Summary

At 0840 on 29 September 1994, the Russian container vessel Kapitan Serykh sailed from Brotherson Dock, Botany Bay under the direction of a pilot of the Sydney Ports Pilot Service and with the assistance of two tugs. The wind was from the north-west at 20-30 knots.

The vessel cleared the dock stem first and was then turned to starboard to make the approach to the dredged departure channel. The two tugs were released as soon as the vessel had been turned in the swinging basin.

Kapitan Serykh failed to provide sufficient propeller thrust and to gain sufficient speed to fully execute the eighty degrees turn into the departure channel, despite the Pilot's repeated call for full ahead and grounded on the south side of the channel at 0900.

The vessel was refloated, with the assistance of tugs, after about half an hour and returned to Brotherson Dock, where divers ascertained there had been no structural damage to the vessel.

Conclusions

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

It is considered that:

1. The grounding was the result of Kapitan Serykh not attaining sufficient propeller thrust/speed to execute the turn on to the leads in the wind conditions at the time.
2. The exchange of information between the Master and the Pilot did not conform to the requirements of the International Convention on Standards of Training, Certification and Watch keeping for Seafarers, or with the guidelines contained in the International Chamber of Shipping's "Bridge Procedures Guide".
3. For reasons unknown, the Master did not provide the manoeuvring full ahead pitch, as indicated on the pilot card, repeatedly requested by the Pilot.
4. The option of putting Kapitan Serykh aground on the sand shelf, as against colliding with no.6 beacon, was the one less likely to cause damage to the vessel.
5. Had the Pilot been informed of the steerage problem during port entry in the high winds on 27 September 1994, he would have been forewarned of a possible problem during departure.
6. It would appear to be appropriate, under strong wind conditions, for a pilot aboard a high windage area vessel to retain the tug(s) until the turn on to the Port Botany leads has been seen to be progressing satisfactorily and for the Port and Pilotage authorities to have a written policy on the subject.

Summary

At about 1100 on 9 August 1994, the Panama flag bulk carrier Kayax was alongside in the port of Portland, Victoria, to load a full cargo of grain.

A Surveyor from the Australian Maritime Safety Authority boarded the vessel to undertake a grain loading inspection and a port state control inspection.

As part of the port state control inspection, the port lifeboat was lowered to the boat deck and then recovered to its embarkation position at the davit head. In this position the surveyor asked to see the lifeboat engine run ahead and astern. After some minutes, with the engine running but the shaft in neutral, the boat suddenly became detached from the lifeboat falls and fell to the water, a distance of a little under 20m.

In the boat were the Second Mate and two ratings. The Master was just getting in when the boat fell. The four men were admitted to hospital with significant injuries, the Second Mate suffering serious head and spine injuries requiring prolonged hospital care and rehabilitation.

The boat was recovered from the water and an investigation initiated into the circumstances and causes of the incident.

Conclusions

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

1. The boat was released by the operation of the releasing handle by one of three people actually in the boat.
2. The port lifeboat on-load release mechanism safety pin preventing movement of the quadrant was not in position and the release system was in the "armed" condition.
3. Although the boats were swung out at regular intervals and the general maintenance ensured the boats were in good working order, the vessel's crew were insufficiently practiced in using the on-load release gear.
4. None of the three people in the boat understood how the on-load release mechanism operated.
5. The two languages used in the instruction manual and on notices inside the boats were inappropriate, given the nationalities of those involved, and the instruction diagrams were not fully understandable without a good knowledge of either Japanese or English.
6. Difficulties in communication through the differing nationalities was a factor in understanding the release mechanism and in passing instructions covering non-standard operations.
7. The incident could have been prevented by the fitting of an operational interlock designed to ensure a two-stage release.

Summary

On the night of 28-29 April 1994, the privately owned Provincial Trader became disabled in the eastern area of Bass Strait, whilst on a voyage from Adelaide to Cairns. Provincial Trader was a former tug of 418 gross registered tonnes [739 tonnes displacement] with a length of 42m.

The skipper advised Melbourne Marine Communications Service of the situation and later contacted the owner in Cairns. The owner arranged for the Eden based 14.8m work boat Broadwater to tow the vessel the 100 or so miles to Eden and also to take out some compressed air bottles to the vessel. Broadwater commenced the tow at 0300 on 30 April but proved inadequate and the tow was relinquished to the fishing vessel Rubicon at 1215 on 30 April.

Water had been accumulating in Provincial Trader's engine room bilge from early on 29 April, eventually causing some concern. However, the engineer was able to start the bilge pump after receiving the compressed air bottles and the water level was reduced and stabilised.

When the tow was approaching Twofold Bay, NSW, early on 1 May, Provincial Trader's engine room suddenly and rapidly filled with water and the skipper ordered the crew to abandon ship. Provincial Trader sank just 530m outside the Eden port limits, the crew being rescued by Rubicon.

Conclusions

It is considered that:

1. Provincial Trader foundered as a result of a sudden great increase in water ingress, but it was not possible to ascertain the cause or the point of ingress.
2. The skipper and engineer acted appropriately to the conditions existing at the various times and the loss of Provincial Trader was not the direct result of those actions.
3. Notwithstanding the fact that the vessel was registered with the South Australian Authorities as a motorboat (pleasure craft), there were insufficient proficient crew members on board to undertake the voyage safely and to respond to the emergency.
4. Broadwater was not a suitable vessel for the task.
5. Had a suitable towing vessel been engaged in the initial stages, Provincial Trader would most probably have been delivered timely and safely to Eden before the flooding occurred.
6. Had a salvage pump been delivered by Broadwater or transferred from Osprey, it is a matter of conjecture as to whether the emergency situation would have arisen. With a salvage pump to back up the bilge pump, the increased inflow of water may have been contained until such time as the vessel had been delivered into Eden harbour.
7. Bearing in mind the age of the vessel, the time out of survey and in lay up, a full survey to ensure seaworthiness would have been appropriate before Provincial Trader sailed from Adelaide.
8. Commonwealth and State legislation is deficient in that not all definitions are standard and common to the various jurisdictions.

Summary

On the morning of 2 June 1994, the Australian Maritime Safety Authority navigational aids service vessel, Cape Grafton was anchored off Dent Island in the Whitsunday Group, Queensland. Cape Grafton, a diesel/electric powered vessel, had arrived in Australia in March, having been built and fitted out in Spain. The vessel was on its first operational deployment and was scheduled to carry out routine maintenance on Dent Island lighthouse.

At about 0740, Cape Grafton started to weigh anchor to move closer to the lighthouse and to make a lee for the work boat, which was used to convey men and materials to the land.

Anchor was weighed at 0752 and the Master manoeuvred towards the lighthouse turning to starboard, away from the island, before making the necessary lee. At about 0755 the vessel suffered a total loss of power for a few seconds, this 'blacked out' all means of propulsion and instrumentation for a critical period. Although electrical generating power was restored within a few seconds and machinery was restarted, control was not restored in time to prevent the vessel running aground, despite letting go the anchors.

The grounding was relatively minor in nature and Cape Grafton refloated without assistance on the afternoon tide. Nobody was injured and no pollution resulted from the grounding.

Such vessels are required to routinely operate close to the shore or navigational hazards, where commercial vessels would not normally navigate.

While the investigation established operational factors which contributed to this particular incident, significant defects in the ship's systems meant that the vessel was vulnerable to loss of control. Put simply, if the accident had not occurred on 2 June, there is a strong probability that it would have occurred at some time in the future due to incorrect control settings, the configuration of interfaces between the main units in the vessel's propulsion system and deficiencies in the supply of emergency power to essential navigational instruments, as they existed at the time.

The report outlines the background to the incident and considers the contributory factors.

Conclusions

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

The Inspector concludes:

1. The grounding of Cape Grafton was the chance coming together of a number of factors at a time when the vessel was close to shore in a vulnerable position and reaction time was limited.

2. There is little doubt that, had those on the bridge and in the engine room worked together properly, had the Master thoroughly understood the operation of the propulsion system and the steering, had the secondary systems and local controls available in an emergency been appreciated and had these been utilised, the grounding could have been prevented. This lack of operational knowledge, however, was compounded by significant systems defects and management deficiencies.

3. The investigation found a general lack of understanding, throughout the AMSA Ship Operations staff, of the operation of the ship's systems, control equipment and protective devices, in particular the interfaces between the various units comprising the propulsion system and its controls, the overload protection system, the engine room data-logger and printout, and the emergency generator and switchboard. This was due, in part, to the absence of any instructions or manuals explaining how the different components worked as a system or detailing the interconnections between each unit, the bridge and engine room control centres. This general lack of understanding, and the lack of any drawings of the overall propulsion machinery system, led to the commissioning of the Novamarine report on the functioning of these systems.

4. Both the absence of accurate 'as fitted' drawings and those defects that were factors in the grounding, together with problems experienced in wiring circuits and other systems not directly related to this report, call into question the quality control regimen followed by the various parties involved and the validity of quality assurance in the face of such defects.

It is further concluded that the following factors contributed directly to the grounding of the Cape Grafton:

1. The Master's lack of understanding of the propulsion system and the fact that he:

(a) did not take early action to stop the propulsion motors, or

(b) declutch the propeller shaft, or

(c) utilise the backup pitch and emergency steering controls.

2. The auto slow down system, intended to protect the generators on overload was defective:

(a) it was disconnected at the propeller pitch control central unit;

(b) there had been a failure to ensure that the system was reconnected after defective sensors had been replaced in Brisbane;

(c) it is possible that, even had these wires remained connected, the system would have failed as the overload trips were set too low and the time setting between the overload signal from the generators and the tripping of the generator circuit breaker was incorrectly set.

3. There was a loss of emergency electrical power to the navigational instruments, particularly the rudder angle and pitch indicators, through:

(a) the design of the emergency generator auto-start system, in that it was able to sense that a main generator was running, although the tie breaker between the main and emergency switchboards was open;

(b) the division of the emergency switchboard into essential and non-essential supplies and the supply of power to the bridge instrumentation, pitch control and one steering system, from the non-essential bus.

4. The wiring of the zero pitch interlock between the KaMeWa system and the propulsion motor starters was not properly connected and allowed the propulsion motors to be started with pitch on the propeller.

5. The lack of interlocks requiring the clutches to be disengaged before a propulsion motor could be started.

6. Defects in the management system leading to:

a) the installation of equipment that was not thoroughly tested in all respects;

b) the installation of systems not thoroughly understood by management or ship staff;

c) ineffective quality control during the installation of electrical and control systems;

d) the failure to undertake a suitable risk assessment for the new vessel, relating to its frequent operation close inshore in hazardous waters.

7. The failure of the ship's emergency generator and associated electrical circuits, to comply with Marine Orders Part 20.6.5.1 (d) (ii), in respect of the maintenance of a power supply to the shipborne navigational equipment, which includes indicators for rudder angle, pitch and the operational mode of the propeller.

8. The lack of clear, uniform operational instructions and procedures, common to bridge and engine room, for starting and operating the ship's propulsion and associated machinery.

9. The absence of any contingency planning for the passing of machinery control from the bridge to the engine room under emergency conditions or plans to utilise the backup pitch control and the emergency steering in the steering flat.

10. The absence of any structured training for the operation of Cape Grafton that would have provided an overall concept of the elements of the propulsion system and how they interfaced with each other.

Summary

On 3 March 1994, the Australian flag tanker Australian Achiever arrived off the floating production storage offloader Griffin Venture off the north-west coast of Western Australia and drifted, during the morning, while awaiting a pilot.

Before morning tea, the Extra Second Engineer showed the Engineer Cadet, the forward domestic fresh water pump and gave him instructions on how to remove the pump to the workshop for overhaul, a task that the Cadet was to undertake after the morning tea break. The Extra Second, in preparation for removal of the pump, ensured that the pump starter isolator and selector switches were in the "off'" position. As the Extra Second was quite clear in his mind that the job involved no electrical work, the fuses were not removed and no "danger" tag was attached to the starter.

During the morning tea break, the Fifth Engineer who was the duty engineer for the day, responded to an engine room alarm which indicated a fault on the vessel's 24 volt DC system, a common cause for alarms.

Shortly after the tea break, the Fifth Engineer again responded to an alarm which he took to be another 24 volt DC earth fault, but which cleared as soon as he "cancelled" the alarm. Later evidence showed that it had been an earth fault on the 440 volt system, in all probability caused by the Cadet having come into contact with a "live" terminal within the starter box for the forward fresh water pump.

At approximately 11 13, some 34 minutes later, the Third Engineer came across the Cadet lying on the deck between the fresh water pumps and the calorifiers. He was not breathing and no pulse could be detected. The door to the starter box for the forward fresh water pump was open and the isolating switch was in the "on" position. The vessel's emergency team was called and resuscitation techniques were applied but without success.

A helicopter, attending the Griffin Venture, was tasked to land on the deck of Australian Achiever and to airlift the Cadet to hospital at Exmouth. Resuscitation techniques were applied throughout the flight but, shortly after arrival, the Cadet was declared dead by hospital staff.

Conclusions

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

1. The findings of the Coroner's inquiry were that the Cadet died by electrocution following contact between his right hand and a live terminal within the starter box for the motor on the forward domestic fresh water pump.
2. The Cadet had been given the task of removing the forward fresh water pump for overhaul, a task which was well within his mechanical abilities. It is considered likely, although it cannot be stated with certainty, that he considered the fuses should be removed prior to commencing work and he was about to do this when he accidentally touched a live terminal with his hand.
3. In order to open the front cover of the starter box to gain access to the fuses, it is necessary to turn the isolating lever to the "off" position. It seems that the Cadet, having opened the front cover, must have turned the isolating switch back into the "on" position, possibly using the spring-steel clip on his key-ring to obtain sufficient leverage.
4. The reason for the Cadet having turned the isolating switch back to the "on" position is unclear. It may have been done during a momentary lapse in concentration or he may have been investigating the function of the interlock. The isolating switch is clearly marked showing the "on" and "off" positions of the small T-bar through the end of the spindle.
5. The alarm for channel 212, recorded on the alarm print-out at a time equivalent to 1039 (ship's time), indicating an earth on the vessel's 440 volt system, was probably initiated by the contact between the Cadet and some live part of the starter for the forward domestic fresh water pump.
6. The Fifth Engineer acknowledged the alarm four minutes later at 1043. As the alarm channel cleared as soon as the "cancel" button was pushed, he was uncertain as to which alarm had been activated and assumed that it was a repeat of the earlier alarm for an earth fault on the 24 volt DC system. The Inspector considers that, as the earth fault was shown as having cleared, there was not cause for further immediate action on the part of the Fifth Engineer.
7. It is not known with certainty whether the Cadet's hand contacted a point in the starter which was at 440 volts or at the control circuit voltage of 110 volts. It is likely, in view of the 440 volt earth alarm recorded at 1039, that it was at 440 volts. In either case, however, heat and humidity in the engine room cause considerable perspiration which would have increased the current flow through his body and, particularly in the case of 440 volts, could possibly have aided in the initiation of an electrical arc. It is not known, either, exactly how long he was in contact with the supply of current as the alarm print-out indicates only the time between the initiation of the earth fault and the time that the alarm was "cancelled" in the control room.
8. The procedures detailed in ASP Ship Management's "Safety and Emergency Procedures Manual", relating to machiney isolation, were not followed. The Extra Second Engineer stated that he had checked that both the selector switch and the isolator for the forward pump starter were in the "off" position. The job of removing the pump was not of an electrical nature and, for this reason, he had not carried out the usual precautions required before undertaking electrical work, such as removing the fuses and "tagging" the starter.
9. The reason for the Cadet having opened the door of the starter cannot be known but, in order to do so, the isolator switch had to have been turned to the "off' position. If, as is possible, he opened it to remove the fuses then under these circumstances, whether or not a safety tag had been attached to the equipment would have had no bearing on the outcome of the incident.
10. The Cadet was found lying on the deck shortly before 1113. No resuscitation techniques were applied before the Emergency Team arrived some minutes later. It was not known at that time that he was dead and, in the absence of a pulse or respiration, CPR should be applied immediately. It is acknowledged, however, that if the alarm at 1039 indicated the time he received the fatal shock, the outcome would have been no different.

Summary

On 19th April 1994 the New Zealand flag ro-ro vessel Union Rotoma was on passage from Nelson in New Zealand to Port Botany in NSW when, at 1835, alarms were sounded by the vessel's automatic fire detection system indicating a fire in the engine room. The duty engineer quickly reported that the aft end of the port main engine was on fire. The fire was spreading very rapidly and the decision was taken to evacuate the engine room and to flood it with the ship's fixed carbon dioxide extinguishing system. A "Mayday" message was transmitted by Inmarsat C and was acknowledged by the Maritime Rescue Coordination Centre in Canberra.

While the crew were shutting down the engine room, the bulk CO was released. The main engines had been stopped from the bridge. Shortly after the release, the running generator stopped, indicating that it had been stifled by the CO. Approximately one and a half hours after the release of CO, two engineers wearing breathing apparatus made an inspection of the engine room and reported that the fire had been extinguished and there were no remaining hot spots.

The engine room was purged of CO before a further inspection was made and the generators were started to restore full electrical power. The inspection revealed that oil, spraying from a fractured pipe on the starboard engine, had ignited on the hot exhaust manifolds of the port engine. The pipe, carrying lubricating oil to the engine's overspeed trip mechanism and to the camshaft bearings, had been fractured by the movement of the camshaft anchor bearing housing moving out of the entablature, into which it had been secured by eight 20mm diameter set bolts, all of which had sheared or worked loose.

Damage caused by the fire was slight, involving mainly instrumentation and wiring. The ship was able to proceed on its voyage to Port Botany using only the port main engine.

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 contributing to the accident and should not be read as apportioning blame or liability to any particular organisation or individual.

1. The fire in the engine room was caused by a spray of lubricating oil, from a fractured pipe on the starboard main engine, being ignited by the hot exhaust manifolds on the port engine.
2. The lubricating oil pipe was fractured when the housing for the camshaft anchor bearing worked its way out of the entablature, consequent upon the failure of the eight securing set bolts.
3. The set bolts which secured the bearing housing in the entablature had no form of locking and should have had cross-drilled heads and been laced with locking wire.
4. It was not possible to ascertain when the securing set bolts had been fitted, but it appears that they must have been fitted when the vessel was in the hands of previous owners. At the time that they were fitted, they were probably not pre-loaded to the required torque.
5. Engine vibration would have contributed to the failure of the bolts.
6. The response of the vessel's firefighting organisation was both fast and effective. This was due in large part to the fact that all officers and key personnel had personal UHF radios and excellent communications were maintained between all those involved throughout the incident.
7. Realistic fire drills carried out on a regular basis, incorporating such techniques as using radios while wearing breathing apparatus and scenarios such as engine room fires requiring C02 flooding, contributed to the efficiency with which the fire was extinguished.
8. No portable oxygen analysers were available on board with which to test the atmosphere in the engine room after it had been vented to clear the CO. Although not a statutory requirement, had one of these been available it would have minimised the risk to personnel when re-entering a space which had been flooded with CO.

Summary

In the early hours of 24 February 1994, the Norwegian flag (NIS) offshore anchor handling and supply vessel Boa Force was engaged in deploying anchors from the offshore construction barge, Support Station III, about half a mile south of Thevenard Island, 11 miles north-west of Onslow, Western Australia.

Anchor handling vessels do not navigate in the accepted meaning of the term but are directed to go in directions determined by the person controlling the operation on board the parent vessel, in this case, using a differential global positioning system and monitor.

In the immediate area of Boa Force's operation, there was a pipeline, marked at regular intervals with temporary buoys and an unmarked subsea wellhead, standing about 3m high in a general seabed depth of under 8m of water. The well itself was not active and had been capped and suspended for some time. To the west, and about 70m from the wellhead, a new pipeline had been laid, running from oil production platforms to Thevenard Island.

At about 0220 Western Australian Standard Time, Boa Force recovered the barge's number one anchor from close to the wellhead. Those on the barge were concerned with the proximity of the wire to the wellhead. Boa Force was ordered to go in a northerly direction to ensure that the wire was clear, before the barge recovered the wire prior to repositioning the anchor.

At about 0250, while moving stem first towards the barge, Boa Force hit the wellhead and holed the engine room space in the only area where the vessel did not have a double hull.

Despite efforts by the Chief Engineer, the Second Engineer and an Integrated Rating, the vessel's pumps could not keep up with the ingress of water. A launch was sent from the Support Station III to stand by Boa Force. A little before 0345, the Master ordered the crew to abandon Boa Force and by 0345 the complement of eleven were on board the launch.

The vessel sank to the seabed partially supported by the wellhead. A boom was deployed to combat any pollution.

An operation to raise and dispose of Boa Force was completed on 6 April. This involved lifting Boa Force clear of the wellhead, patching the breach in the hull, and recovering all oil and other pollutants. The vessel was then towed beyond the continental shelf and scuttled.

The incident occurred in Western Australian State waters, where shipping is administered by the Western Australian Department of Transport, and the general operation, connected with the petroleum industry, came under the provisions of legislation administered by the Western Australian Department of Minerals and Energy. Boa Force was a "declared vessel" under the provisions of the Navigation Act 1912 and its Australian Master and crew held Commonwealth qualifications. Therefore, in addition to the flag State, three Australian administrations had jurisdiction to investigate the incident (Commonwealth Department of Transport, Western Australian Department of Transport and the Western Australian Department of Minerals and Energy), however, by mutual agreement the authorities agreed to conduct a joint investigation in accordance with the provisions of the Navigation (Marine Casualty) Regulations.

Conclusions

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

The sinking of Boa Force was the result of a series of factors which combined to cause the vessel to make contact with Saladin No.3 wellhead.

These were:

1. The failure to temporarily mark the location of Saladin No.3 wellhead with an adequate buoy.

2. The failure to use adequate and accurate charts, or drawings, or plans to enable the anchor laying operation close to the south of Thevenard Island to be conducted in safety.

3. The provision of bathymetric data which was in error by about 1.6m.

4. The failure to supply a differential global positioning system monitor to Boa Force to provide the Master with a display of the operation upon which known hazards could be plotted.

5. The lack of appreciation on board Support Station III of the problems in manoeuvring an offshore anchor handling vessel in a relatively confined area for a prolonged period without an effective point of reference.

6. The failure of the job safety analysis to properly take into account the operational safety issues of an unmarked subsea well.

7. The lack of local marine knowledge and expert marine advice in the planning and operational stages to address the above issues.

8. The failure of the Master of Boa Force to check known depths on 20 February, following an apparent bottom contact, particularly as it was known that the vessel would have to operate in the same area to retrieve the anchor at a later time.

9. The possibility of fatigue, resulting from the operational program, cannot be ruled out.

Other Conclusions:

10. Boa Force met the requirements of the Navigation Act 1912 and subordinate regulations and orders. All certificates were valid.

11. The provision of plans and documents in the Norwegian language did not facilitate the effort by those on Boa Force to control the emergency.

12. The Master, Deck Officers and Engineer Officers should have considered trying to restrict the extent of the flooding by closing all doors and hatches, consistent with the safety of the engineers in the engine room. Any decision not to close doors should have been based on known effects of flooding of the vessel.

13. The damage stability characteristics of the vessel met the relevant criteria for an offshore supply vessel under the provisions of Marine Orders Part 46 and IMO Resolution A. 469(XII), but the criteria did not allow for penetration of the hull inboard of the line of the inner bulkheads of the side tanks.

Summary

On 14 February 1994, while Searoad Mersey was sailing from Grassy Harbour and making the turn around Grassy Island, fog obscured the leading marks which when in line indicate the centre line of the main channel. The Master continued his manoeuvre onto the correct course, but the ship made contact with the northern end of Omagh Reef.

Although the hull was penetrated in way of three ballast tanks, once the situation had been stabilised the ship was able to continue its voyage to Melbourne.

The Master had been appointed to the ship at short notice and had little experience of the port, where masters have to do their own pilotage. With the leading marks obscured, there were no other visual aids to indicate the ship's location with respect to the centre of the 150m wide channel.

Conclusions

It is considered that the contact with Omagh Reef was brought about by a combination of a number of factors, the most important being:

1. The obscuring by fog of the Grassy Harbour front and rear lead marks, these being the only visual aid to indicate a ship's position relative to the centre of she departure channel.

2. The Master's lack of experience of the port.

3. The Master's conservative use of propeller pitch, giving a reduced rate of turn, together with the delay in the commencement of the turn and wind drift due to the easterly wind, resulted in the turn being too wide.

It is further considered that:

4. The long period between the Master's familiarisation voyages and his appointment to the ship nullified the value of the familiarisation voyages.

5. A beacon located on the 4.2m sounding off Grassy Island would provide a point of reference, other than the leads, for making the tight turn around Grassy Island.

Summary

On the evening of 31 January 1994, the Port of Melbourne Authority's suction dredger A M Vella was operating at the eastern end of the South Channel, Port Phillip Bay. The cargo vessel Searoad Mersey, under the command of a "pilot exempt" master, entered Port Phillip Bay on its regular scheduled service. The vessel had received clearance to enter from Point Lonsdale Signal Station, which also advised of the A M Vella dredging operation.

The weather was fine, with good visibility, however, with the sun having set, the light was fading rapidly.

At 2150, while trying, to pass A M Vella "port to port", Searoad Mersey made contact with No. 15 beacon, on the south side of the channel, then at about 2151, collided with AM Vella, striking the dredger on its starboard side, immediately abaft the forecastle.

Both vessels sustained damage, but no-one was injured, and no pollution occurred as a result of the collision.

Conclusions

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

It is considered that the collision was brought about by a series of factors:

1 . In the first instance, the Master of Searoad Mersey did not ascertain the actual position of A M Vella in the channel.

2. Having acquired A M Vella as a target on the ARPA, the Master conducted Searoad Mersey on an assumption based on the initial information from the ARPA and did not properly monitor A M Vella's movements.

3. In endeavouring to maintain a "port to port" passing., the Master. kept the ship on the southern boundary of the channel with the result that it made contact with No. 15 beacon.

4. When Searoad Mersey made contact with No.15 beacon, the Master lost his orientation, overreacted and applied excessive helm.

It is further considered that:

5. There was no momentary failure of Searoad Mersey's steering gear.

6. The apparent alteration of course to port by A M Vella, observed by the Master of Searoad Mersey; was a momentary swing to port, under port helm, as the dredge head was raised from the seabed.

7. Early VHF contact between Searoad Mersey and A M Vella would have been prudent.

8. The advice contained in the Port of Melbourne Authority's three Notices to Mariners was explicit, however, a chart delineating the three areas to be dredged would have been beneficial.

9. Advice passed to vessels by Point Lonsdale Signal Station should provide full, definitive information regarding any operations or changes in navigational aids.

10. Where a master holds a pilotage exemption, it is of the utmost importance that the officer of the watch fully understands his responsibilities and fully monitors all that is going on.

Summary

On 19 January 1994, the Australian flag tanker Osco Star was loading a cargo of petroleum products at No.2 Jetty of the BP Refinery at Kwinana, near Fremantle, W.A.

At about 1420, aviation jet fuel (AVTUR) was being loaded into No.5 port and starboard wing tanks and nearing, the required finishing, ullage in both tanks when the duty mate in the cargo control room shut No.5 port wing tank filling valve. This action put the full loading rate, of about 1200 m /hour, into No.5 starboard tank and, shortly afterwards, cargo overflowed onto the deck from the pressure/vacuum release valve on No.5 starboard cargo tank.

Immediately, shore pumping was stopped, no.1 centre was opened as a "crash tank" and the manifold valves and all cargo tank filling valves were closed.

When the clean-up of the spilt oil was completed, soundings were taken of all cargo tanks. From these, it was established that the level in No.5 starboard tank was falling, while that in No.4 starboard was increasing - an indication that these two tanks were now common in some way.

The cargo in Nos.4 and 5 starboard tanks was pumped to other tanks in the ship and the two tanks were then cleaned and gas-freed prior to being inspected.

Inspection revealed that there was extensive damage to the structure between the two tanks caused by No.5 starboard tank having been hydraulically over-pressurised. The bulkhead had ruptured, leaving a hole of approximately 1 X 1.5 metres. Various other sections of the corrugated bulkhead were bulging, and a weld fracture was found in the aft bulkhead of No.5 starboard tank.

The vessel was eventually allowed to load its original cargo and to proceed to Sydney and thence Geelong, for temporary repairs.

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 contributing to the accident and should not be read as apportioning blame or liability to any particular organisation or individual.

1. The structural damage to the vessel was caused by hydraulic over-pressurisation of No.5 starboard wing cargo tank during the loading of a cargo of jet fuel. The facility for relief of pressure, i.e. a single "Press-Vac" pressure/ vacuum relief valve is not designed to be able to relieve excess pressure under these circumstances.

2. The over-pressurisation of No.5 starboard wing tank was caused by operational errors on the part of the duty deck officer, the Second Mate, in the Cargo Control Room. These were:

i) Loading at an excessive rate into a single wing, tank.

ii) Not opening, the filling valve to No. 1 centre cargo tank before closing off the filling, valve to No.5 port.

iii) Not switching the digital display readout to no.5 starboard tank immediately after shutting off No.5 port.

iv) A mathematical error in his calculations for "time to go" before topping-off No.5 wing tanks.

v) Not accepting an alarm displayed on the Autronica VDU.

3. The Second Mate was not fully aware of all aspects of the operation of the Autronica ullage monitoring system, in particular, the fact that "unaccented" alarms on the computer screen will inhibit the sounding of any further alarms which may be activated.

4. It is probable that the Second Mate's thought processes and concentration were affected to some degree by both fatigue and personal problems. This may account for his forgetting to open the filling valve to No.1 centre, forgetting to switch over the selector switch on the digital display to No.5 starboard tank after closing off the cargo filling to No.5 port, and his mathematical error when calculating the "time to go" before topping off the wing tanks.

5. Both the training, and experience of the Second Mate appear to the Inspector to be insufficient for the operation in which he was employed and the responsibility which he held at the time of the incident. This was due, in part, to the lack of opportunity for an effective induction into the ship's routines and systems, and in part to the lack of information, concerning the level of his experience, being, passed to the Master by ASP Ship Management.

6. The definition and literal meaning of the responsibilities of a "responsible officer" as detailed in Marine Orders Put 3, Seagoing Qualifications, indicate that it was not appropriate for the Second Mate to take responsibility for critical cargo-handling duties, such as the topping-off of cargo tanks.

7. The position of the cargo valve control console, the Autronica computer VDU screen and the tank digital display unit a-re such as to constitute a poor ergonomic layout for single person operation of the control room.