LOCAL SAFETY ACTION

Following this and other similar occurrences, Airservices Australia has changed the TAAATS system to reduce the possibility of similar false radar couplings. This change consisted of adding an additional longitudinal check that limits the size of the Coupling Corridor to within a defined Variable System Parameter (minutes) ahead and behind the estimated position of the aircraft based on FDP time estimates. Initially this parameter was set to 12 minutes. This additional longitudinal check was only to be applied for Flight plans that were "Active" or "Inhibited".

The software carrying this fix was installed in the ML FIR on the night of January 17th, 2001, and in the BN FIR on the night of May 10th, 2001.

The helicopter was being used to conduct basic helicopter training at Jandakot. There was an accumulation of raindrops on the helicopter's canopy due to showers that had recently passed through the area. The instructor reported that both he and the student were getting hot from prolonged hovering and that he decided that a short flight was needed to cool the cockpit. The instructor took control of the helicopter from the student and transitioned into forward flight, climbing at about 35 kts to approximately 50 ft before commencing a continuous left turn to return to the hover. The instructor reported that while he was looking out to his left at the area where he intended arriving, he realised that the helicopter was too low to the ground. The helicopter's left skid hit the ground then the helicopter rolled right and the main rotor blades hit the ground. The helicopter then cartwheeled two or three times before skidding and coming to rest on its right side. The fuel tanks ruptured and the helicopter caught fire. Just after both pilots escaped through the front of the shattered canopy, the wreckage exploded. The student sustained minor injuries while the instructor suffered burns to his right arm and head. The pilots were not wearing helmets. The pilots reported that the helicopter was operating normally before it hit the ground. The investigation could not determine if the raindrops that had accumulated on the canopy had affected the instructor's visual perception.

Summary

On 9 November 1999, the Australian flag bulk carrier Warden Point was southbound off the north coast of New South Wales, en route to Melbourne, with a cargo of fly ash. At about 0230, the weather changed due to an intense low-pressure system approximately 300 nautical miles to the south. By 0800 the vessel was experiencing near gale force winds from the south. The vessel was pitching heavily in large seas submerging the lower poop deck, at times, under 2-3 m of water.

At 1400, the duty engineer reported that the rope locker hatch lid, on the lower poop deck, was leaking and that water had entered the rope locker and adjoining steering flat. The crew subsequently managed to reseal the hatch lid after some problems due to waves that were periodically sweeping the deck and running over the hatch.

At 2330, Australian Eastern Standard Time (EST), the second mate came on the bridge to take the watch. After the watch was handed over, he instructed the 12-4 integrated rating (IR) to go through the accommodation and advance the clocks 1 hour, he also instructed the IR to check the rope locker and steering flat. The IR rang back a short time later to report that the rope locker and steering flat were awash and that the water was running over the steering motors. The second mate started the stand-by steering motor and called the duty engineer. Just as he put the phone down one steering motor failed, followed by the other motor about 10 seconds later. The second mate stopped the ship and called the master. The time was 0115, Australian Eastern Summer Time (EDT), 10 November 1999, with the vessel east of Sugarloaf Point, north of Newcastle. Once the vessel lost headway it became beam-on to the large sea and rolled heavily.

All the engineers and integrated ratings were called to the engine room to work on restoring the steering and pumping the steering flat and rope locker dry. Both steering motors were dismantled and found to be damaged beyond repair. There was no spare motor so the lower rated stand-by main engine jacket cooling water pump motor was used to make an emergency repair. While the crew were completing the emergency repairs to the steering the cargo shifted, causing a port list of 2-3° and a noticeable trim by the head.

At 0852 on 10 November 1999, with the steering finally restored, the vessel headed for Newcastle, the nearest port of refuge, to effect permanent repairs. However, Newcastle Port closed at 1526 on 10 November 1999, due to the bad weather, and the decision was made to divert Warden Point to Port Kembla.

Warden Point arrived at the Port Kembla pilot boarding ground at 1000 on 11 November 1999 by which time the list had increased to over 5°. The steering was limited to a maximum of 15° helm and the vessel was berthed using two tugs. At 1236, the vessel was finally made fast alongside no.1 coal berth. The ships engineers and shore contractors worked into the night on the steering gear and rope locker hatch lid. The cargo was inspected and found to have moved in both holds. The list was corrected by re-trimming the cargo in no.1 hold.

Warden Point departed Port Kembla at 0830 on 12 November 1999 and completed the voyage to Melbourne without further incident.

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.

On 9,10, 11 November 1999 Warden Point experienced a series of events in which the ship suffered significant damage and which endangered the vessel and crew.

1. The initial failure of Warden Point's steering gear was a result of the steering pump motors failing after contact with seawater.

2. The seawater gained access to the steering gear flat via the two lowest penetrations in the bulkhead between the steering flat and the adjacent rope locker, which had been flooded as a result of its leaking hatch lid.

3. The rope locker hatch lid leaked as a result of seawater over the lower poop deck, and the poor seal between the hatch lid and the hatch coaming. The rope locker hatch lid had not been maintained in a watertight condition in that the worn dogs and wedges were not exerting sufficient clamping pressure to secure the hatch lid given the recent fitment of soft new sealing rubber.

4. The seawater contamination of the fuel service tanks was a result of poorly maintained breather vents and the weight of seawater over the vents in the poor weather conditions.

5. The vessel's initial list to port was a result of the fly ash cargo shifting. The shift of cargo was the direct result of the movement of the vessel when lying starboard beam-on to the large sea.

Although not contributing factors, it is further considered that:

6. The initial stability conditions for the vessel should have been calculated after completion of loading at Gladstone. Some assessment of the vessel's stability should also have been made after the cargo had shifted.

7. Safety harnesses and lifelines would have minimized the risk of crew members being swept overboard when working on resealing the rope locker hatch while the lower poop deck was being regularly swamped by waves.

8. The absence of a bilge alarm fitted in either the rope locker or steering flat prevented the crew being alerted to the water ingress in sufficient time to avert the failure of the steering motors.

9. The knowledge of the transportation properties of the Gladstone power station fly ash is insufficient; an accurate stowage factor needs to be ascertained and the 'cohesive' categorisation of the cargo reviewed. Adequate measures also need to be prescribed to minimise the risk of cargo shifting in adverse conditions.

10. The decision to divert the vessel to Port Kembla, rather than a closer port of refuge, may have unnecessarily endangered the vessel and crew with the continued movement of the cargo.

11. The efforts of the crew on the days of 9,10, 11 November, in resealing the rope locker hatch, restoring the steering and navigating Warden Point safely to port in such adverse conditions, were commendable.

Summary

At 0155 on 9 October 1999, the prawn trawler May Bell II was about 50 miles east of Newcastle, NSW, heading slowly west. The skipper and the deckhand were recovering their nets when the deckhand heard the sound of a ship's wash just forward of the trawler. He ran to the wheelhouse where he put the engine full astern but, a few seconds later, the two vessels came into contact.

The deckhand sounded the trawler's horn, leaving it on, but there was no answering signal from the ship. He was unable to make out a stern light or the ship's name on the stern as the ship continued on towards the northeast.

The bow of the trawler was holed by the impact, but there was no ingress of water. The skipper called Sydney Radio on VHF (very high frequency radio) to say that the trawler had been struck by a ship, informing the station of the position and time of the collision and adding that he was returning to Sydney.

The trawler returned to Sydney that afternoon, whereupon the Australian Transport Safety Bureau (ATSB) interviewed the crew and obtained samples of paint deposited, as a result of the collision, on the stem of the trawler.

AusSAR, the Australian search and rescue organisation, provided the ATSB with a surface picture (surpic) of ships in the area at the time of the collision. Positions were obtained from certain ships on the surpic and a woodchip carrier, Craig The Pioneer, was close enough to the position of the collision to warrant further investigation.

When Craig The Pioneer arrived at Bell Bay in Tasmania in November 1999, interviews were conducted with the master, deck officers and the AB (able-bodied seaman) who had been on watch with the 2nd mate. The 2nd mate and AB, who had been on the navigation watch at the time, denied all knowledge of the incident stating that they had not seen the trawler either visually or by radar.

The ATSB also obtained paint samples from the ship. Paint samples from both vessels were analysed by the Scientific Unit, Forensic Services, of the Australian Federal Police at Canberra, the report concluding that there was strong evidence that the ship and fishing vessel had come into contact.

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.

• On the basis of the positions of both vessels and the analysis of paint samples from the fishing vessel and the ship, the Inspector is satisfied that Craig The Pioneer collided with May Bell II.
• Those on watch on the bridge of Craig The Pioneer did not maintain a proper lookout either by sight or by radar. Under the conditions of optimum visibility at the time of the incident, the lookout being maintained on board the ship would have to be considered seriously deficient to miss seeing the trawler prior to the collision.
• The skipper and deckhand of the trawler were on deck, concentrating on retrieving nets, when the collision occurred and were not keeping a proper lookout.
• The vision of both the skipper and deckhand of the trawler was significantly impaired from working under bright lights.

It is also considered that the fitting of a radar reflector or similar device to the fishing vessel to enhance its radar returns would have increased the likelihood of it being detected by a ship.

Summary

The Panamanian flag general cargo vessel Sun Breeze berthed at the West Australian port of Bunbury on 16 August 1999 to load a cargo of sawn timber.

The vessel loaded packs of timber of various sizes, most of which had no weights marked on them. During loading, the master estimated weights of cargo loaded in each of the vessel's two hatches by draught survey. When the hatches were full, the weight of cargo loaded on the hatch tops and deck was limited by the master's requirement to maintain a minimum metacentric height (GM) of 50 cm.

After loading was completed on 21 August, the vessel's GM, after allowing for free surface effects in certain tanks, was calculated to be 47 cm.

After lashing of the deck cargo was completed, Sun Breeze sailed at 1800 the same day for China. The vessel was upright when the harbour master piloted it from the port. After the harbour master disembarked, the engine revolutions were increased to sea speed at 1830.

When the master left the bridge, the 3rd mate changed the steering from manual to autopilot, at which time the ship started turning to starboard on its own accord. He changed back to manual steering, ordering helm to bring the vessel back on course. The vessel then seemed to him to list initially to port before listing to starboard.

The master returned to the bridge, by which time the list was about 15° or 20° to starboard. He stopped the engine and the list increased before settling at about 25°. The vessel lost some packs of timber from no. 1 hatch top over the side at this time. A distress message was sent out at about 1848 before the master anchored the vessel at 1900. The harbour master went out to the ship and non-essential crewmembers were disembarked by a tug.

The master corrected the list by ballasting side tanks. He advised the owner of the ship of the situation and obtained permission from the harbour master to re-enter the port after a surveyor had verified the vessel's stability.

The vessel berthed at Bunbury once more at 1310 on the 22nd August. The cargo was restowed and secured and the amount of deck cargo was reduced, after which the vessel sailed for the discharge port in China, where it arrived safely on 10 September 1999.

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.

Based on all the evidence available, the following factors are considered to have contributed to the incident:

1. All fuel, diesel, fresh water and some ballast tanks were slack, reducing the vessel's stability.
2. The cargo in the holds and tween decks was not secured to prevent movement in a seaway in accordance with the approved cargo securing manual.
3. The ship's stability was based on an inclining experiment that did not meet IMO approved standards. As a result, the position of the lightship centre of gravity is in question.
4. The stability information supplied to the ship contained incorrect data on free surface moments.
5. Packages of timber were not marked with their weights and the master had to estimate weights in each compartment by draught survey.
6. The lashings at hatch no. 1 were incorrectly set up, opening to permit the cargo to be lost overboard after the vessel listed.
7. The voyage instructions mentioned lashings for the deck cargo. It made no mention of securing arrangements for cargo in the hatches.
8. The master did not have a copy of the charter party, neither was he informed of correct stowage factors or weights of the type of cargo to load. He did not have sufficient information with which to prepare a proper loading plan and exercise proper oversight of loading.
9. The owner, master and the vessel's agent did not inform the Australian Maritime Safety Authority that the vessel would be loading timber deck cargo.
10. The master did not have a copy of the code of safe practice for the carriage of timber deck cargoes, neither did the ship's approved cargo securing manual include timber deck cargoes.
11. The stability calculations did not allow for absorption of water by the deck cargo or for consumption of fuel from low tanks once the vessel was at sea.

In addition, the Inspector considers that the master would have been justified in delaying loading of the cargo until he was given all information necessary to ensure the ship's safety.

Summary

The Italian flag tanker Laura D'Amato berthed at the Shell Terminal Gore Bay Sydney, at 1224 on 3 August 1999, with about 90,957 tonnes of Murban Crude Oil. The loading arms were connected to the ship, the tank ullages measured and the quantity of oil on board checked. The mate and the Shell shore officer conferred and signed the 'Ship/Shore Safety' checklist. The checklist was also counter signed by a Sydney Ports inspector.

At 1412, the ship commenced discharging using no. 2 cargo pump. Initially, the water bottoms were removed at a slow rate of pumping. At 1430, all the cargo tanks were opened to lower their levels and the discharge rate was increased to 1000 m/h. At 1650, some cargo tanks were shut, the rate was further increased to 1500 m/h, and the suction valves for the two slop tanks (six wings port and starboard) opened.

By about 1815, the mate decided the level of the slop tanks was falling too slowly. To draw more directly from these two tanks and to increase the rate of discharge, the mate decided to open no. 3 cargo line to no. 2 pump by opening two 'crossover' valves on the main sea line in the pumproom. At about 1820, he ordered the cadet to open the two valves.

At 1825, the Shell wharf watchkeeper was returning from a routine check of the loading arms and moorings, when he suddenly smelled a strong odour of hydrogen sulphide. He immediately contacted the shore officer reporting the smell and asking whether the ship was venting its tanks for any reason. It was established that this was not the case.

The wharf watchkeeper went back to the shore manifold but detected no sign of a leak. The smell of hydrogen sulphide was still strong and, as he checked the water between the ship and the shore, he detected a slick of oil, which he traced to the ship's port side. He reported to the shore officer, who immediately ordered the ship to stop pumping.

The ship's pumps were stopped at 1836. The Shell emergency plan was implemented immediately.

The mate, who had already ordered the cadet to close the two valves that he had just opened, then ordered the 3rd mate to stop the cargo pump. He went ashore to see if he could locate the source of the oil spill. The wharf watchkeeper showed him the position on the port side, of the vessel, where oil was seen to be welling to the surface of the water. The mate and the pumpman then went to the pumproom and checked all the valves. They found the two sea-chest valves on the sea suction line were fully open.

When the two men attempted to close the sea-chest valves, they found the large, manual, butterfly valves 'back-seated' open. To close the valves, both men had to use a large wheel key to break the seat. In closing the valves, any security seals placed between the two adjacent valve handles were broken.

At this point, the flow of Murban crude oil from Laura D'Amato into Gore Bay ceased.

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.

The factors which lead to the escape of crude oil cargo from Laura D'Amato into Sydney Harbour include but are not limited to:

1. The sea-chest valves on the sea suction line adjacent to the port sea chest in the vessel's cargo pumproom were open.
2. The use of the sea suction line as a cargo pump suction crossover line led to cargo filling the line and escaping through the open sea-chest valves overboard.
3. The ship's cargo system did not provide for a separate designated cargo pump suction crossover line or some means of isolating the cargo system from direct connection to the sea chest.
4. The presence, at various times, of seals placed between the sea-chest valves lead to a false assumption on the part of the ship's staff that the sea-chest valves must therefore be shut.
5. The false assumption contributed to the fact that the ship's staff did not properly check the sea-chest valves, as required by the ISM Code procedure, the ISGOTT Guide and normal tanker operations, before loading in Jebel Dhanna and discharging in Sydney.
6. There was no remote monitoring, on the cargo control console, of the positioning of the two sea-chest valves.
7. The vessel's Safety Management System did not adequately detail the pressure test procedures to be carried out on the sea-chest valves each time they were to be checked for tightness.
8. The independent cargo surveyor in Jebel Dhanna did not recognise that the sea-chest valves were, in fact, open.
9. The Ship/Shore Checklist procedures, in Jebel Dhanna and Sydney, did not physically check and identify that the sea-chest valves were in a closed position.
10. The probability is that the sea-chest valves were opened some time after leaving Zhanjiang and before arriving at Jebel Dhanna. There was no operational reason for opening these valves.