Outline of incident

The fishing vessel 'TAMMY-R' departed Eden on Wednesday 18 April 1990 bound for fishing grounds off Gabo Island.

According to the crew, after some trawling the vessel completed its last trawl near position 37 56'S 149 56'E at approximately 0300 hours Eastern Standard Time on Thursday 19 April 1990. After boxing and stowing the catch, the Skipper decided to return to Eden in order to have a minor oil leak in the hydraulic steering repaired.

The Skipper set a course to clear Cape Howe and about half an hour later the trawler was apparently in collision with a merchant vessel and sank. The two crew members took to a life raft, eventually being rescued by helicopter some seven hours later.

Conclusions

It is concluded that:

1. The TAMMY-R sank as a result of a collision with another ship.
2. On the balance of probabilities TAMMY-R was in collision with METAL TRADER.
3. The most likely time of the collision is considered to be within the period 0414 - 0421.
4. The collision was brought about by the failure of TAMNY-R to give way to METAL TRADER crossing on the starboard bow.
5. The Skipper of TAMMY-R was negligent in that he failed to ascertain the course of METAL TRADER and whether a danger of collision existed before handing over to the relatively inexperienced Deckhand.
6. The Deckhand was negligent in that:
   a) he failed to ascertain that a danger of collision existed
   b) he failed to give way as required by Rule 15 (COLREGS) to a vessel crossing from starboard
   c) he failed to keep a proper lookout as required by Rule 5 (COLREGS).
7. The Master of METAL TRADER did not stop to offer assistance to TAMMY-R as, at the time, he was apparently unaware that a collision had occurred.
8. The Master of METAL TRADER failed to respond to the distress relays broadcast by Melbourne Radio as they were not received due to a fault in the ship's radio equipment.
   
   It is further considered that:
9. As it is not possible to determine with any certainty whether or not the Officer of the Watch of METAL TRADER was in fact aware that the collision had occurred, either:
   
   (a) the Watch aboard METAL TRADER was inefficient with respect to
   i. keeping a proper lookout (COLREGS Rule 5) in that TAMMY-R was not observed visually or on the radar.
   ii. in that it was unaware that the ship had been involved in a collision,
   
   or
   
   (b) the officer of the Watch was negligent in that:
   i. he failed to take necessary action to avoid collision as required by Rule 17(b) (COLREGS)
   ii. he failed to notify the Master that he had been involved in a collision; and
   iii. he wilfully ignored international conventions in that he failed to stop and render assistance to TAMMY-R.

Outline of incident

At 0505 hours local time on 21 February 1990 the Australian flag bulk carrier 'IRON KEMBLA', whilst on passage from Newcastle NSW to Tobata, Japan, collided with the Japanese fishing vessel 'KASUGA MARU' in a position approximately 4 miles WSW of Hino Misaki lighthouse in Kii Suido.

The fishing vessel capsized and one of the crew members lost his life.

Conclusions

1. Had both ships maintained their course and speed as those for the period 0452-0459, the collision would not have occurred.
2. The collision is considered to have been brought about by the KASUGA MARU altering back onto an easterly course after having first altered onto a northerly course, parallel to that of the IRON KEMBLA. This second alteration occurred almost simultaneously with the alteration to starboard (towards the east) by the IRON KEMBLA. The coincidence of the alterations made the collision inevitable.
3. The KASUGA MARU was not exhibiting the correct navigation lights, either those for a power-driven vessel under way or those for a vessel engaged in fishing, as required by the International Regulations for Preventing Collisions at Sea.
4. The Master of the IRON KEMBLA was correct in ordering an alteration of course to starboard when the KASUGA MARU was observed to alter course to port to run on a parallel course.
5. The Master of the IRON KEMBLA was correct in advising the Japanese Authorities immediately after the incident that a collision had occurred.
6. The master of IRON KEMBLA was correct in turning about in order to offer assistance to the crew of the capsized fishing vessel.
7. The Master of IRON KEMBLA is considered to have been at fault in assuming the KASUGA MARU to be power driven and that he therefore had the right of way, when the lights reportedly observed were those required to be shown by a sailing vessel.
8. The master of IRON KEMBLA could have prevented the situation developing by making an early, small alteration of course to port, to assist the small vessel to cross his bow.
9. The Master of IRON KEMBLA is considered to have been negligent in that he did not make use of all of the navigational equipment available to him in conning the ship.
10. The Master of the IRON KEMBLA is considered to have been remiss in not reducing speed immediately the capsized fishing vessel was sighted.
11. The Bridge Procedure aboard the IRON KEMBLA were deficient in that the Officer of the Watch did not, as a matter of course, monitor shipping on the radar so as to assist the Master by keeping him informed of the distances of other ships, or by targeting other ships on the ARPA.

Outline of incident

The Panamanian registered bulk carrier ALEXANDRE-P, a ship of 94532 tonnes deadweight and some 250 metres in length, loaded a cargo of iron ore at the Western Australian port of Dampier on 12 March 1990.

On completion of loading the ship proceeded to the outer anchorage in order to close and secure hatches, departing from the anchorage at 1610 hours Western Australian Standard Time on 13 March 1990, bound for Cape town and Gijon, Spain.

At 1400 hours WAST on 14 March 1990 the ship made a daily routine position report to the Federal Sea Safety Centre, Canberra under the Australian Ship Reporting System. The ship failed to keep its next scheduled broadcast at 1400 hours WAST on 15 March 1990 and 'ship overdue' procedures were put into motion at the FSSC.

Air searches commenced when the ship became 24 hours overdue on the afternoon of 16 March, flotsam eventually being located on 18 March in the area centred on position 20S 112E. The ship ENERGY SEARCHER arrived on the scene on 20 March and retrieved a life raft which was identified by the owners as belonging to the ALEXANDRE-P. No survivors were found.

Conclusions

1. The cargo of iron ore, lumps and fines, was presented for loading in a proper manner.
2. The cargo was loaded in accordance with the Master's/Chief Officer's requirements.
3. The loading sequence, which was modified as a result of No. 3 hatch jamming, although perhaps not the most preferable, is not considered unreasonable or to have placed undue stress upon the ship.
4. From the observations of witnesses, it is considered that the ALEXANDRE-P had not been well maintained, that there was heavy corrosion and wastage around the main deck and cargo hatches and also in the upper sections of the transverse bulkhead between holds 2 and 3.
5. From the position of the flotsam, it is considered that the ALEXANDRE-P foundered sometime around 1800/1900 hours ship's time on 14 March 1990 in approximate position 2020S 11200E.
6. Due to the fact that no distress message was heard by either coast radio stations or other shipping and due to the lack of survivors or further bodies, it is concluded that the foundering was both sudden and rapid.
7. The wind and sea conditions being light, are not considered to be causal factors to the loss.
8. A 2-3 metre swell from the southwest would have caused the ALEXANDRE-P to pitch moderately and also to roll slightly.
9. Although the cause of the foundering cannot be determined with any certainty and although beyond the scope of this investigation, it is considered that either a sudden, massive structural failure occurred, with the ship breaking into two sections or, there was some form of explosion in the engine room, of sufficient magnitude to rupture the ship's hull and cause rapid flooding and sinking.
10. Professional opinion is that the two recovered corpses bore evidence of flash burns and blast injuries, indicating that some form of explosion did occur.
11. If the foundering was in fact due to a major structural failure, it is considered that inspection at Dampier under the port state control provisions of the International Conventions would have been unlikely to prevent the foundering.

QF002 was scheduled for departure from London Heathrow at 1315 hours UTC on 25 March 1990. Due to engineering problems with the aircraft allocated for this sector, VH-EBY was dispatched from Sydney as a replacement, thus causing a subsequent 18-hour delay in the departure of QF002. The flight eventually departed London at 0704 hours UTC on 26 March 1990 as QF002A. On arrival at London Flight Dispatch the crew were issued with the Flight Plan and accompanying Notams, Intams and company documentation. Prior to departure the crew was issued with a runway 27L, Brookmans Park 3G SID. This departure requires a right turn, shortly after take-off, towards the Burnham VOR. At a position 6DME from London, another right turn is required to intercept a track of 058 degrees to Chiltern NDB. Noise abatement procedures apply to this departure as well as an altitude requirement of reaching 3,000 ft nearing completion of the turn towards Chiltern NDB, above 4,000 ft over Chiltern NDB and a crossing altitude of 6,000 ft at Brookmans Park VOR. A speed constraint of 250 knots existed below 10,000 ft. The seating configuration on the flight deck for departure is shown at Figure 1. The First Officer was flying this sector from the right hand pilot's seat.

Following representations by the Australian Flight Attendants' Association concerning a newly installed seating configuration on VH-OJF, a Qantas Boeing 747-400, a special investigation was undertaken to determine if safety standards had been compromised. The upper deck seating configuration on VH-OJF was compared to the previous exit configuration utilised on Qantas 747-400s. Further comparisons were made between the Boeing 747-200 and SPs operated by Qantas. The investigation determined that while the new seating configuration did meet the regulatory requirements, the previously installed standard did provide a far superior emergency exit facility.

Introduction

This special investigation was initiated after a letter was sent to the Minister for Transport and Communications by the Australian Flight Attendants' Association (AFAA). This communication detailed a number of objections to a seating configuration which had been installed on the upper deck of VH-OJF, a Qantas Boeing 747-400. 

The Association's objections to the new seating configuration are: 

(1) the downgrading of the upper deck emergency exits from Type A to Type I; 

(2) the jump seat protrudes fully into the exit; 

(3) no assist space is available; 

(4) insufficient recess for the flight attendant to direct the evacuation; 

(5) the reversal of the jump seat to a forward facing seat; and 

(6) emergency procedures are not applicable to the exit. 

The following report details the background to the investigation and addresses the issues raised by the flight attendant's union. The aim of the investigation was to evaluate the safety deficiencies, if any, of the new configuration in relation to the previous configuration and those in situ on other 747 series.

At 1144 hours Eastern Summer Time, on 22 December 1990, during a search for a missing aircraft, Cessna 210 aircraft VH-PLD crashed in inhospitable terrain following a complete loss of engine power. The aircraft was destroyed by impact forces; the pilot, co-pilot, and two observers received fatal injuries, and two other observers suffered serious injury. The Bureau determined that a failure of a connecting rod bolt resulted in the loss of engine power. The connecting rod penetrated the crankcase, allowing engine oil to escape. The oil was blown back onto the windscreen, probably obscuring the pilots' vision during the forced landing approach.

Outline of incident

At 1142 Eastern Standard Time (EST) on 24 July 1989 the Cypriot flag liquefied gas carrier "Kouris" anchored off Bate Bay, New South Wales.

During the afternoon the westerly wind dropped to light airs. At about 2330 EST the wind began to freshen backing to a little east of south. At about 0315 EST on 25 July the officer of the watch reported to the Master that the ship was drifting. Initial attempts to start the engine failed and the second anchor was dropped. At about 0335 EST the ship grounded in shoal water near Merries Reef.

Driven by the wind and sea the "Kouris" was blown clear of the shoal water. Although the engines were available at about 0345 EST the rudder failed to operate. At approximately 0418 EST the ship grounded on Cronulla Beach and by 0436 it was apparent that the ship could not be freed by use of its engines at that time, and assistance was requested through Sydney Harbour Control.

The ship eventually refloated at 0315 EST on 27 July 1989 and berthed in Sydney late on 27 July to assess damage.

Captain CW Filor, Director Ship Operations, Department of Transport and Communications was appointed under the provisions of section 377A of the Navigation Act 1912 to conduct a preliminary investigation to determine the reasons for the grounding and to establish what actions the Master took to prevent pollution and to safeguard the lives of the crew. Captain MD O'Keeffe, of the Maritime Services Board also took part in the investigation.

Conclusions

The Cypriot liquefied gas carrier "Kouris" came into heavy bottom contact in shoal water off Merries Reef at about 0335 on 25 July 1989, disabling the ship's rudder and sustaining extensive bottom damage. Through being unable to steer and manoeuvre normally as a result of the rudder damage the ship grounded on Cronulla Beach at approximately 0438. The cause of the contact with Merries Reef and the subsequent grounding are as follows:

1. the starboard anchor carried away under a shock load in excess of its nominal breaking load.
2. the failure to maintain the engine in a running condition when first started between approximately 0325 and 0330; this failure may have been due to either: - (a) an intermittent failure in the engine control system, or (b) human error in failing to recognise the need to cancel the "Emergency Stop - Engine Overspeed" control and/or ensure sufficient air supply to start engine.
3. the failure of the port anchor cable at approximately 0327 through the sudden load put on a short scope of cable when the cable stopper was applied with between 2 and 3 shackles paid out in approximately 20 metres of water.
4. The failure by the Master, Chief Officer and Second Officer to obtain weather forecasts and strong wind and gale warnings.
5. The failure of the Master at 0200 25 July to appreciate the significance of the wind shift and that the ship was anchored to a lee shore.
6. The general lack of communication and understanding of responsibility by the officers aboard.
7. Captain Schluchter used six shackles of cable rather than the eight shackles theoretically required in 25 metres of water. Had he used eight shackles he would have used the total length of cable available to him and had none in reserve. The investigating officers are satisfied that the use of six shackles under the conditions prevailing on the afternoon of 24 July was reasonable.
8. In not allowing the crew to leave the ship Captain Schluchter reduced the risk of injury to the crew and ensured that the ship had sufficient crew when the "Kouris" refloated.
9. In completing the inerting operation of the cargo tanks the risk of fire or explosion was minimised, thus protecting life and property.

Outline of incident

The Philippine registered bulk carrier SINGA SEA, a ship of 26586 tonnes deadweight and some 175 metres in length overall, loaded a mixed bulk cargo of mineral sands and copper ore at the West Australian ports of Geraldton and Bunbury between 27 June and 2 July. At 0915 hours Western Standard Time (WST)* the ship sailed for Rotterdam via Cape Town, where it was expected to take on bunker fuel.

At 0600 Universal Co-ordinated Time (z) (1400 WST) on 3 July the vessel made a routine position report to the Department of Transport and Communications' Federal Sea Safety Centre (FSSC) under the Australian Ship Reporting System (AUSREP) based on the ship's noon position at 1200 WST. The ship failed to keep its next scheduled broadcast at 1400 WST on 4 July and the search and rescue procedures were put into operation by the FSSC.

At 1018 WST on 7 July a "P3" Orion of the RAAF took off from Pearce RAAF base to search for the missing ship, followed by another sortie on 8 July with the primary task of searching for survival craft. Neither search found any trace of the ship.

On 12 July a search was undertaken of the West coast of Australia by a chartered civil aircraft, as it was possible that liferafts or debris may have drifted onto the coast by then. No trace was found of SINGA SEA, or of any pertinent wreckage.

By 27 July the SINGA SEA had failed to arrive in South Africa and no radio traffic had been heard from the ship. As the cargo had been loaded in Australia and the ship hab been participating in the AUSREP System, a preliminary investigation was commenced into the loading of the ship and the procedures followed by the Federal Sea Safety Centre as they related to the reporting of the SINGA SEA under the AUSREP scheme.

Shortly after midnight WST on the night of 2/3 August, the Greek flag bulk carrier STANDARD VIRTUE saw a single red flare in approximate position 34°19'S 112°22'E, and subsequently recovered six survivors from a lifeboat belonging to the SINGA SEA.

The survivors reported that the vessel had sunk rapidly, after breaking in two in heavy seas, on 4 July 1988. They had been adrift in the lifeboat since that time.

The survivors all definitely stated that no other person had survived the wreck of the vessel, and that no other life raft or boat had been seen subsequent to the sinking. No further searches were therefore carried out for survivors.

The STANDARD VIRTUE diverted towards Fremantle where, on 4 August, the six survivors were lifted off by helicopter arranged by the Sea Safety Centre. After being landed at Fremantle, the survivors were briefly hospitalised before being repratriated to the Philippines.

*See Appendix A for an explanation of the times used in this report.

Conclusions

The actions and procedures of the Federal Sea Safety Centre between the time that the position report from the SINGA SEA became overdue and the time 24 hours had elapsed were correct and in accordance with the AUSREP guidelines.

By deciding not to initiate an air search after the scheduled position report from the SINGA SEA was 24 hours overdue, having established that the ship had not been heard by ships specially tasked to attempt radio contact, or by coast radio stations handling traffic from the ship, the stated objective of the AUSREP scheme was compromised.

The decision by the Director not to fly an air search for the vessel on 6 July was made in the face of mounting evidence that something may have been amiss with the vessel and was not consistent with the primary objective of AUSREP.

The air searches carried out on 7 and 8 July were conducted properly and in accordance with sound and established search and rescue practices.

Given the circumstances of this particular AUSREP incident and the availability of an RAAF aircraft the decision not to fly a daylight visual search for survival craft on 9 July, or subsequent days, was questionable, following the unsuccessful flare search of 8 July.

Following notification of the rescue of survivors from the SINGA SEA on 3 August, an air search for survivors was undertaken. The decision not to conduct further searches after 3 August was correct, and made on the information available.

At approximately 1609 hours on 20 May 1988, Cessna 172-N registered VH-HIZ and Piper PA38-112 Tomahawk registered VH-MHQ collided on the downwind leg of the right hand circuit for Runway 14 at Coolangatta, Queensland. The aircraft had been engaged in training flights in the Coolangatta circuit area. Both broke up after the collision and fell into swampland. A flying instructor and a pilot under instruction in each aircraft received fatal injuries.

Outline of incident

On the evening of 3 December 1987, the small Australian coastal trader Leichardt was passing through Endeavour Strait, northern Queensland, on passage from Horn Island to Weipa. The Mate took over the watch from the Master at 2000, navigation being conducted by radar, there being no lights in the area.

After rounding Entrance Island, Leichhardt was more than half a mile south of the intended track. Although the Mate adjusted course to regain the track, the vessel grounded momentarily on a charted shoal. The vessel was stopped & soundings showed flooding in No 2 starboard fuel tank, which was empty.

Clearance was eventually granted to the vessel to proceed to Groote Eylandt, where it arrived safely on 7 December 1987.

Conclusions

Poor passage planning, in particular the laying off of the course line only two cables from a known danger, in an area where currents were known to be strong.

Navigation was not carried out using the appropriate, large-scale chart.

Not only was the Mate unfamiliar with the Endeavour Strait, he did not appreciate that the vessel was standing into danger.