.35 miles. The anchor position was about 4.5 cables north and east of Columbus Victoria. The tanker had a cargo of non-volatile (kerosene type) solvent in four centre tanks. The weather at this time was fair with a south-south-west to south-west wind at about 8 knots. Sea watches were maintained on the bridge and the engine was left on instant (3-4 minutes) readiness.

From about 1400 on 17 November, the wind backed and increased in strength. At 1800, the wind speed was recorded at the Harbour Control Centre as west of south at 17-25 knots. By 2200, the wind was noted as southerly at 21-31 knots, gusting to 35 knots, with rain. The sea at the anchorage was described as 'short and choppy'.

At about 2215, the officer of the watch aboard 'Columbus Victoria' detected the ship was dragging anchor, the Master was called, and the engine room given notice that the engine was required.

At about 2220, the officer of the watch on Sampet Hope realised that Columbus Victoria was dragging anchor and that risk of collision existed. He called the Master and at 2226 the engine was ordered. At about 2230, crew members of 'Sampet Hope' were deploying fenders as the container ship approached. The engine and bow thrust were ready for use.

At a time put at between 2232 and 2233, the two vessels collided. The initial impact was taken forward of the tanker's collision bulkhead, on the bulbous bow and the flare of the starboard bow. At about this time 'Columbus Victoria' let go the other anchor, but it did not arrest the drift.

A second impact occurred at 2236. By using the bow thrust, engine and rudder, Sampet Hope cleared Columbus Victoria at 2240 and the tanker weighed anchor at 2252 and the master repositioned the ship.

At about 2240, the engine on Columbus Victoria was ready for manoeuvring. At 2250, the vessel started to manoeuvre and weighed anchor at 2305, re-anchoring at 2330 with 7 shackles in the water to the south of its original position.

Conclusions

These conclusions identify the different factors contributing to the incident and should not be read as apportioning liability or blame to any particular individual or organisation. The following factors are considered to have contributed to the collision between Columbus Victoria and Sampet Hope.

1. The Master and Officers on Columbus Victoria took insufficient account of the increase in wind strength and the likelihood that pronounced yawing could trip the anchor out of its holding ground.

2. The time required to prepare the Columbus Victoria's engine for manoeuvring was excessive in the circumstances and the engine should have been ready for immediate use.

3. The 2000 anchor position did not appear to cause concern to the watchkeepers on Columbus Victoria and any ambiguity between the 2000 position and other positions plotted on the chart was not resolved.

4. The lack of decision to move the vessel at 2000 when the Master of Columbus Victoria voiced his annoyance at Sampet Hope's position, when the distance between the two ships had apparently reduced from 0.5 miles to 0.3 miles.

The Inspector further considers:

5. The Master, officer of the watch and crew of Sampet Hope reacted promptly to the emergency and did all that was possible to avert the collision.

6. The anchors on Sampet Hope are apparently not arranged so that they can be slipped in an emergency.

Summary

On the morning of Saturday 19 October 1996, the Antigua and Barbuda flag cargo vessel Karin B entered Corner Basin, Victoria, bound for Esso Australia Limited's private terminal at Barry Beach, where it was to discharge sections of a new drilling rig. Outside the bar, off Corner Inlet, the wind was very fresh from the north-west, but it eased to about 15 knots as the vessel passed through the inlet. Although the sky was threatening and a frontal change forecast, those on the bridge considered they had time to berth the vessel before the front arrived.

While making the turn from Toora Channel into the dredged Barry Beach Channel, Karin B was caught by a sudden increase in wind and was blown on to the mud bank to the starboard side of the dredged channel. The vessel listed 18 to port before stabilising and was towed off the bank during the next flooding tide by the supply vessel Lady Valesia.

No damage was sustained by the vessel and no pollution occurred.

There is no pilotage at Corner Basin, but in compliance with a Gippsland Ports Authority requirement, an offshore supply vessel master, with local knowledge of Corner Basin and Barry Beach Terminal, was engaged to provide advice to the Master of Karin B.

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.

Karin B was caught by a sudden strong wind associated with the passing of a cold front during the manoeuvre into the confined approach channel to Barry Beach Terminal.

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

1. Inadequate strategic and operational planning, in particular in the consideration, by all parties involved, of the safety case and the determination of safety parameters and precautions to be taken for the berthing operations.
2. The function of the offshore supply vessel master was not clearly defined so as to be fully understood by all parties involved.
3. The loose use of the term "pilot", which misled the ship's Master as to the situation at Corner Basin.
4. Readily available, up to date information on the approaching front was not obtained from the Bureau of Meteorology.
5. A perceived need, on the part of the Adviser, to get the job done, which would have affected the level of caution adopted.
6. A lack of communication and co-ordination between the two principal companies, which resulted in the vessel being misinformed.

After taking off on an aerial agriculture flight, the aircraft was observed to turn left at low altitude and dump the load. The left wing continued to drop and the aircraft collided with the ground.

Witnesses observed the aircraft at a height of approximately 200 ft soon after take-off from a local grass strip. The aircraft did not gain height and entered a steep nose-high attitude before apparently stalling. The aircraft then pitched down steeply and collided heavily with the ground. The aircraft was subsequently engulfed by fire. The pilot and two passengers sustained fatal injuries.

The pilot of an aircraft reported that a second aircraft (which was travelling in company) was making a forced landing. He reported a rough running engine and severe vibration. Both aircraft were above broken cloud at the time and were having difficulties finding a clear hole to descend through.

A helicopter found the wreckage near last light on the third day of the search. The aircraft had impacted the ground in a 70-degree dive among trees.

FACTUAL INFORMATION

The pilot had arrived at the property to commence spraying operations on the day before the accident and had been provided with a map of the area by the property owner. In addition, the property owner briefed the pilot on the location of relevant powerlines and other obstructions. However, the pilot did not carry out any spraying on that day, but instead flew the aircraft to Scone, in order to have a minor engine problem rectified. He then flew to Mudgee where the aircraft remained overnight.

The pilot returned to the area the next morning, arriving on site at about 0645 ESuT. After spraying approximately 175 acres on an adjoining farm, he commenced an aerial inspection of the next property to be treated but declined an offer by the property owner to accompany him in the aircraft so the property boundaries and powerlines could be pointed out. The aircraft was seen to make three passes over the area before it descended in an easterly direction, toward a crop of barley. A gentle rise, which included a dam bank located at the corner of the crop, had to be negotiated in order for the pilot to position the aircraft at the correct operating height for the swath run. A spurline, suspended over the crop and running in a northerly direction, was located a further 40 m beyond the dam.  A witness reported that the aircraft had appeared to be maintaining level flight, and had commenced spraying, when it struck the spurline, then impacted heavily with the ground and overturned, fatally injuring the pilot. The weather in the area at the time of the accident was reported as fine, with light winds.

The aircraft struck a three-wire spurline which ran in a northerly direction over the crop, at right angles to its flight path. The line spanned 165 m from the main powerline to the first spurline pole, located about 100 m from a house and to the left of the flight path. A number of large trees nearer to the house provided a backdrop to the spurline pole. A strainer wire stemming from the main powerline was positioned some 92 m further on in the direction of the intended flight path. It was about 10 m in length and ran parallel to the spurline. The strainer wire passed over a road and was attached to a support pole located one metre from the edge of the barley crop. The pilot had commenced the first swathe run by flying in an easterly direction, towards distant rising ground which was cloaked in shadow, whilst the powerline in the foreground was set against this backdrop.

The aircraft was an Airparts New Zealand Fletcher FU-24/A4, fitted with a Lycoming 10-720, 400 hp engine and a three bladed, constant speed Hartzell propeller. Such aircraft are used widely in New Zealand, and to a lesser extent in Australia, principally for agricultural operations. Although they are most often used for the aerial spreading of solids onto crops and pastures, this particular aircraft could be equipped for spreading or spraying. The hopper had just been refilled prior to the pilot's aerial inspection and was believed to contain about 1000 kg of a non-toxic spray medium. The spray equipment fitted to the aircraft consisted of booms with standard spray nozzles, and a wind-driven spray pump. Depending on the conditions, spraying with this equipment generally required the aircraft be flown with the spray nozzles at a maximum height of 6-10 ft above the crop. At the time of the accident the aircraft was being operated at or near its maximum weight. The aircraft was not fitted with wire deflectors or cutters.

An on-site examination of the wreckage revealed that the powerline had removed the cockpit canopy before slicing off a major portion of the vertical fin. The aircraft then continued forward a further 90 m, before it collided with the ground and overturned. The design of the aircraft provided limited rollover protection, with the result that the upper cockpit area was grossly disrupted.

Given the position at which the spurline wires had sliced through the vertical fin, it was calculated that the aircraft was flying some 8-10 ft higher than the normal spraying height. There was no evidence found of any condition which may have affected the normal operation of the aircraft.

The pilot held a valid licence for the operation being undertaken. He had accumulated some 7,200 flying hours, of which 5,500 hours had been flown in helicopters. Of the 1,700 hours of fixed wing flying, some 800 hours was agricultural flying. He had completed a biennial flight review on 2 October 1996 but had not flown any aircraft between 28 April 1991 and 21 August 1996. The pilot had not flown a Fletcher before commencing work for the operator one month prior to the accident flight. He had then flown about 28 hours in the aircraft, with much of that time engaged in the aerial spreading of superphosphate and urea, an operation which is normally carried out at a height of about 200 ft.

Three days before the accident the pilot commenced taking two prescribed medications for diarrhoea and nausea resulting from an intestinal condition. An aviation medical practitioner indicated that the main concern with such a condition is dehydration, possibly exacerbated during the initial days of treatment by the medications. Some of the effects of dehydration are general fatigue, reduced levels of concentration and drowsiness.

ANALYSIS

Aspects of the pilot's experience, his general wellbeing, and the visual cues available to him to locate the position of the spurline, were considered to be significant factors in the development of this accident. Pre-existing aircraft equipment and structural design factors were also considered relevant to the non-survivability of the pilot.

Whilst the pilot had considerable overall flying experience, he had not flown during the previous five years, having only returned to flying about one month prior to the accident. In addition, he had limited experience on the aircraft type, particularly in low-level spraying operations. This would have made it more difficult for the pilot to accurately position the aircraft at its correct operating height for the swathe run, after manoeuvring to negotiate the gentle rise and dam bank.

It is possible that the performance of the pilot may have been somewhat impaired by the effects of his medical condition. This could have included fatigue, reduced levels of concentration and drowsiness, resulting in a momentary lapse in awareness prior to striking the powerline; or he may simply have been unaware of its location.

If the pilot had not located the position of the spurline during his aerial inspection, due to the unobtrusive location of the spurline poles, he may have believed the line was located further along the swathe run due to the more obvious presence of the support pole adjacent to the crop. As a result, he could have considered he had more space in which to descend, in order to pass beneath what he thought were the only powerlines passing over the crop. There would have been little opportunity for the pilot to have seen the line during the approach to the crop. The orientation of the spurline in relation to the flightpath, the lack of contrast available to discern the wires from the background, and the difficulty in locating the poles of the spurline, were factors which support this view.

Damage resulting from the wirestrike may have been reduced or eliminated, had the aircraft been fitted with a suitable wire deflector/cutter system. The installation of such equipment was not required for the operation being conducted. The design of the aircraft provided limited structural rollover protection, and in this occurrence, the degree of disruption to the upper cockpit area made the accident non-survivable, even though the pilot was wearing a protective helmet.  With the canopy already separated from the fuselage, and with no other form of rollover protection, the pilot was exposed to the brunt of the impact forces as the aircraft overturned.

SIGNIFICANT FACTORS

1. The pilot had limited recent flying experience.
2. The pilot had limited experience on the aircraft type, particularly with regard to low-level spraying operations, prior to the accident.
3. The performance of the pilot may have been impaired by the effects of a medical condition he was suffering from.
4. The location of the spurline was difficult to see and may have been confused with an apparent powerline, further along the intended flight path.
5. The aircraft was not fitted with any form of wire deflector or cutter.
6. The aircraft provided limited structural rollover protection for the pilot during the accident sequence.

The task was to spray a paddock which contained two sets of wires. The pilot was aware of the wires and planned to fly under the high-tension wires mounted on pylons, and over the smaller dual set of supply wires. On about the sixth spraying run, and after successfully flying under the high-tension wires, the aircraft was seen to level off in the pull-up manoeuvre and attempt to fly under the second set of wires. The aircraft contacted the wires and descended into the ground. It then bounced up in a fireball and impacted the ground a second time.

When observers arrived at the scene, the aircraft was burning fiercely, and rescue of the pilot was not possible.

The pilot was given a briefing and a map of the area to be sprayed. Both of these included information about the two sets of wires on the property. The pilot told the aircraft owner that he planned to fly under the first set of pylon wires and over the second set of smaller, lower wires. He was seen to orbit the paddock a number of times after arriving in the area and before commencing his first swath run. The pilot operated according to his stated plan for about six runs before he struck the wire.

The pilot was reported to have a safety orientated work ethos and demonstrated a professional approach to his work. His chief pilot had observed him on several occasions when he would have been unaware that he was being watched and, on these occasions, he did not demonstrate any unsafe tendencies.

Studies have been conducted over the years aimed at identifying deficiencies in agricultural operations, in particular, those associated with wire strikes. It is generally accepted within the aviation industry that wires present a constant hazard to agricultural flight operations, and, in this case, the pilot took appropriate actions to minimise the danger to his task. It was not determined why the pilot did not fly over the second set of wires, after successfully clearing them on about six previous occasions. The tolerances in an under and over operation, such as this, are narrow, and small distractions to the pilot's focus on the wires could result in a miscalculation.

No evidence of aircraft or engine malfunction was found in the investigation, nor was any predisposing medical condition identified. The pilot showed no signs of fatigue, and his demonstrated skills were suitable for the task allocated.