Summary

On the afternoon of 27 April 1998, the Australian flag tanker Barrington was inbound to the Ampol Wharf in the Brisbane River. A pilot was conducting navigation of the vessel. The vessel was in ballast and was to load a cargo of petroleum products. Barrington negotiated Pelican Banks Reach and entered Lytton Rocks Reach where she was to make fast the tug Austral Salvor, prior to turning and berthing starboard side alongside.

Austral Salvor left her berth at Whyte Island Tug Base at 1635 and waited off Clara Rock for Barrington to approach. A trainee tugmaster was at the controls of the tug with a supervising Tugmaster close at hand. When Barrington was off Clara Rock, the tug approached the vessel from astern on the port side.

'The tug approached within ten metres of the ship close to where she was to secure a line to the ship. The trainee tugmaster adjusted the tug's speed to enable him to position the tug correctly off Barrington.

While the tug was closing with the ship, the trainee tugmaster was in the process of reducing the speed further, when he noticed the bow of the tug sheering to starboard towards the ship.

The Tugmaster took control of the tug and attempted to arrest the sheer. The sheer of the bow was halted, but the stern swung in and the tug rolled, making contact with the ship just above the waterline. The shell plating on Barrington was holed at the point of contact, in way of a fuel oil storage tank, spilling fuel into the river.

The tug made fast to the ship at 1650, and Barrington was secured to the berth at 1736. Meanwhile, ship's staff had reacted promptly, transferring oil from the ruptured tank and were informed by the tug, at 1730, that the leak had stopped. The Port authorities had been alerted and initiated the Port of Brisbane Oil Spill Contingency Plan.

Permanent repairs were carried out to the damaged area at a repair berth in Brisbane and the vessel was able to load its cargo and proceed on its next voyage shortly after the 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. Based on all the evidence available, the following factors are considered to have contributed to the incident:

1. In handling the unilever to adjust the speed of the tug, the Trainee left on a component of starboard thrust, causing the bow to sheer to starboard.
2. The Tugmaster corrected the sheer of the bow to starboard. However, as the stern of the tug closed within four metres, interaction forces contributed to the tug's momentum towards the ship causing the stern of the tug to make contact with the ship's side.
3. On balance, the probability is that only the tug's stern made contact with Barrington.
4. No action by Barrington contributed to the collision. It is also noted that:
5. The collision caused indentation and penetration of Barrington's hull in way of the port heavy oil storage tank. Both the indentation and penetration of the shell plating were caused by contact with a steel bracket on the tug which was used to attach the after fender to the stern of the tug.
6. The training regime, training manual and instructions provided for prospective Tugmasters would seem to be comprehensive and were not contributing factors in this incident.

Summary

On 11 June 1998, the Netherlands flag dredger Leonardo da Vinci was engaged in widening the approach channel to the Parker Point Terminal at Dampier, Western Australia.

At approximately 1750, the fire alarm sounded and crew members in the engine control room saw a fire on No. 1 diesel engine. The engines were stopped, the fuel supply shut off and the engine room battened down. A fire party attacked the seat of the fire with portable dry powder extinguishers, but as the party could not be certain the fire was fully extinguished, the Halon system was activated.

Two harbour tugs provided assistance in boundary cooling until a shore fire brigade party arrived on board. Members of the shore fire brigade party entered the engine room and, after a careful inspection, declared the fire to be fully extinguished.

The fire was caused by diesel fuel oil spraying onto the hot exhaust trunking of the engine. The source of the diesel fuel oil leak was traced to the shut-off cock to the pressure differential indicator on the No. 1 engine fuel oil filter. The bonnet of the cock had become dislodged, permitting diesel oil, under 8 bar pressure, to be sprayed upwards onto the exhaust trunking.

The fire caused extensive damage to electrical wiring and fittings, resulting in Leonardo da Vinci being out of commission for three weeks. One person was injured in the incident, receiving burns to the face and left forearm.

Conclusions

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

• The fire occurred when diesel oil sprayed from a shut-off cock on No. 1 engine fuel filter on to the hot exhaust trunking of No. 1 diesel engine.
• Over an undetermined period, the spindle bonnet of the shut-off cock had vibrated loose, had unscrewed and had been blown off, permitting the escape of diesel oil under 8 bar pressure.
• At some undetermined time, the handle of the shut-off cock had been removed, to allow access to the square head of the spindle and had not been replaced. This action removed the locking, or keep-safe, portion of the valve.
• Although five spare shut-off cock assemblies were held on board, missing handles had not been replaced on two shut-off cocks, indicating a laxity towards maintenance.

The following factors are considered to have contributed to the Technician sustaining burn injuries:

• When leading the way out, the Electrician chose a route that took them into the engine room, the compartment in which the fire was burning, and he did not maintain physical contact with the Technician, so that they became separated in the dark/smoke.
• On first boarding, the Technician had not been given a formal induction session, to ensure he understood the emergency signals and was familiar with the escape routes from the areas in which he was to be working.
• The exits and emergency exits from the engine room and workshop areas were not clearly marked.

Summary

After clearing its berth at Burnie, Tasmania on the morning of Sunday 15 March 1998, the ro-ro vessel City of Burnie stopped within the harbour to conduct a lifeboat drill. The drill involved the launching of the port lifeboat with a crew of eight.

The lifeboat was duly launched and coxswained by the Mate, it cruised around the harbour for about ten minutes. After the lifeboat had returned and the boat's crew had hooked on the falls, the recovery party, under the charge of the 2nd Mate, found that the electric motor for the falls winch would not start. The Chief Engineer went to the motor contactor panel, located in the funnel, where he operated the falls winch motor by manually pushing in the contactor. He used a portable radio to maintain contact with the 2nd Mate.

The lifeboat was hoisted by this method to deck level, where it was necessary to stop the hoisting while the boat's crew aligned the fall hooks with the davit heads. Hoisting was then resumed, in similar fashion, with all the eight men still in the boat. Despite a warning shout, the winch motor was not stopped before the davits brought up hard against the stops and the wire falls parted. The lifeboat fell to the water, turning over as it did so, spilling out most of the crew.

A number of small leisure craft rushed to the scene, rescued all eight crew members from the water and took them to the yacht club launching ramp. From there, ambulances took the crew members to Burnie hospital.

All eight crew members suffered some form of injury, two suffered major bone fractures, but fortunately no one was killed. The lifeboat was extensively damaged.

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 fall wires parted when the davits were hauled hard home under electrical power, the force exerted on the wires exceeding their breaking strain. The following factors are considered to have combined to cause the incident:

• The fracture, at some earlier date, of the winch safety switch cover plate, which had allowed the entry of salt water, causing corrosion within the switch and an electrical open circuit.
• The instructions for routine checks of the winch safety switch and davit cut-out switches at lifeboat drills, contained in the manufacturer's Instructional Manual, were not followed.
• The use of the winch motor to turn-in the lifeboat by means of manually holding in the electrical contactor.
• Although intermittent faults had been experienced with the operation of the electrical winch motors over a number of years and lifeboats had been raised by holding in the electrical contactors on other occasions, the ship's Safety Committee had not developed a written procedure to be followed under such circumstances.
• The on-board practice for boat drills which resulted in the 2nd Mate not knowing the procedures followed for restowing the lifeboats, although he had served on City of Burnie for six years.
• Neither the Mate nor the 2nd Mate was aware that the limit switches were by- passed and so would not operate when the electrical contactor was manually held in to operate the winch motor.
• The absence of a company organisational mandatory reporting procedure, to keep shore management informed of operational malfunctions.
• The design and positioning of the guideways, which prohibit safe, unimpeded transfer of persons from the lifeboat to the deck, resulting in the full boat's crew remaining in the lifeboat until it is fully housed.
• The hook twisting problems experienced with the single wire fall, which resulted in the 2nd Mate's concentration, from habit, being on the davit heads and hooks.

Summary

On the morning of 5 April 1998, the fishing vessel Melina T was proceeding on a westerly course at full speed, about 7 knots, headed back to its base at Mooloolaba. One of the deckhands was on watch in the wheelhouse and the steering was in the automatic mode.

The Panamanian bulk carrier Eternal Wind was proceeding due north at 13 knots, on passage from Port Kembla to Niihama, Japan, with a cargo of coal. At 0800, the 3rd Mate took over the watch from the Mate, who had instructed the AB watchkeeper to take temperature and atmosphere readings of the cargo hold. The wind was from the south-east at force 5, which was generating a moderate to rough sea on a low swell, and the visibility was good.

At 0815, the two vessels collided, the bow planks of the fishing vessel being sprung by the impact, causing the fishing vessel to flood. Eternal Wind turned about to stand by Melina T, and took the four-man crew aboard when they had to abandon their vessel.

Melina T sank at 1027 and Eternal Wind diverted from its passage to land the four fishermen off Point Cartwright, where the men were disembarked to a water police launch. Eternal Wind then continued on its voyage to Japan.

The Master, officers and crew of Eternal Wind were interviewed when the vessel loaded at Hay point, Queensland on the subsequent voyage.

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 lookout being kept aboard Eternal Wind was ineffective in that Melina T was not seen in sufficient time to prevent collision.
• The watch officer aboard Eternal Wind ceased to keep a lookout when he set about checking the error on the compass.
• The 8-12 seaman watchkeeper aboard Eternal Wind had been assigned duties on the main deck and was not available to keep a lookout while the watch-officer was engaged in other navigational duties.
• The officers aboard Eternal Wind placed an over-reliance on radar for lookout purposes in open waters.
• The lookout being kept aboard Melina T was ineffective in that Eternal Wind was not seen until it had closed to two miles distance and a watch on the vessel was not then maintained to ascertain whether risk of collision existed.
• The Skipper of Melina T had not reacquainted the relief deckhand with his standing instructions that he was to be told whenever another vessel was sighted.

It is further considered that the positioning of the nails securing the hull planking to the athwartship bulkhead, being close to the engine room side of the bulkhead, prevented effective plugging of the gaps and contributed to the foundering of Melina T.

Summary

On 2 January 1998, the Bahamas flag geared bulk carrier Maersk Pomor was undergoing a Port State Control inspection, by a surveyor of the Australian Maritime Safety Authority, at the port of Gladstone, Queensland.

As part of the inspection, the Surveyor requested that the engine of the free-fall lifeboat be started and the movement ahead and astern tested. The 3rd Engineer boarded the lifeboat, started the engine, operated it in the ahead and astern modes and, the test satisfactory, stopped the engine. The Surveyor then requested that the lifeboat's rudder be operated, to port and to starboard.

Standing on the lifeboat boarding platform, from where he could see into the lifeboat, the Surveyor observed the 3rd Engineer unsuccessfully try to turn a spoked wheel, aligned fore and aft adjacent to the coxswain's seat. The 3rd Engineer then restarted the lifeboat engine, after which he again tried to turn the spoked wheel, this time with success. However, instead of the rudder turning, the lifeboat was launched, the 3rd Engineer being thrown to the bottom boards of the lifeboat.

The ship's rescue boat was launched, the lifeboat retrieved and taken alongside the wharf, where the 3rd Engineer was transferred to an ambulance. At Gladstone Hospital it was ascertained the 3rd Engineer had suffered a crush fracture of the first lumbar vertebra and concussion.

Conclusions

These conclusions identify the factors contributing to the incident and should not be taken as apportioning either blame or liability. The main contributing factors are considered to be:

1. The 3rd Engineer's lack of knowledge about the free-fall lifeboat controls.
2. The 2nd Mate's and Electrical Engineer Officer's lack of knowledge about the free-fall lifeboat controls.
3. The training regimen on board, in that it had not ensured that the three officers were fully conversant with the free-fall lifeboat controls.
4. The labelling and instructions for the lifeboat release gear, although clear, were not in the language of the crew.

Summary

On 8 January 1998, the Singapore registered livestock carrier Carabao 1 anchored with 3 shackles of cable about 240 m off the outer berth of the jetty, in the port of Broome in the north-west of Western Australia. The holding ground was considered to be good, and the vessel lay securely at anchor to the tides and westerly winds that predominated over the next six days.

On 14 January, westerly winds of between 10 and 15 knots were experienced, dropping in the early evening to a gentle 5 knot westerly breeze. At about 2225, about one and half-hours before high water and with the ship lying to the tidal stream and heading north-east, a sudden squall was experienced at Broome generating storm force easterly winds. Within seconds, Carabao 1 started to drag anchor directly toward the outer berth.

The Master, who was on watch, informed the engine room that he required the engine immediately, and called out the crew. The Chief Mate and Boatswain went forward to stand by the windlass.

At about 2228, the vessel's starboard bow, just aft of the anchor, came into contact with the eastern corner of the jetty. The vessel, drifting rapidly in a westerly direction, was then driven through the moorings of local fishing vessels. Four vessels were damaged, one of which broke from its moorings and was driven beneath the jetty by the wind and tide.

Between 2230 and 2235, the anchor held once more and Carabao 1 came to a stop close to the shore. Soundings at the ship's stern showed that there was about one metre of water under the keel.

By 2245 the wind had dropped below 20 knots, and the ship was able to recover its anchor at 2318 and move clear of the small craft moorings. By this time the wind had dropped completely away and Carabao 1 anchored once more, 440 m off the outer berth.

No one was injured as a result of this incident. In addition to the four smaller vessels damaged, Broome jetty suffered some damage and Carabao 1 sustained an isolated indentation to its hull plating forward and some superficial paint 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 organisation or individual. The following factors are considered to have contributed to Carabao 1 dragging anchor and making contact with the jetty and fishing vessels:

1. The proximity of the ship's anchor position to the jetty in the event that Carabao 1 was driven toward the west.
2. There was no information available to the Master to warn him of the possibility of squalls developing and causing strong easterly winds.
3. The delay, however minimal, of starting the ship's engine It is also considered that:
4. The likelihood of occurrence of such squalls should have been known to the local harbour authority and the pilot.
5. Even if, with the engine available, contact with the jetty could not be prevented, there was the possibility that dragging of the anchor further west through moored small craft, could have been avoided.

During a search mission, the crew of the P3 Orion aircraft, operating at 1,200 ft, sighted a Cessna 402 on a reciprocal track at 1,000 ft. The Orion crew took avoiding action. The incident occurred near the boundary of the designated search areas of the two aircraft.

The agent reported that the company that supplied the fuel had since conducted an audit and had recommended a change to the procedures. The change required that when an order was made by telephone or radio, the person receiving the order was to read back the fuel type and quantity.

1. The centre of gravity of the aircraft was at or near the aft limit.
2. Gusting, strong wind conditions were conducive to low-level windshear.
3. The limited flying experience of the pilot with regard to the conditions encountered.

Local safety action

As a result of this occurrence, the Civil Aviation Safety Authority has published Airworthiness Advisory Circular AAC1-111, dated 8/99, detailing the flutter problems that can be associated with inadequate maintenance of trim tab systems. The information has been published in the CASA Flight Safety magazine in order to give it a wider distribution than is possible through the Airworthiness Advisory Circular.

ATSB safety action

As a result of the investigation into this occurrence, the Australian Transport Safety Bureau (formerly BASI) issued interim recommendation IR19990187 to the Cessna Aircraft Corporation on 16 December 1999.

It is recommended that Cessna Aircraft Corporation take appropriate action to ensure that Cessna elevator trim-tab actuator component parts affected by this safety deficiency are recoded so that they cannot be purchased separately. In addition, it is recommended that Cessna Aircraft Corporation review comparable designed trim-tab actuators to ensure that they are not affected by this safety deficiency.

Additionally, the ATSB identified the following safety deficiency:

A number of incidents have occurred where the elevator trim-tab actuator jackscrew thread contact area of Cessna 300/400 series aircraft has deteriorated to a point where the threads either disengaged or "jumped" threads. This event appears to be the result of non-adherence by operators to the instructions in the manufacturer's technical manuals. This condition could result in control surface flutter or a jammed control surface, with a resultant loss of flight control.

The ATSB issued the following safety advisory notices on 16 December 1999:

SAN19990188

The Civil Aviation Safety Authority should note the safety deficiency identified in this document and take appropriate action.

SAN19990189

The US Federal Aviation Administration should note the safety deficiency identified in this document and take appropriate action.

SAN19990218

The US National Transportation Safety Board is advised of the recommendation made to the aircraft manufacturer and safety advisory notices issued to the Civil Aviation Safety Authority and the US Federal Aviation Administration.