Summary

At 0600 on the morning of 6 May 1997, the Panamanian flag woodchip carrier Taio Frontier arrived at the pilot boarding ground off the entrance to the Tamar River, Northern Tasmania, to embark a pilot to proceed to Bell Bay. Due to a north-easterly swell, the two pilots assigned the job were unable to get to the pilot ladder, rigged on the port side, and they requested the Master to go full ahead and hard to starboard, in order to make a lee.

The Master ordered hard to starboard, but because of concern about the closeness of Hebe Reef, only ordered slow ahead. As soon as both pilots were on board, he ordered full ahead and hard to port, then instructed the helmsman to steady on 160. On gaining the bridge, the first pilot realised the ship was headed for West Reef and ordered full ahead, hard to port.

When the ship had swung to a heading of about 102, there was a shudder as though the ship had struck the bottom, but the ship maintained its forward movement. Speed was reduced to half ahead and the pilot took the ship to anchor, close to the pilot boarding ground, where all tanks were checked, and machinery and controls tested. Everything appeared normal and there was no ingress of water or sign of oil pollution, therefore the pilotage was resumed.

From the estimated position of the contact, the charted depth was around 16 m to 17 m, with a rise of tide of one metre, while the draught aft was 7.72 m. Subsequent inspection by divers revealed the tips of two adjacent propeller blades had been damaged and the heel of the rudder set upwards, indicating contact with an obstruction of relatively small area.

Conclusions

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

• The pilot ladder was rigged on the weather side, preventing the Pilots from boarding until a lee had been provided.
• The lack of any planning of the approach, with no delineation of danger areas or safety limits on the chart, or consideration of possible contingencies.
• A misunderstanding on the part of the Master of what the Pilot requested regarding the making of a lee.
• Inappropriate action to provide the necessary lee to enable the Pilots to board.
• The lack of Bridge Resource Management procedures, in that the Master did not inform the Mate of his intended actions or seek the Mate's support in monitoring and advising him on the progress of the manoeuvres; in that the Mate did not provide active support to the Master; and in that navigational equipment was either ignored or not used to full effect.
• The differing ethnic/cultural backgrounds of the Master and the deck officers, which inhibited the Master in his dealings with those officers.

Summary

Early on 25 April 1997, the Australian steel hulled, long-line fishing vessel Exterminator was repositioning to the south, before shooting its line, about 19 miles east by south of Green Point, New South Wales. The Skipper was on watch in the wheelhouse and had noticed, on the radar, a vessel coming up from astern, shaping to pass clear on the port side.

Suddenly, at about 0040, there was a loud bang and a jolt, and the Skipper was thrown to the deck on the port side of the wheelhouse as Exterminator rolled heavily to port. Pulling himself back to a standing position, the Skipper saw the hull of a large vessel, in a light condition, passing up the fishing vessel's starboard side. As Exterminator rocked as a result of the initial collision, it came into contact twice more with the hull of the other vessel.

The Skipper put out a number of calls on VHF16 but received no response. He reported the collision to AMSA, then, after contacting the owner, returned to Eden to assess the damage.

The 110,461 tonnes deadweight Liberian tanker Unisina had sailed, in ballast, from Gore Bay, Sydney, on the morning of 24 April 1997, bound for the FPSO Cossack Pioneer, located on the Northwest Shelf.

At midnight on 24 April, the vessel was in a position 20.5 miles east of Green Cape, making good a speed of 11.6 knots on a course of 196. Shortly after 0030, the officer of the watch started altering course slowly to starboard for a vessel, which he considered to be northbound and crossing from starboard to port. After about five minutes and with the ship heading about 235, the officer applied hard to starboard rudder, then port rudder, in an apparent attempt to avoid a collision.

Scientific comparison by the Australian Federal Police Scientific Branch matched paint taken from the hull of Unisina with paint deposited on Exterminator, indicating that Unisina was the vessel that collided with the fishing vessel.

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.

Unisina collided with Exterminator after the Watch Officer mistook the lights of Exterminator to be those of a more distant, crossing vessel and altered course towards the fishing vessel. The following factors are considered to have contributed to the incident:

• A proper lookout was not maintained on the bridge of Unisina between midnight and 0030.
• A proper appraisal of the situation was not carried out by the Watch Officer, by using either visual bearings or radar, before he altered course to starboard.
• Reduced alertness on the part of the Watch Officer, brought about by a sleep debt and 'jet lag'.
• The absence of any guidelines to owners and operators by the Flag Administration, or instructions to masters by the vessel's operator, on rest period requirements to overcome the effects of long-distance travel prior to joining a vessel.
• A proper lookout was not maintained on Exterminator.
• The inappropriate display of fishing signal lights by Exterminator.

The investigation was discontinued.

Summary

On 8 March 1997, the Australian tanker Osco Star was in the southern Coral Sea south of Lihou Reefs, on a loaded passage from Geelong to Port Moresby. The vessel had been experiencing east-south-easterly gale force winds since passing Fraser Island on the evening of 6 March.

To the north of Lihou Reef, a tropical depression, moving slowly in a south-westerly direction, had been developing to cyclone status and had been allotted the name 'Justin'.

During the early evening of 8 March, Osco Star experienced a gradual decrease in the wind to force 2, then the wind backed to the east-north-east and increased in strength, indicating the vessel had passed close eastwards of the cyclone's centre. By late evening the wind had shifted to the north-north-west, at gale force, and the engine speed was reduced due to the heavy weather.

Towards daybreak on 9 March, the wind increased to storm force. At 0620, an earth fault alarm in the engine control room led to the eventual discovery that seawater had entered the emergency generator room, located on the port side of the poop deck, and was sloshing up underneath the emergency switchboard.

During attempts to rectify electrical faults in the emergency generator room, fuses were removed in the 24-volt rectifier/charger unit, inadvertently stopping all engine room pumps. The main engine, however, continued to run, and only stopped once the fuses had been replaced nearly two minutes later. At about 0841, as the fuses were replaced, there was a complete loss of electrical power.

The main engine was restarted from the emergency manoeuvring position at 0925, but short circuits had damaged the 220-volt section of the emergency switchboard, causing the loss of some engine room instrumentation. Seawater had also caused the failure of the 24-volt rectifier/charger unit. The 24-volt system had switched to battery back-up and the batteries were discharging. By about 1100, the battery voltage had fallen to the point where the contactors in the pumps automation system started to drop out. The main lube oil pump stopped, the stand- by pump failed to start and the engine continued to run until, following some confusion, it was manually stopped by the Chief Engineer.

After carrying out checks on the engine it was restarted but, at 1248, was again stopped for a brief crankcase inspection after loud metallic banging was heard as speed was increased. Nothing was found amiss during the inspection. After again getting under way, there were more noises from the engine and it was noticed, later that afternoon, that the crankshaft had moved about 25 mm forward.

That evening, debris from the crankcase, including paint flakes, white metal, shards of steel and brass shims started to block the lubricating oil strainers which required cleaning at 11-minute intervals.

The ship was nursed to Brisbane where, upon opening up the main engine, it was found that the ahead pads in the thrust bearing had been dislodged, and the crankshaft had moved at least 30 mm forward. The engine had suffered extensive damage to the crankshaft, connecting rods, main bearings (which had been carrying the thrust), crossheads and the axial vibration damper. The bedplate had also suffered 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 individual or organisation. The following factors are considered to have contributed to Osco Star sustaining considerable damage during tropical cyclone Justin:

1. Timely action was not taken to avoid an encounter with the tropical cyclone.

2. A proper appraisal of the possible movement of the cyclone was not made, and no account taken of the steady fall in barometric pressure and lack of wind directional shift, which resulted in Osco Star passing close to the centre of the cyclone.

3. There was no full exchange of views, in line with Bridge Resource Management procedures, on the developing situation and the appropriate action to be taken. 4. Reliance was placed upon the wind conditions being experienced beyond the immediate area of effect of the cyclone, rather than on the Bureau of Meteorology's predicted wind strengths.

5. The poop and boat decks were not properly secured against the ingress of water into the steering flat and the emergency generator room, which occurred during the cyclone and which initiated the events which led to electrical, and subsequent mechanical, damage.

6. The design of the bulwark around the poop deck prevented the rapid freeing of water trapped in that area and probably contributed to its ingress into the emergency generator room.

7. The design of the weathertight, rather than watertight, doors and flaps and the poor design of the access to the emergency generator room for electrical shore connections, contributed to water gaining access to those spaces which open onto the poop deck.

8. The design of the ship's 24-volt system and associated alarms was such that the battery voltage was able to drop to a critical point where the engine safety system was disabled, without the ship's engineers becoming aware of the situation.

9. The ship's staff appeared unaware of the fact that;
- Removal of the fuses in the 24-volt rectifier/charger unit would stop all running pumps including that for main engine lubrication.
- The main engine would not stop while the fuses were out.
- After failure of the 24-volt rectifier/charger unit, the system was running on the back-up batteries and they seemed unaware of the consequences of the discharge of these batteries.

10. The loss of voltage from the back-up batteries, as they discharged, caused contactors in the Pumps Automation System to drop out and the running lubricating oil pump for the main engine to stop.

Summary

On the morning of 13 April 1997, the tug Wambiri was assisting in the departure of the Singaporean flag vehicle carrier Salome from berth No. 2 North Quay, in the port of Fremantle. Wambiri was made fast aft and was using its own, forward towline, the eye of which was placed over a bollard on Salome's poop. After Salome had been manoeuvred clear of the berth, Wambiri was instructed to accompany the vessel on a slack line until the Pilot was satisfied he had steerage way.

When the order was given to let go the tug, before Salome's crew could lift the eye off the bollard, weight quickly came on the towrope, the Tugmaster misinterpreting the signal to slack away as heave away. The towrope parted in the eye and, recoiling, struck one of the tug's integrated ratings, who suffered severe internal and external injuries.

Conclusions

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

The towrope, which injured the rating aboard the tug Wambiri, parted at the bollard aboard Salome, after the Tugmaster quickly took the way off the tug before it had been let go.

The following factors are considered to have contributed to the incident:

• Low level of alertness, and possible acute fatigue, of the Tugmaster, caused by the recent shift change.
• The misinterpretation of the signals made by the crew on the poop of Salome.
• The uni-lever in the neutral position, to slow the tug down, expecting the towrope to pull clear, before the eye was seen to be clear of the Panama lead on the vessel. This resulted in the rapid stopping of Wambiri before the towrope had been removed from the bollard on Salome and a consequent shock loading of the towrope.
• It is possible unidentified damage to the eye of the towrope, sustained on some earlier occasion, which resulted in the towrope being less resilient to shock loading.

Also of relevance is the lack of Bridge Resource Management procedures and communication aboard Salome, in that the 2nd Mate was unaware of the Pilot's intended retention of the tug and misinterpreted the slack line to mean the tug wanted to let go.

Summary

On the afternoon of 13 March 1997, the Royal Australian Naval patrol vessel Fremantle left an anchorage off the Flinders Group of Islands, at the eastern side of Princess Charlotte Bay, and, in company with two other patrol boats following astern, commenced passage for Thursday Island. The vessels followed a planned route utilising the inner route of the Great Barrier Reef at a speed of about 15 knots.

At this time the Australian bulk carrier River Embley was on a south bound loaded passage approaching Piper Reef some 150 miles to the north. River Embley was loaded to a draught of about 12.2 m and while underway, at speeds of between 13 and 14 knots, was drawing about 13.5 m allowing for squat. The navigation was under the direction of a licensed Reef pilot.

At about 2100, the three warships were approaching Heath Reef from the South and River Embley was approaching the reef from the north. The depth of water in the area meant that River Embley was obliged to keep to the eastern side of the two-way route and pass about 3 cables off Heath Reef. VHF contact between those on the bridge of HMAS Fremantle and River Embley was established and the message passed that River Embley was a deep draught vessel and the distance the Pilot intended passing off the Reef. The vessels were closing at about 28.5 knots on nearly reciprocal courses with the first two of the three patrol boats crossing ahead of River Embley.

A few minutes after 2100, the lead patrol boat HMAS Fremantle crossed ahead of River Embley, followed by the second vessel in line, the third altered course to pass between River Embley and Heath Reef. HMAS Fremantle made a number of slight alterations and, at about 2108 the rudder was put 20 to starboard. The patrol boat collided with River Embley. There were some slight injuries sustained aboard the patrol vessel as a result of the collision, but nobody on either vessel was seriously hurt. No pollution resulted from the collision.

Damage was sustained to the port side of the patrol boat and some damage was caused to the hull plating close to River Embley's bow and further aft in way of number 3 ballast tank.

Conclusions

These conclusions identify the different factors which contributed to the circumstances and causes of the incident and should not be read as apportioning blame or liability to any particular organisation or individual.

The collision between HMAS Fremantle and the bulk carrier River Embley was caused by the alteration to starboard of HMAS Fremantle when on River Embley's starboard side. The alteration by HMAS Fremantle was made at such a time that, regardless of being constrained by her draught, River Embley could not have taken any action that could have avoided the collision.

The reasons for HMAS Fremantle's actions are the subject of a Naval Board of Inquiry. They involve a complex chain of human factors, which include, but are not limited to:

• incomplete passage and contingency planning
• being unaware of the traffic in the reef
• lack of experience in traffic encounters within the Great Barrier Reef
• the decision to apply 20 of starboard helm based on incomplete and scanty information.

The absence of the deep draft signals on River Embley cannot be said to have directly contributed to the casualty. The patrol boats were advised that she was constrained by her draught, and this was apparently acknowledged. However, had the signals been exhibited, they may have provided an additional prompt for those on Fremantle, as may the use of the Aldis lamp to attract attention had it been easily to hand.

Summary

Early on 13 March 1997, the Cypriot flag bulk carrier Aikaterini L was lying at anchor off the Western Australian port of Geraldton, where it was to load a cargo of mineral sand and barley. In ballast, the 20,297 tonnes deadweight vessel had a calculated draught of 4.1 m forward and 5.67 m aft. The anchor was weighed at 0640 and at 0700 the Duty Harbour Master boarded to pilot the vessel to its berth.

After an exchange of greetings and brief formalities, and with the telegraph on full manoeuvring speed, the Harbour Master steadied the vessel on a south-easterly course, to pass about 300 m seaward of the Pimple Buoy, an orange marker buoy protecting the wave-rider buoy to the north of the entrance channel. His intention was to alter course to port tightly around the Pimple Buoy, into the entrance channel.

'. However, when the ship had turned through about 45, a shudder went through the vessel, followed by a second shudder a few seconds later.

The vessel continued to make way and tests showed that both the steering gear and the main engine were fully functional, so the vessel was berthed as planned. However, underwater inspections by divers on 14 March revealed substantial damage, with hull penetration into double bottom ballast tanks beneath holds 2 and 4. There had also been an ingress of water into No. 4 fuel oil tank, but no pollution occurred.

After temporary underwater repairs had been carried out, Aikaterini L sailed from Geraldton in ballast on 19 March, bound for Singapore to undergo permanent repairs.

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. Aikaterini L came in contact with a charted rock ridge to the south of the entrance channel after the Harbour Master overshot the intended alter-course position to the west of the Pimple Buoy. The following factors are considered to have contributed to the incident:

1. A loss of concentration and awareness by the Harbour Master.
2. A reduced alertness on the part of the Harbour Master, due to the combined effects of his work regime and a slight sleep dept.
3. The Harbour Master's instinctive order of 'hard a port' when he realised, he had overshot the wheel-over position.
4. The pressures induced by the local environmental conditions and the local commercial climate.
5. The absence of Bridge Management procedures, as a result of which: i. the pilotage plan was not discussed; ii. the Master and Third Mate were not fully informed of the Harbour Master's intentions and so were unable to monitor his actions; iii. the Master and his officers had not drawn up their own pilotage plan and the vessel's progress was not monitored properly, so the overshoot was not recognised.

Summary

On 7 March 1997, the Polish flag general cargo vessel Lodz 2 was lying at no. 24 berth, Victoria Dock, Melbourne. Using one of its own cranes, the ship was discharging a general cargo of steel products, including bundles of steel pipes, from no. 2 hold and tween deck.

At about 0740, the sixth load of steel pipes, for that morning, was being discharged onto the wharf by no.1 crane, a 12.5 tonne capacity crane situated on the aft end of the forecastle on the ship's centreline. The crane was being driven by one of the waterside workers.

The load, weighing approximately 8.6 tonnes, consisted of 18 lengths with diameters varying up to 273 mm. As the load reached the side of the ship, there was a violent jolt and a bang as the slew bearing failed, then the crane fell from its pedestal into the port tween deck of no. 2 hold. The jib struck the port bulwark, setting it down and out from the ship's side, while the body of the crane hit the inboard edge of the port hatch coaming, before rotating through 180 and finishing up, upside-down, in the tween deck.

The driver was able to climb out through one of the broken cab windows and up the ladders, out of the tween deck to the main deck, before the effects of shock caught up with him. He had fallen, in the cab of the crane, approximately 17 metres into the tween deck from the crane's position on its pedestal.

An ambulance was called and the crane driver and a waterside worker acting as the hatchman, also suffering from shock, were taken to a medical clinic but were not detained. The crane was severely damaged, and the badly twisted jib had to be cut up to remove it from the ship.

The incident was investigated by the Marine Incident Investigation Unit under the provisions of the Navigation (Marine Casualty) Regulations.

Conclusions

These conclusions identify the different factors which contributed to the circumstances and causes of the incident and should not be read as apportioning blame or liability to any particular organisation or individual.

1. No. 1 deck crane collapsed due to a catastrophic failure of the slew ring bearing. The crane was not overloaded at the time of the failure.
2. The slew ring bearing failed following a prolonged period of progressive wear which went undetected at any statutory survey or examination.
3. The extreme wear which led to the bearing failure was induced largely by an almost total absence of lubrication for the bearing.
4. The vessel had no established planned maintenance or lubrication schedules for the deck cranes.
5. There was no record relating specifically to a measurement of the bearing clearances at any time since the vessel was built, and there was no record on board of the initial bearing clearances, by which the wear rate could have been established. 6. Damage to the jib of the crane, as witnessed by repairs, may also indicate that damage to the slew ring bearing was initiated by some earlier incident. 7. The standard of record keeping and the absence of detail in certification, together with the condition of the slew bearing of no. 1 crane at the time of the incident, would suggest that the standard of survey over the last five years had not been of an acceptable quality.

Summary

On 22 February 1997 the Bahamas flag bulk carrier Clipper Kawa was lying at the outer anchorage off the port of Albany, Western Australia. The ship had just completed a voyage in ballast from Singapore and was preparing to load a cargo of Australian wheat for Inchon in South Korea.

At about 0815 on the morning of Saturday 22 February, the Bosun, with the two deck cadets and two seamen set to work transferring used dunnage lying on the hatch cover of No.3 hold to the space between the break of the forecastle and No.1 hatch. The plan was to partly deballast No.3 hold for maintenance.

The Bosun and the two cadets went to unlash the forward gantry crane. This done, the senior cadet remained in the starboard driving cab while the Bosun, the junior cadet and the two seamen slung the dunnage. On completion, the Bosun and the two seamen alighted from the port side of the hatch cover, while the junior cadet alighted on the starboard side. The two seamen then went forward, and the Bosun, having received an 'all clear' signal from the cadet on the starboard side, signalled the driver to move the gantry forward to No.1 hatch.

After the gantry crane arrived at No.1 hatch and lowered the dunnage, the Bosun noticed that the junior cadet had not arrived up forward. He walked aft on the starboard side and found the cadet, apparently unconscious, lying against the hatch coaming of No.2 hold. The crew carried him into the crew's recreation room in the accommodation and the Chief Officer started to apply CPR.

Shortly afterwards, on unzipping the overalls of the cadet, it was found that his abdomen had burst open and it was concluded that he was dead.

The postmortem revealed that he had died from shock and haemorrhage following multiple crush injuries.

The incident was investigated by the Marine Incident Investigation Unit under the provisions of the Navigation (Marine Casualty) Regulations.

Conclusions

These conclusions identify the different factors which contributed to the circumstances and causes of the incident and should not be read as apportioning blame or liability to any particular organisation or individual. It is concluded that:

1. The junior deck cadet on board Clipper Kawa died from shock and haemorrhage as a result of multiple crush injuries received after being caught between the power belt idler wheel, on the starboard leg of the forward gantry crane, and the after coaming and hatch cover guide on No.2 hold.
2. The cadet must have been aware that the crane was moving as he had, shortly before, given an 'all clear' signal to the Bosun and had walked forward to a position ahead of the moving crane.
3. There was no sound reason for the cadet to have been in that particular position at the same time as the moving gantry crane and it cannot be known what was in his mind immediately before the incident.
4. There is a possibility that the cadet, mistakenly thinking he had time to cross in front of the moving crane, attempted to cross the crane track to get to the space between the after end of No.2 hold and the deckhouse.
5. The audible alarms on the gantry cranes are not sufficiently loud or 'startling' as to hold a person's attention while the cranes are moving along the deck, particularly in a strong wind and against the background noise of the hydraulic machinery.
6. Although possibly not a significant factor in this incident, the gantry cranes have no warning notices to indicate that they may start moving at any time.
7. Neither fatigue nor alcohol are considered to have been contributing factors in the death of the cadet.

Summary

The Maltese flag general cargo/container vessel Cape Arnhem sailed from the port of Gladstone, Queensland just before midnight on 24 February 1997. As No.2 hatch was clear of containers, the Agent had informed the Master that the Pilot would be taken off by helicopter. The Master had queried this but was assured by the marine Pilot that there was ample room at No.2 hatch for safe helicopter operations.

At 0045, 25 February, the marine Pilot asked the Master to have all the deck lights switched on and for No.2 crane to be topped and swung out to port in readiness for the helicopter. These requests were complied with, No.2 crane being topped and slewed to maximum, the hook also being raised to 'cut-out' position. When this had been carried out, the Pilot informed the helicopter that it was safe to approach the vessel from the starboard side.

The helicopter landed on the starboard side of No.2 hatch at 0105, when the vessel was in the vicinity of S1 and S2 buoys. The marine Pilot went down to the deck and boarded the helicopter, fastening himself into the starboard front seat, next to the helicopter pilot.

The helicopter lifted off the hatch, hovered briefly, tilted and started to move forward, across the hatch, towards the port side. It then started to climb, accelerated and, according to those watching and to their concern, it banked to the left. There was then a loud bang as the main rotor blades struck the hook block of the topped No.2 crane. The helicopter started to rotate, the tail rotor also striking the hook block. The helicopter then flipped upside down and fell to the sea, about 20 m from the ship's side.

The Master immediately informed Gladstone Port Control, started to slow the vessel down and mustered the emergency lifeboat's crew. As soon as way was off the vessel, the lifeboat was launched and sent to the area of the accident.

A local fishing vessel was first on the scene, rescuing the helicopter pilot and recovering the body of the marine Pilot. A marine rescue boat from Gladstone was able to retrieve the upturned helicopter.

The helicopter/aviation aspects of the incident were investigated by the Bureau of Air Safety Investigation (BASI).

Conclusions

These conclusions should not be read as apportioning blame or liability to any particular organisation or individual.

The clear area available at no.2 hatch was in excess of the 16 m required for a Hughes 500 helicopter.

From the evidence provided by the master and officers:

• Cape Arnhem maintained a steady course and speed during the helicopter operation;
• the helicopter banked to the left as it climbed from the hatch.

Although it had no bearing on this incident, the crew were neither well versed nor drilled in helicopter operations, which raises the question of the advisability of utilising a helicopter when there is likely to be no emergency support procedure in place.

The helicopter/aviation aspects of the incident will be the subject of a report by the Bureau of Air Safety Investigation (BASI).