Executive summary

On 23 October 1997, at 0632 hours, coal train DR396 collided with the rear of another coal train, MT304 standing at Tarro, en-route to Port Waratah. The collision occurred in clear conditions on the up coal road, adjacent to the western end of Beresfield railway station. Both trains were operated by FreightCorp.

The driver and observer of DR396 suffered serious injuries, as did a person standing on the station platform. The Stationmaster also suffered minor injuries.

The three locomotives and first ten coal wagons of DR396 were derailed, as were the three rear wagons of MT304. Wreckage blocked both coal roads and adjacent mainlines. Beresfield station and associated structures also suffered extensive damage. Considerable disruption to passenger and freight operations resulted from the accident.

The response to the emergency by local services, and rail organisations, was carried out with speed and efficiency, substantially in accordance with established procedures. Restoration of services was largely accomplished by 27 October, without further injury.

The investigation found the circumstances of the accident were consistent with the crew of DR396 failing to comply with caution and stop signal indications protecting the stationary MT304. Reduced driver alertness, associated with work related fatigue, was found to be a significant factor in the events leading to the collision, together with a system intolerant of human error, and inadequate safety defences.

During the investigation a number of safety deficiencies were identified for further study by the NSW Department of Transport.

Summary

On 19 December 1998, the Australian flag tanker Tasman was alongside at No.28 wharf in the port of Melbourne where it was undergoing some modification work and survey. This included welding work in the aft peak tank.

Shortly after 1100, the duty engineer was in the control room answering alarms which indicated low generator fuel pressure. As he was turning to leave the control room, the fire alarm sounded. At about the same time, those on deck saw thick smoke issuing from the funnel and from openings around the poop deck.

The duty engineer left the control room and tried to enter the generator room with a fire extinguisher. Because of the heat he was forced to withdraw and, realising that the fire was substantial, he made for his fire station.

The 1st engineer, meanwhile, isolated the fuel to nos. 1 and 2 generators then, partly opening the forward door to the generator room, he directed a jet of water from a hose through the door toward the fire, which he could discern was burning mainly in the port aft corner of the space. The heat was such that he was unable to advance past the door.

A report was received that a shore worker was still in the aft peak tank, immediately adjacent to the scene of the fire. The 2nd engineer and an IR, both wearing breathing apparatus, descended the vertical ladder from the poop deck to the steering gear compartment to search for the man. The smoke was intense. Unable to find him in the aft peak tank, they turned their attention to the fire in the generator room. They were unaware that the shore workers had mustered on the wharf, and all had now been accounted for. At the aft entrance to the generator room, they found that, although there was still much heat and smoke, the fire appeared to have been extinguished by the hose which had been directed through the forward door.

At the forward door of the generator room, the chief and 1st engineers were continuing to hose down no. 1 generator and the port aft corner of the space. They had, by this time, been able to advance one or two metres into the generator room and, although the space was still very hot, the fire was out.

At 1118, a message was passed to the bridge that the fire was out. At about the same time, the fire brigade arrived alongside the vessel.

At 1200, after an inspection of the engine room, the fire brigade established a control position, isolating the engine room to a single point of access in order to control entry by ship's staff or others. After conducting a number of inspections with a thermal imaging camera and thoroughly ventilating the engine room, the fire brigade finally declared the space safe at 1340.

It was later found that the fire had been started by a fuel pipe on no. 1 generator, the securing screws for which had become loose allowing fuel to spray into the hot-box and leak to the bilge, before igniting on the exhaust pipes. The fire had then spread to the oil in the bilge. The fire caused some damage to no.1 generator, but the most significant damage was that sustained by electric cables in cable trays beneath the deckhead.

Conclusions

The different factors identified as contributing to the incident should not be read as apportioning blame or liability to any particular organisation or individual. These are:

1. The fire in the generator room was initiated by vibration loosening two Allen screws securing the fuel suction pipe to the no. 2 fuel pump on no. 1 generator.

2. The source of ignition of the fire could not be determined with certainty, but was most probably the exhaust manifold, the temperature of which exceeded the auto-ignition temperature of the fuel oil, and which was not sufficiently screened against spray from the engine hot box.

3. The design of the hot box was such that fuel was able to escape and flow to the bilge, where a bilge fire ensued.

4. The situation of the fuel leakage alarm, at the forward end of the engine, combined with the vessel's trim by the stern, rendered the alarm ineffective.

5. Although not conclusive, lack of evidence of interaction on the flanks of the screw threads indicates that the screws may not have been sufficiently tightened during previous assembly of the pipework. Although not contributing factors, it is further considered that:

1. When tightening up the 8 mm allen screws on the fuel system of the generators, the ship's staff had been using the incorrect torque, namely that specified for the cap nuts on the high-pressure injection pipe.
2. There was no routine in place on Tasman for recording the coming and going of personnel from ashore, with the consequence that two of the ship's staff carried out an unnecessary search for a shore worker, in a hazardous area adjacent to the fire scene.
3. The response to the fire by the ship's staff was prompt and effective.
4. The retrofit of isolating valves in the fuel supply and return lines to the generator rooms was a safety measure which proved its worth in this incident.

Summary

At 0545 on 16 December 1998, the Barbados flag self-discharging bulk carrier, MV Claudia arrived off Pioneer Concrete's Bass Point jetty at Shellharbour to load a cargo of aggregate. The vessel manoeuvred alongside, starboard side to, against an offshore wind of 15 to 20 knots and was all fast at 0650.

About 10 minutes after loading commenced, MV Claudia developed a starboard list (See figure 1). The ballast was adjusted but the list continued to increase. At 0737, when the list had increased to about 15 degrees, loading was suspended, and the cause of the list investigated by the vessel's crew. On sounding the vessel's ballast tanks and void spaces it became apparent that the vessel had a hole in No 1 void space (starboard). It was apparent that as the draught increased with loading more water entered No 1 void space (starboard) thus increasing the list. The hatch covers and watertight doors on the vessel were closed, and No 1 void space pumped out. Temporary underwater repairs were effected to seal the hole and the vessel sailed for Sydney without loading any more cargo.

Investigation into the cause of the hole in the hull showed that a horizontal steel girder on No 3 dolphin protruded beyond the dolphin's piles below the high tide level. It was evident that in berthing, the vessel had made contact with the girder causing it to pierce the hull.

No one was injured and no pollution occurred as a result of the damage.

Conclusions

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

The following factors are considered to have contributed to the contact damage:

1. The hole in the hull was caused by the steel girder proud of No 3 dolphin.
2. Nobody on the vessel knew that there was any obstruction on the dolphin.
3. No warning was given by the owners of the jetty as to any possible obstruction at the jetty.
4. Although the Master inspected the jetty before the vessel commenced the service, he did not notice the steel girder which was located in a rather inconspicuous position.
5. The speed of the capstans and the drums on the anchor windlass are such that mooring lines could not be retrieved with sufficient speed, given the jetty configuration and its exposed nature.

Summary

The Australian bulk carrier Iron Spencer anchored off Port Hedland at 0736 on 27 November 1998, about 2 miles SSW of Minilya Bank. At 1246 on 3 December, the anchor was weighed, and the Master started to manoeuvre the ship to the pilot boarding ground. The wind was easterly, force 6 to 7 and there was a tide setting north-westerly at about one knot.

The ship was turning to port under full rudder when Port Control called Iron Spencer asking the Master, amongst other things, to hold the ship in its present position. Since the anchor was aweigh the Master was unable to hold Iron Spencer's position in the strong wind and the prevailing tide. The turn to port continued.

At about 1312 the Master ordered full ahead manoeuvring revolutions. A few minutes later he ordered that the rudder be put amidships to allow the engine revolutions to pass through the critical range and, subsequently, to allow the pilot helicopter to lift off.

Shortly after this the rudder was put hard to port. At about 1322, with the Pilot still on the main deck, the speed on the doppler log was seen to drop from 10 knots to about 1.8 knots. A crew member on the poop saw mud and sand discolour the water. The Master contacted the engine room saying that the ship might have touched bottom, but the Chief Engineer replied that all temperatures and pressures and other machinery parameters were normal.

After the Pilot arrived on the bridge, the Master retained the con for some minutes before relinquishing the conduct of the navigation to the Pilot. The Master and Pilot completed the pre-berthing declaration and checklist and the ship proceeded to its berth.

When manoeuvring to the berth, the Chief Engineer detected unusual vibration for certain rudder movements. Suspecting there may have been some bottom contact off Minilya Bank, the Master arranged for divers to undertake an inspection of the ship's bottom. Loading of Iron Spencer was delayed until this was completed.

The divers reported that there was evidence that the ship had made contact with the seabed. Further investigation showed that the rudder was working normally.

Nobody was injured as a result of the contact and no pollution resulted.

Conclusions

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

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

1. The Master did not follow the directions given to the vessel at 1128 by the tower at Port Hedland.
2. The Master weighed anchor and got under way to head for the pilot boarding ground without obtaining clearance from the tower.
3. Although a passage plan was stated to have been available, it was not used by any of the ship's staff.
4. Ship's staff did not comply with Company standing orders and Master's standing orders in that positions were not plotted with the frequency required for these waters.
5. There was no effective appraisal for the change in plan at about 1257 when the Master altered course, while Iron Spencer was swinging to starboard, and brought the vessel around to port.
6. Lack of bridge resource management principles contributed to the grounding.
7. The Master did not take the opportunity to call the tower and seek clarification of the instructions.
8. The Master did not query the message from the tower stated to have been transmitted at 1305, neither did he inform the tower that it was not possible to maintain the ship's position.
9. Whatever the message from the tower, the bridge team did not understand that the helicopter with the marine pilot on board was about to land.
10. The helicopter landed before receiving confirmation that the vessel was prepared and that the landing party were standing by.
11. Once the helicopter had landed on board, the Master maintained course in accordance with guidelines in the Australian Code of Safe Practice on Ship-Helicopter Transfers.
12. It is likely that maintaining the course and delaying the turn to port, was the final link in a series of factors that resulted in the vessel making contact with Minilya Bank.
13. Advice in the Port Information booklet on radio procedures between ship and helicopter and the actual procedures in force at the time of the incident are inconsistent and liable to create confusion.

Summary

The Singapore flag livestock carrier Norvantes sailed from the Queensland port of Karumba, in the Gulf of Carpentaria at 2218 on 19 November 1998. Norvantes carried 1509 head of cattle, together with the necessary fodder and water. The navigation of the ship was under the direction of a licensed pilot.

Norvantes cleared the Norman River and entered the approach channel marked by buoys and beacons. At about 2300 the ship turned on to a westerly heading in 'Elbow Reach' with about 2700 m (1.458 miles) to run before the final west-north-westerly course to the fairway buoy. Ahead, the Pilot could see No.9 beacon and two red buoy lights. Instead of both buoys being seen to the north of the beacon, one was apparently to the south. The Pilot instructed the pilot launch, which was travelling alongside Norvantes, to go ahead at best speed and investigate. The ship was slowed from half ahead to dead slow ahead and the ship steered for the port (southern side) of the channel to stay clear of the buoy and the pilot boat.

The coxswain of the pilot boat reported that No.8 buoy, which marks the junction of Elbow Reach and the Bar Reach to the fairway buoy, was out of position. The pilot boat crew put a line around the buoy and towed it in a northward direction out of the channel. The buoy was pulled to a position close west of No.10 buoy. Norvantes passed the buoy as the pilot boat crew released the improvised towline.

When the pilot judged that Norvantes was in the wheel over position for the alteration of course to the fairway buoy, course was progressively altered to starboard. As the vessel was brought to a heading of about 285, the ship stopped turning. Norvantes was aground on the eastern side of the channel.

Attempts to refloat the ship continued until about 0240 but were unsuccessful. The Pilot left the ship at 0250. The following day another pilot boarded the vessel in preparation for the refloating of the ship.

Norvantes was refloated at about 1750 on 20 November using its rudder and engine and with the aid of a local workboat and the pilot boat. The vessel went to anchor close to the fairway buoy. After the ship was found to have sustained no damage and cattle had been examined, it sailed for the Philippines port of General Santos.

Conclusions

These conclusions identify the factors contributing to the incident and should not be taken as apportioning either blame or liability. The livestock carrier Norvantes grounded as a result of a number of factors, chief of which was that:

• No. 8 temporary buoy was out of position, most probably because its dump was of insufficient mass to anchor it in the prevailing conditions. Also the following factors contributed to the incident:
  • The Pilot relied solely on his own knowledge and experience of the port and did not use bridge resource management principles to engage the ship's staff in the pilotage.
  • Although the Pilot and Master knew that No. 8 buoy was out of position, neither used the time between 2300 and 2318 to fix a position using alternative marks.
  • The Pilot had no alternative plan to identify safe turning positions in the event of the failure or movement of any channel marker.
  • The visibility from the bridge was severely limited by the stowing of fodder forward of the bridge.
  • The leading lights were partially obscured at the western end of Elbow Reach by the background lighting connected with the development works in the port of Karumba.
  • The Pilot's experience of piloting in the port was limited by the preference for senior pilots to operate in the east coast ports of the Cairn's region.
  • There was some degree of tension between the bridge team and the Pilot.
  • The ship did not carry the most up to date chart of the Channel showing the correct position of buoys and beacons or the correct numbering system.
  • The scale of 1:50,000 of the inset chart of the 'Approaches to Karumba' on chart Aus 303, 'Nassau River to Wellsley Islands', is insufficient for effective passage planning in pilotage waters.
  • The ship, although visiting the Port of Karumba regularly, undertook no proper planning for the pilotage passage.
  • There was potential for a degree of ambiguity in the monitoring of the ship' s progress by the ship's staff in that they and the Pilot were not using the same channel marker numbering system.

Summary

At 0600 on 18 November 1998, the Singapore flag offshore anchor-handling vessel and ocean-going tug Britoil 22 was engaged in deploying anchors for the offshore construction barge Java Constructor, approximately 1 mile* northeast of Varanus Island, which lies 6 miles north-east of Barrow Island, Western Australia.

Java Constructor was in the process of laying a new 16-inch gas pipeline from the mainland to Varanus Island, as part of The Varanus Island Pipelines Project. The role of Britoil 22 was to reposition the mother vessel's anchors to allow forward travel of the barge.

The immediate area of operation of Britoil 22 contained several submerged gas and oil pipelines, and many coral pinnacles in shallow water. The weather at the time was good, with wind from the south-south-west at force 3-4. There was a low swell, and the tide was just past low water.

At about 0605, Britoil 22 was directed by Java Constructor to move the port 3 anchor. In the process of approaching the anchor to raise it, the vessel struck and rode up on a submerged object. The vessel was subsequently moved astern clear of the object. Fearing the vessel had been damaged, the master instructed the mate and second engineer to sound the tanks and check all spaces. A short while later they reported no sign of damage.

The anchor was approached from a new direction, raised, and successfully re-deployed in the new required position.

Britoil 22 was next instructed to move the port 1 anchor. At 0730, after raising the anchor to the stern roller, an engine room bilge alarm sounded. Investigation revealed the engine room was taking water. The anchor was dropped, and the available engine room bilge pumps brought online. Britoil 22 proceeded immediately back to Java Constructor, where the flooding was brought under control and the hole located and temporarily plugged by a diver. The engine room bilge was pumped dry and an internal 'cement box' repair effected over the hole.

Britoil 22 proceeded, with the materials barge Sea Sovereign in tow, back to Dampier, finally arriving at 1425 on 19 November. A damage survey was conducted, and a condition of class was placed on the vessel. The vessel was subsequently re-delivered to the owners in Singapore and the charter prematurely terminated under the terms of the contract.

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.

Britoil 22 either made contact with Java Constructor's port 3 anchor or grounded on an uncharted coral head in the shallow water adjacent to Varanus Island. Given the pattern of damage and the Fugro statement concerning the possible existence of a 1 m 'high mound' in the port 3 anchor position, it is more likely that the vessel made contact with the anchor.

The grounding or contact and consequent holing of Britoil 22 was the result of a combination of factors. These factors include but are not limited to:

1. The initial route survey data was misinterpreted by the construction survey team and thus specific hazards to the anchor-handling vessels in the shallows of Varanus Island were not identified.
2. There was poor and/or insufficient communication of operational information, in the form of adequate survey data, between project control on the pipelay barge and the anchor-handling vessels.
3. There was a lack of a cohesive plan or procedure identifying the specific responsibilities, hazards, actions and contingencies for the shallow water anchor-handling operations adjacent to Varanus Island.
4. There was a lack of anticipatory action by project control, in the form of a supplementary survey, when knowledge of uncharted hazards came to light.
5. The difficulties associated with anchor-handling operations in shallow waters, in low light and adverse tidal conditions, were not sufficiently considered.
6. There was inadequate adherence to the OSV Code with respect to the provision of agreed written procedures and, in fact, any reasonable operational dialogue between the pipelay barge and anchor-handling vessels.

Summary

In the morning of 17 October 1998, the Australian tanker Helix was discharging oil products at the Shell terminal berth at Pinkenba, on the Brisbane River.

At 0800, three of the ship's crew were in the engine room, starting on a daily routine of maintenance. In the cargo control room, the Mate was handing over the cargo watch to the 3rd Mate. Shortly after 0800 a fire broke out in the machinery space housing the motors and pumps for the hydraulic power units. A fireball travelled through the ventilation grating where the exhaust trunks penetrated the bulkhead to the main machinery space.

The three personnel in the engine room made their escape, two by way of the door to the steering flat and one by way of the encased escape from the bottom main machinery space plates. In the cargo control room, personnel heard a thump and felt a sensation through the deck. Almost simultaneously smoke filled the internal stairwell to the main deck and rolled along the deckhead.

The cargo pumps closed down automatically, and the Mate directed crew on deck to close the cargo manifold valves. The fire alarm was sounded, and the shore supervisor called the Queensland Fire and Rescue Authority at 0804.

The crew mustered at their fire stations. The ventilation fans and motors were stopped, and all remote fuel stops were closed. Two crew, dressed in breathing apparatus, made an entry to the main machinery space from the main deck level. Although there was some smoke in the upper level they were able to reach the machinery control room level and to then descend to the hydraulic room level. They could see an isolated piece of lagging burning outside the ventilation grille, which was extinguished using a portable extinguisher. On entering the hydraulic machinery space, they found a small fire burning in one corner of the "save-all" beneath the hydraulic pump units. This too was extinguished.

The remainder of the lower levels of the engine room were checked and no fire found. Five units and a commend vehicle of the Queensland Fire and Rescue Authority arrived at 0816 and fire officers boarded the ship. At 0839 the ship was declared safe.

Damage was limited to destroyed light fittings, melted indicator and warning lights and smoke damage. Little damage was sustained to the ship's electrical cabling.

Initial examination indicated that two screws securing the hydraulic oil filter on No .3 hydraulic unit had failed, allowing a spray of fuel to come into contact with a source of ignition, most likely the exhaust trunking of the diesel engine driving No. 3 hydraulic pump.

Conclusions

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

1. The fire was initiated by a combination of two factors: the failure of the bolts securing the pulse damper unit to the hydraulic pump, together with the failure of the supporting brackets connecting the damper to the pump body flange.

2. The failure of the bolts was initiated by fatigue crack growth due to insufficient preload (torque) upon assembly.

3. The failure of the supporting bracket was caused by vibration and inadequate design, once the weight of the HP filter unit had been added to the pulse damper.

4. Ignition of the resulting spray of hydraulic oil was, most probably, caused by oil mist contacting a hot surface on the exhaust trunking of No.3 diesel, the temperature of which was above the auto-ignition temperature of the oil.

5. The design of the installation in the hydraulic machinery room provided insufficient separation, or screening, between the pressurised components of the hydraulic system and the hot surfaces of the prime movers.

It is also considered:

6. The response by the ship's crew was rapid and effective.

7. Evidence from this and other incidents suggests that procedures relating to entry into spaces while fires are burning, or after they are believed to have been extinguished, should be reviewed and appropriate safety measures implemented.

8. The terminal emergency procedures for calling the Queensland Fire and Emergency Services are effective and appropriate.

Summary

The Australian steam turbine bulk carrier Fitzroy River sailed from the Lorim Point bauxite berth, Weipa, at about 1800 on 24 August 1998. The Master, who held a pilotage exemption certificate for the port, conducted the outward pilotage.

The outward passage proceeded routinely between Lorim Point jetty and Gonbung Point. After executing the turn to starboard off Gonbung Point, the Master found that the ship was south of the intended course line and he steered a course into the 'Bellmouth' to compensate.

With the ship steering a course of about 285, and when the bridge was on the line of leads marking the centre of the South Channel, the Master ordered port rudder to turn the ship into the South Channel. Very soon afterwards, the Master realised that the ship was not turning fast enough and he ordered full port rudder.

The ship's heading had reached 240 when the bow grounded on a spit of shoal water extending about 200 m east-north-east from Bn.18, which marks the north bank of the inner eastern end of South Channel. Immediately the engine was put to about 70 rpm astern, but the ship proved to be securely aground with the bow about 130 m from Bn.18 on a heading of 243.

The Master reported the grounding to the ship's managers and the ASP Ship Management emergency plan was activated.

The ship was refloated the following morning with the assistance of tugs. Nobody was injured as a result of the grounding and no pollution resulted.

An inspection of the ship showed that it had sustained no material damage, and the vessel was able to continue in service.

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 following factors are considered to have contributed to the grounding:

1. The intended use of Bn.25 and Bn.33 in transit was inappropriate and impracticable given that:

• they were astern of the ship;
• Fitzroy River has limited visibility astern;
• Bn.33 would be over 1.4 miles away and difficult to see;
• there were insufficient people on the bridge to monitor the transit from the port side of the ship;
• there were adequate cues and prompts for conning Fitzroy River ahead of the ship; and
• looking for the transit was a distraction.

2. Reduced underkeel clearance affected the rate of turn between Bn.28 and Bn.20.

3. Given Fitzroy River's distance from Bn.20 and the ship's heading when the Master ordered the rudder to port to turn into South Channel, the order was given too late.

4. At the time of the order to put the rudder to port, there was a residual swing to starboard, which built in a critical delay in the turn.

5. The Master's relative inexperience resulted in his not detecting a reduced set to the north between Bn.30 and Bn.32, which should have alerted him to a possibly reduced tidal flow in the Embley River.

6. Although there is some evidence of a slightly reduced tidal flow in the Embley River, it was the series of small errors of judgement, rather than the reduced rate of the tidal stream that were the main contributors to the grounding.

7. The reduced manning on the bridge did not allow for full use to be made of the electronic navigation aids, particularly the radars.

8. Deficiencies in the training of exempt masters.

• Written advice to masters seeking exemption is based on notes made by past pilots. These notes have no official standing and do not include tidal data provided to the port authority.
• The ad hoc nature in the training of exempt Masters for the Port of Weipa, resulted in a lack of structure in training and the Master not receiving critical information.

9. Although a number of bulk carriers at maximum draught have grounded on the outward passage in the port of Weipa, none of the reports are made available to masters seeking pilotage exemption and no overall analysis is available from which lessons can be It is further considered that:

10. The Helmsman steered the ship proficiently, in accordance with the Master's orders.

11. After the grounding, the Master and crew followed all the correct procedures. These actions, combined with the ASP Ship Management Emergency Plan and the operation of the tugs, contributed to the safe refloating of the ship.

Summary

On the evening of 18 June 1998, the Panamanian flag container ship MSC Katie embarked a Port Phillip Sea Pilot off Port Phillip Heads to proceed to Swanson Dock, Melbourne. The vessel crossed Port Phillip Bay at full sea speed and reduced to slow speed for passage up the Yarra River. Three tugs were made fast when the vessel was in the vicinity of the Westgate bridge and the vessel arrived at the swinging basin, off the entrance to Swanson Dock at 2338.

The tugs swung the vessel to starboard so that it was positioned to enter Swanson Dock stern first and the Pilot manoeuvred the vessel slowly up the dock towards the allocated berth, No. 3 East. No vessels were berthed at Nos. 1 and 2 East. As the vessel's bridge cleared No. 2 berth, the aft tug eased the stern in, to angle the vessel towards the berth.

The Pilot ordered dead slow ahead, to bring the vessel to a stop, but the engine failed to start. The starboard anchor was let go and the tugs took the weight to stop the vessel and to pull it away from the berth, but the port quarter of MSC Katie made contact with the stem of P&O Nedlloyd Sydney, berthed at No. 4 East. Both vessels sustained relatively minor damage.

After MSC Katie was safely moored alongside, the reason for the engine failure was traced to a blocked pipe to the main bearing lubricating oil pressure gauge/safety switch. This had created a spurious lubricating oil low pressure reading, which had initiated an emergency trip of the main engine, causing the fuel pumps to lift and preventing the supply of fuel to the engine.

Conclusions

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

• The engine failure was caused by a blockage in the lubricating oil piping to a pressure safety switch. The blockage caused a 'low pressure' alarm, which initiated a main engine emergency trip mode, which in turn prevented the engine being started. There are no engine manufacturer's instructions or recommendations on periodic checking of such piping, and it is not standard practice on board ships for such checking to be carried out.
• The lack of communications, between the bridge and engine room teams, resulted in the bridge team not keeping the engine room team informed of progress; and the engine room team not immediately informing the bridge team about possible ramifications of the engine 'emergency trip' alarm.
• The lack of Bridge Resource Management principles on board, resulted in the members of the ship's bridge team not informing the Pilot about the main engine emergency trip and not keeping the Pilot informed about engine response.
• There was an absence of a safety assessment of, and contingency planning for, the berthing operation. In addition, there was an absence of sufficiently detailed discussion of the berthing operation under Bridge Resource Management principles. As a result, no suitable lines were ashore to check the movement astern and, during the final approach to the berth, the bow tug was not in the optimum position to stop the vessel's movement astern, thus there were no safety barriers in place.

Summary

At about 0230 on 22 July 1998 a fire broke out in the engine room of the Antarctic research and supply vessel Aurora Australis. The ship was about 1300 miles south of Tasmania with 54 special purpose personnel (or expeditioners), 24 crew and an ice pilot on board.

About 25 minutes before the outbreak of the fire, the duty engineer had been woken by an alarm on the unmanned machinery space monitoring panel in his cabin. He went to the machinery control room and inspected the engine room. He cancelled the alarm and returned to his cabin at 0213. At that time, everything in the engine room appeared to be normal.

The duty engineer was roused again at 0225 by another alarm and, returning to the engine room, he discovered a fire at the forward end of the port main engine, around the turbocharger. The engine was stopped and the fire alarms sounded.

The fire at the turbochargers was attacked by engineers using portable extinguishers and apparently extinguished. A few moments later, however, at about 0236, a fireball erupted and the engineers were forced to evacuate the engine room. The expeditioners and crew were mustered on the helicopter deck and the fire teams deployed. Preparations were made for the operation of the fixed fire fighting system protecting the engine room.

The Halon 1301 fixed smothering system was released at 0252.Following the release of the halon gas, a MAYDAY message was transmitted and communications were established through Sydney Maritime Communications Centre.

From 0340 onwards, the engine room was re-entered on a number of occasions using self-contained breathing apparatus.

After consultation with the Tasmanian Fire Service by facsimile, ventilation of the engine room commenced at 1444. At about 1540 the engine room could be entered without breathing apparatus for a full inspection.

Although there was some damage to the port engine and turbochargers, the critical damage was to the electrical wiring of power and control circuits carried in cable trays affected by the fire. There was also some water damage, the result of water freezing in pipes in the Antarctic conditions.

Over the next three days, the ship's crew carried out repairs and 'jury rigged' electrical wiring to restore propulsive power to the starboard engine and electrical power to ancillary equipment.

Aurora Australis arrived back in Hobart on 31 July 1998, under its own power.

Investigation of the fire scene showed that the fuel source was from a split flexible hose between the port engine fuel filters and a length of rigid pipe on the fuel spill line.

It was also found that out of ten halon gas bottles, four had failed to discharge.

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 fire:

• The fire was caused by diesel fuel from a split in the flexible fuel hose in the spill line from the main engine coming into contact with a component of the port engine turbo-chargers, the temperature of which was in excess of the auto-ignition temperature of the fuel.
• Failure of the hose was due to its age and to 'wear and tear'.
• Although recommendations relating to fixed pipework on the engines, contained in the Wrtsil Technical Bulletin 'Safety aspects on and maintenance of fuel supply system of VASA 32' issued three years earlier, were implemented by the company, the recommendations in the same bulletin relating to the fitting, care and maintenance of sheathed hoses in the low pressure fuel system, were not followed.
• When fitting the flexible fuel hoses at some time between 1991 and 1992, the ship's drawings were not altered to show the modification to the system.
• Consultations between the company and Lloyd's Register, and the company and Wrtsil, on the use of flexible hoses were 'ad hoc' and no record of consultation or approval concerning their fitting was made by any party.
• No approval was sought from the Australian Maritime Safety Authority for the fitting of flexible hoses.
• Knowledge that the flexible hoses had been fitted under the floor plates was lost with the turn-over of engineers.
• The fact that other flexible hoses were fitted to the engines was well evident, but this did not alert either class or AMSA surveyors to the fact that the modifications were not approved.

It is also considered that:

• In general the response to the fire by the ship's crew and the expeditioners on board was measured, effective, demonstrated initiative and reflects great credit to all on board. Entry into any area adjacent to a fire, however, alone and without breathing apparatus or backup, is extremely hazardous and could compromise an entire firefighting effort.
• The poor design of the electrical operating system for the Halon 1301 fixed smothering system led to its unreliable operation and to the partial discharge, only, of the halon.
• The maintenance of the halon system involved at least three contractors and ship's staff, leading to a lack of continuity in maintenance and probably to the fitting of inappropriate fuses in the 24 volt supplies to the main control units.
• Those involved in restoring propulsion to the ship showed considerable ingenuity, skill and initiative.