Summary

The Hong Kong registered motor bulk carrier Mineral Diamond of 141028 tonnes summer deadweight, sailed from the Western Australian port of Dampier on 11 April 1991 for the Netherlands port of Ijmuiden, by the way of the Cape of Good Hope. On sailing the vessel filed a voyage plan and indicated that it would participate in the Australian Ship Reporting System (AUSREP).

Six routine AUSREP messages were received by the Marine Rescue Co-ordination Centre, Australia (MRCCAUS), from the Mineral Diamond. The last of these messages at 0600 UTC (1400 Western Australian Standard Time) on 17 April reported that the vessel had reduced speed to six knots in force 9 to 10 winds (45 to 50 knots) in six metre seas, in position 30 degrees 21 minutes South 087 degrees 48 minutes East. When the Mineral Diamond failed to send her next scheduled message officers of the MRCCAUS initiated routine procedures to establish the safety of the ship and crew. When routine procedures failed to establish the ship's safety an air search was launched early on 20 April, coordinated by MRCCAUS and conducted by the Royal Australian Air Force, centred on a position 1500 miles west of Perth. When no trace of either ship or survivors was found the search was abandoned on the evening of 24 April.

It is assumed that the Mineral Diamond foundered with the loss of all hands in a position some 1500 miles to the west of Perth.

The Australian Marine Investigation Unit, in accordance with the International maritime Organization Resolution A440 (XI) "Exchange of Information for Investigations into Marine Casualties" and under the provisions of the Navigation (Marine Casualty) Regulations, undertook an investigation of the evidence that was available within Australia to assist the Hong Kong Authorities.

Conclusions

The re-analysis of the surface pressure field indicates that the strongest surface winds would have been experienced in the 12-hour period from about 0000 UTC 17 April 1991. Satellite pictures indicate a northward surge of cold air and the development of a new front in the vicinity of "Mineral Diamond" at about 1200 UTC leading to very squally conditions. The estimated 10-minute mean winds are in the order of 50 knots. Accordingly, significant waves to about 9 metres can be expected to have developed at this time in the vicinity of "Mineral Diamond" with a maximum wave to around 18 metres. Although the winds then eased, significant waves to 7 metres would have persisted through 18 April with a maximum wave up to 14 metres.

Summary

The Panamanian registered bulk carrier Starfish sailed from Port Walcott, Western Australia on 22 March 1991 with 53549 tonnes of iron ore fines for the Polish port of Swinoujscie.

It is reported that the Starfish diverted to Port Louis, Mauritius on 1 April, when the ship's crew observed the vessel to be riding low in the water and water was discovered in numbers 6 and 7 cargo holds. The vessel arrived off Port Louis on 3 April but was ordered from the outer anchorage on 7 April when the ship threatened to cause a major pollution incident.

The Starfish was escorted to deep water, 40 miles west of Mauritius and some 60 miles north of Ile de La Reunion, by a vessel of the Mauritius National Coast Guard. The crew of the Starfish was taken on board the Coast Guard vessel before the Starfish sank on 8 April.

Conclusions

It is considered that:

1. The cargo of iron ore fines was presented in a proper manner, in accordance with the requirements of the Code of Safe Practice for Solid Bulk Cargoes.
2. The physical properties of the cargo were accurately detailed in documents handed to the Master.
3. The cargo was loaded in accordance with the instructions of the Master and ship's staff.
4. In the event that Starfish foundered as a result of structural failure, in addition to the working stresses pertaining at the time, a relevant factor would be any excess stresses placed upon the hull in recent times. However, in the absence of key witnesses and the ship's longitudinal strength data, the investigation was not in a position to reach any conclusion as to whether the permissible stresses were at any time exceeded during the loading operations at Port Walcott.
5. The issue of interim Statutory certificates provided prima facie evidence that the ship was seaworthy. Unless the Classification Society had recently conducted a comprehensive inspection of the ship, the issue of such certificates on the strength of the existing certificates means that they were issued without a full knowledge of the actual condition of the ship.
6. From the Bureau of Meteorology's analysis, the wind and sea conditions prevailing at the time in the area through which Starfish passed should not have caused problems to a well-found vessel.
7. There is insufficient evidence within Australia to indicate the cause of Starfish taking water into the cargo holds.

Outline of events

At 0320 West Australian time, 14 February 1991, the Panama registered bulk carrier Sanko Harvest grounded in shoal water between Hastings Island and Hood Island, in position 34°07.4' South, 122°05.1' East, approximately 19 miles south-south-east of Esperance while on passage from Tampa, USA, via Cristobal, Panama, to Esperance, West Australia, loaded with 30,791 tonnes of fertiliser.

No person was killed or injured as a result of the grounding, but extensive bottom damage was sustained from the impact with the reef, resulting in the release of heavy bunker oil from the double bottom fuel tanks. The National Plan to Combat Pollution of the Sea by Oil was activated by 0600 14 February.

From the 14 February onwards, the condition of the ship deteriorated, being in a position exposed to the prevailing weather and swell, resulting in the progressive breach of further tanks and cargo holds. On the advice of the ship's owners the Sanko Harvest was evacuated by the crew, for their safety, at 1655 15 February. The ship broke into three sections and sank during the night of 17/18 February.

Captain CW Filor, Inspector of Marine Accidents, undertook an investigation into the circumstances leading to the incident with the object of identifying the cause.

Note:

• The measurements of depth, dimensions, and quantities of cargo and fuel are expressed in metric measurement.
• Distances are expressed in nautical miles (1853.18 metres).
• Times are expressed in 24-hour notation in local ship time. On 14 February this was Western Australian Time (UTC+8).
• All courses and bearings are expressed in 360° notation relative to true north.
• Depths shown on chart extracts from charts Aus 4709 and Aus 119 are shown in metres; and from BA 1059 and BA 3189 in fathoms. 

Conclusions

The inspector concludes that the grounding of the Sanko Harvest was caused by:

1. The lack of appreciation by the Master and Second Officer (and other officers who were aware of the planned approach to Esperance) of the warnings contained on the charts and Australian Sailing Directions, Volume 1.
2. The failure of the Second Officer to properly apply the available corrections to the charts of the area, in particular his failure to enter small correction Aus 219 of Admiralty Notices to Mariners, weekly edition 20 of 21 May 1988, which described the geographical location of the shoal water upon which the Sanko Harvest grounded;
3. The Master's decision to navigate in an area where acceptable hydrographic surveys were either incomplete or had not been undertaken;
4. The ship had on board the appropriate charts, notices to mariners and other publications to allow safe navigation;
5. Had the charts held on board, particularly Aus 119, BA 3189 and BA 1059, been properly corrected, they would have provided proper and reliable navigational information;
6. The 1990 edition of chart Aus 119 was not available to the Master and hence the outcome of the voyage had the ship been in possession of this edition is not an issue;
7. The grounding was caused by human failure alone. Neither the cargo, nor the mechanical equipment, nor navigational equipment contributed to the incident;
8. Neither the master nor the Second Officer were in any way under the influence of drugs or alcohol;
9. There is no evidence that fatigue was a contributing factor.

Two aircraft were operating on reciprocal routes between Brisbane and Darwin when the crew of one aircraft became aware that both aircraft were flying at the same level near Mount Isa. The crew initiated avoidance action and clearance for operation at a lower level was given. Each crew saw the other aircraft pass less than 1 min later.

The pilot was conducting a short joy-flight with six passengers from the Sea World complex. About 4 km north of the complex, the helicopter was seen to climb steeply in a near-vertical nose-high attitude. As the helicopter fell backwards from the nose-high attitude, the tail boom was severed by the main rotor blades. The cabin and the separated tail boom fell to ground on the ocean beach of South Stradbroke Island; The main body of the helicopter exploded and caught fire, scattering debris over a wide area. All seven occupants received fatal injuries.

At about 2045 hours ESuT, Piper aircraft VH-MRQ crashed onto the northern face of a small tree-covered hill on Oxley Island. The accident site was located on a bearing of 098 degrees from Taree Airport, at a distance of 6.5 km. Both occupants were fatally injured in the accident.

The aircraft had departed Taree at 1849 for a return flight via Port Macquarie and Forster. The purpose of the flight was to conduct a Command Instrument Rating flight test. NDB aerial work was planned to be carried out at Port Macquarie, Forster and Taree. The last reported contact with the aircraft was at 2041, near the completion of the flight, while it was conducting aerial work at Taree.

The aircraft was seen and heard by witnesses located near the accident site. Some of these witnesses reported that the aircraft had appeared to be operating normally prior to it entering a sudden descent. However, others reported hearing the aircraft engine apparently operating erratically before seeing the lights of the aircraft descend rapidly from a relatively low altitude. A sudden increase in engine noise was followed almost immediately by the sounds of an impact. The accident was non-survivable.

The aircraft struck the tops of large trees at a height of 18 m before impacting heavily onto a 12 degree uphill slope. The left wing was torn off as it struck a tree adjacent to the ground impact point. The aircraft overturned and slid tail-first up the hill before coming to rest 80 m beyond the initial tree contact. Damage to the aircraft was extreme and was consistent with it having struck the ground at a relatively high speed, with the engine delivering substantial power.

Weather at the time of the accident was overcast and dark, with no low cloud or rain, and with a light wind from the north-east.

No evidence was found of any mechanical failure or pilot incapacity. The reported erratic operation of the engine shortly before the accident could be consistent with the exhaustion of fuel from one fuel tank, although more than sufficient fuel had been carried for the flight. The circumstances of the accident were consistent with a loss of control. However, there was insufficient evidence to establish the reason for the loss of control.

On 21 December 1991, at 1646 hours Eastern Summer Time, a Boeing 737-376, VH-TAJ, operating a scheduled passenger service, landed at Sydney (Kingsford Smith) Airport.

Shortly after reverse thrust was selected, a failure occurred in the right engine. The aircraft veered abruptly from the runway centreline and oscillated laterally before being stabilised.

Two flight attendants who were in forward facing seats in the rear of the aircraft received minor injuries during the aircraft deceleration, when their restraint system permitted excessive lateral movement.

The investigation determined that the right engine failed following the ingestion of a thrust reverser cascade, which had detached as a result of a fatigue failure of the mounting flange. The flight attendants' seat and restraint system did not comply with applicable Australian design requirements.

The aircraft was tasked to carry out a marine pilot pick-up from a departing tanker. The flight was conducted by two pilots operating under night visual flight rules. Conditions were a moonless night with no defined horizon, no outside lighting other than from the ship, and a surface wind that was light and variable. The ship was steaming in a northerly direction at 12.5 kts.

The flight proceeded normally until the aircraft was established on final approach to the helideck. As the aircraft descended through 500 ft the rate of descent had increased to about 1,000 ft/min. Although the pilot in command increased main rotor pitch, the aircraft's rate of descent continued to increase until just prior to impact with the water.

Both occupants were rescued approximately 1 h after they evacuated the helicopter. The report concludes that the standard approach technique used by the pilots, coupled with the prevailing weather conditions, caused the aircraft to enter a high rate of descent shortly after the aircraft started its normal final approach to the deck.

The high rate of descent was probably the result of entry to the incipient stage of Vortex-ring state'. A lack of visual cues and inadequate management of cockpit resources prevented the crew from recognising the abnormal situation until the aircraft was well into the descent. Recovery action was commenced too late to prevent impact with the water.

On Monday 12 August 1991, at 1023 hours Eastern Standard Time (EST), a McDonnell Douglas DC-10 Series 30ER aircraft (DC-10) operated by Thai Airways International was landing on runway 34 at Sydney (Kingsford Smith) Airport. The DC-10 was carrying 185 persons. At the same time, an Airbus A320-211 aircraft (A320), operated by Ansett Australia was on a short final approach for landing on runway 25. The A320 was carrying 110 persons.

Runways 34 and 25 intersect, and Simultaneous Runway Operations (SIMOPS) were in progress.

Landing instructions to the crew of the DC-10 included a requirement for the aircraft to be held short of the intersection of runways 34 and 25.

A Qantas Airways Boeing B747 aircraft was holding on taxiway Victor ('V'), north of runway 25 and west of runway 34, awaiting the landing of the A320 and a subsequent clearance to cross runway 07/25. The B747 was carrying 372 persons.

While observing the DC-10's landing roll, the captain of the A320 judged that the DC-10 might not stop before the intersection of the runways. He elected to initiate a go-around from a low height above the runway.

Under heavy braking, the DC-10 slowed to about 2 kts ground speed, at which time the nose of the aircraft was approximately level with the edge of runway 07/25.

During the go-around executed by the crew of the A320, that aircraft passed above the DC-10 on its left and the B747 on the right of its flight path.

On 22 November 1991 at 0912 hours Australian Central Standard Time (Greenwich Mean Time + 9.5 h), a Bell 214ST helicopter was ditched into the Timor Sea shortly after take-off from a floating production facility. The two crew and 15 passengers evacuated uninjured from the floating helicopter, prior to the right main flotation bag being punctured and the helicopter capsizing.

The report concludes that at a critical stage of the take-off, at an altitude of approximately 120 ft above the sea, one of the engines experienced a high-side speed excursion. This was followed by an aircraft main rotor speed increase which illuminated a cockpit indication warning that the aircraft main rotor speed was out of limits. The captain reacted to what he thought was an engine power loss by lowering the collective, which is the prescribed response to that situation, thereby unloading the main rotor which rapidly accelerated to 116.7%.

The electrical control unit of the ungoverned engine, sensing a power turbine overspeed, actuated the fuel sequence valve to shut off fuel to the engine. As the over speeding engine accelerated, the other engine, while attempting to compensate, decelerated to idle power because of the lowered collective command.

The captain's action in lowering the collective exacerbated the rapidity of the event, and because of insufficient aircraft altitude, there was not enough time for the engine still under power to pick up the load, or for the captain to take further corrective action to avoid a sea ditching. At the time of the emergency, the captain was demonstrating a take-off to his co-pilot.