Recommendations

As a result of the investigation into this occurrence, the Bureau of Air Safety Investigation issued the following recommendations:

IR970014

"The Bureau of Air Safety Investigation recommends that Airservices Australia review the requirements detailed in AIP Supplement H73/96, (10 October 1996) Simultaneous Opposite Direction Parallel Runway Operations Sydney (KSA) and:

1. develop a SID which incorporates a standard left hand turn after take-off, and tracks the departing aircraft through the heads of Botany Bay in accordance with accepted separation and noise-abatement procedures,
2. have the departing aircraft remain on tower frequency until the assigned turn has been completed, and
3. develop a pilot aid for inclusion in departure and approach procedures (DAP) East. This chart should depict the expected flight path of aircraft departing and arriving under SODPROPS, and could be similar to the pilot-aid (Issue 1, 14 September 1995), located in DAP East, advising pilots about independent visual approaches at Sydney Airport."

Response from Airservices Australia received 4 March 1997:

"BASI has made three recommendations arising from Occurrence 9700052

Airservices has recently conducted a post implementation review (PIR) into SODPROPS at Sydney. Specific action undertaken by Airservices to address the BASI recommendations is as follows:

1. An appropriate SID will be developed which will be standard for all departures from Rwy 16L (not specific to SODPROPS). Until then the RADAR 6 departure with specific headings will continue to be used.

   The BOTANY BAY HEADS Visual departure is no longer considered practical for jet aircraft owing to the difficulty in navigating to the Heads with high body angles and the possibility of entering cloud above 3000 feet prior to reaching the Heads.

2. An instruction has been issued requiring ADCs to instruct departing aircraft under SODPROPS to remain on Tower frequency until established in the appropriate left turn.
3. The recommendation to produce a pilot aid for inclusion into DAP (East) has been referred to CASA Flying Operations Branch for consideration/action.

While supporting these recommendations, Airservices is concerned that the report does not address the principle causal factor of the occurrence, namely flight crew error.

No reference is made to the following factors:

The assigned heading was correctly read back by the pilot but not entered into the FMS;

The pilot called departures radar at the appropriate time but failed to read back the assigned heading;

The use of FMS below the LSALT."

Response classification: Closed-Accepted

Response received from the Civil Aviation Safety Authority 22 April 1997:

"I refer to BASI Interim Recommendation IR 970014 addressed to Airservices Australia concerning Simultaneous Opposite Direction Parallel Runway Operations (SODPROPS) at KSA Sydney. The following comments are provided from a CASA perspective.

The first point of the recommendation is that "a SID be developed which incorporates a standard left hand turn after take-off and tracks through the heads of Botany Bay in accordance with accepted separation and noise abatement procedures". The SODPROPS standard is a visual standard and obviously the last line in separation would be the visual element. The ATC procedures specified in the local instruction indicated that a Botany Bay visual departure should be issued to departing aircraft. CASA believes there is no point in developing a Standard Instrument Departure (SID) for a visual procedure, in fact it could stop pilots from looking outside.

The second point is that the departing aircraft should remain on the tower frequency until the departure turn has been completed. Airservices Australia have since implemented this.

Finally, it is recommended that a pilot aid on SODPROPS be developed. This is probably worthy of consideration but CASA believes that AIP SUP H73/96 may require amending to specifically indicate a section on departing aircraft. Other than a reference in the standard section to course divergence there is no specific indication regarding aircraft departure requirements."

Response classification: Closed-Accepted

R970150

"The Bureau of Air Safety Investigation recommends that Airservices Australia conduct a comprehensive systems safety analysis of simultaneous opposite direction parallel runway operations (SODPROPS)."

The Bureau also made the following recommendation (R970151) to the Civil Aviation Safety Authority:

"The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority review the Operational Standard "Simultaneous Opposite Direction Operations" to ensure that it provides an acceptable level of safety."

Response received from Airservices Australia 1 December 1997:

"I am writing in response to your occurrence report and the associated recommendation that Airservices "conduct a comprehensive systems safety analysis of simultaneous opposite direction parallel runway operations (SODPROPS).

In addressing this recommendation, I commissioned a team to conduct an independent analysis of the SODPROPS procedure itself and the analysis that was conducted prior to the implementation of the procedure at Sydney Airport. This team comprised representatives from ATS' Safety and Quality Management Branch, [and] ATC specialists from Sydney and Brisbane. The team was assisted by expert support from CASA and the major domestic airlines.

In essence, the analysis team has produced a Safety Case (copy enclosed) addressing the safety issues identified by the original SODPROPS implementation team. This Safety Case has been augmented by a Fault Tree Analysis of the risk of failure of the SODPROPS procedure.

I must emphasise that the bulk of the analysis presented in the SODPROPS Safety Case reflects the extensive hazard analysis and risk mitigation work that was done by the implementation team prior to the implementation of SODPROPS.

Whilst it can be said that the data was not collated into a concise document (for which CASA and Airservices now advocate a Safety Case), the data was available in relevant files within the Sydney management system at the time of the BASI investigation.

The data used in this report was available in relevant files within the Sydney management system at the time of the BASI investigation.

The Fault Tree Analysis was compiled using probability data on human performance and on historical incident data. The SODPROPS Safety Case provides the necessary assurance that SODPROPS is being operated at an acceptable level of safety."

Response classification: Open

R970151

"The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority review the Operational Standard "Simultaneous Opposite Direction Operations" to ensure that it provides an acceptable level of safety."

The Bureau also made the following recommendation (R970150) to Airservices Australia:

"The Bureau of Air Safety Investigation recommends that Airservices Australia conduct a comprehensive systems safety analysis of simultaneous opposite direction parallel runway operations (SODPROPS)."

Response received from the Civil Aviation Safety Authority 27 November 1997:

"I refer to your letter dated 1 October 1997 reference BS/970061 regarding Recommendation R970151.

CASA has reviewed the Operational Standard "Simultaneous Opposite Direction Operations" as you have recommended. Following Occurrence 9700052 on 5 January 1997 the instructions in AIP OPS paragraph 19.4 were changed by NOTAM to require pilots to remain on Tower frequency until instructed to change, thus enabling Tower to correct the kind of confusion evident during the occurrence. The amendment will be correctly inserted into the AIP OPS text by AIP Amendment List 20, effective 4 December 1997.

Given the change to procedures our conclusion is that the standard expressed in the CASA Manual of Operational Standards (MOS) Part 3 Chapter 5.9 is adequate.

The MOS standard will be further reviewed in the light of any study which may be undertaken by Airservices in response to your recommendation R970150."

Response classification: Open

Following the provision of the SODPROPS safety case the Bureau elected to have the document reviewed by an independent consultant with international experience in aviation risk management practices and procedures. The intent of the review was to ascertain whether the safety case undertaken by Airservices was a comprehensive safety case and whether it had adequately demonstrated that SODPROPS could be conducted at a reasonable level of safety.

The review of the safety case was conducted in the last week of March 1998. On receipt of the consultant's report it will be reviewed and any further action by the Bureau will be subject to the findings of the report.

As a result of the investigation into this occurrence, the Bureau of Air Safety Investigation made the following recommendation to the Civil Aviation Safety Authority in conjunction with the Gliding Federation of Australia on 13 August 1997:

R970092

The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority in conjunction with the Gliding Federation of Australia;

1. establish a protected circuit area around airfields that have considerable gliding activity;
2. establish a procedure that all inbound aircraft be required to make an all-stations radio call advising their intention to enter the protected circuit area mentioned above;
3. apply a speed restriction of 80 kts indicated airspeed to gliders operating in this protected circuit area at all times other than during official competition events (aircraft other than gliders should operate at minimum safe speed within the area); and
4. investigate the benefit of the application of high-visibility markings for all Australian registered gliders.

Gliding Federation of Australia response

An initial response was received from the Gliding Federation of Australia (GFA) on 12 September 1997, rejecting all but the last recommendation. A further response was received from the GFA on 9 October 1997. The response stated in part:

Summary

1. The GFA recognizes that the rate of mid-air collisions involving gliders is unacceptably high in the circuit areas of aerodromes and will implement measures to improve discipline in flying the pattern and making better use of the radio.
2. The GFA is unwilling to accept the imposition of mandatory radio for gliders in an area where it is optional for all other traffic.
3. Although it is, on the face of it, difficult to argue with the recommendation for a speed limit for gliders, there are considerable numbers of fast homebuilt aircraft such as the Long Eze which have a frontal area not much different from that of a glider and are thus just as difficult to see. In fact, because of their shorter wingspan, they have even less frontal area in some cases. Given that the Tocumwal accident occurred above the circuit area and there are no other accidents on record where high glider speed in the circuit was shown to be a factor, there is no justification for the recommendation.
   
   In spite of the above comment, GFA will closely examine the feasibility of requiring in future that any "abnormal" circuit entry, be it a high-speed entry or an inadvertent entry from an unusual position, be preceded by an "all stations" call from a radio-equipped glider, warning other traffic of the glider's position and intentions. In the case of a non-radio glider, a high speed circuit entry will not be permitted (except at a NOTAMed contest) and pilots "caught out" by conditions and entering from unusual positions must fly so as to avoid other traffic in accordance with the CARs.
4. A shift in emphasis is needed in cross-country training, from the euphoria of completing the task to a positive concentration on the complex circuit-joining task ahead and its consequent need for a full lookout scan and any radio calls that may be appropriate. For all joining traffic, whether from cross-countries or not, the concept of a "wake-up call" when about to enter the circuit area must be developed and we are working on that.
5. A strategy needs to be devised to cope with the increasing complexity of cockpit instrument systems, especially when entering known busy traffic areas.
6. BASI has identified the phenomenon of "skill fatigue", one of the symptoms of which is fixed vision and a failure to scan the sky. Given that the complex nature of many gliding tasks makes skill fatigue a likely factor in our sport, there will be an education campaign warning of the need to "keep something in reserve" for the complex task of joining a known busy part of the sky after the relatively low-risk enroute task which has just been flown.
   
   I trust this explains and summarises the GFA position on this matter".

Response classification: CLOSED - PARTIALLY ACCEPTED

GFA/BASI Meeting

Subsequently a meeting between BASI and the Director of Operations of the GFA was held on 13 January 1998. The following is a summary of the outcomes of that meeting:

1. The proposal for a protected area around aerodromes with significant gliding activity was not supported. Instead it was agreed that the size of the CTAFs at these locations be reduced from a non-standard 15 NM radius to the standard 5 NM radius.
2. It was agreed that the GFA recommend a circuit entry broadcast become a standard operational procedure for all radio-equipped gliders that, due to variation in conditions or unforeseen circumstances, can not enter or comply with the standard traffic pattern for that location. The GFA publication "Airways and Radio Procedures for Glider Pilots" to be amended accordingly. It was also agreed that a procedure would be developed for non radio-equipped gliders to follow in similar circumstances.
3. The recommendation for an 80 kt speed restriction to gliders operating in the circuit area was rejected. An alternative course of action to address this issue, as suggested by CASA, was the avoidance of abrupt vertical manoeuvres in the circuit area. It was proposed that BASI discuss with CASA the incorporation of the avoidance of abrupt vertical manoeuvres in the circuit area, into the relevant section of the Aeronautical Information Publication.
4. The GFA expressed a willingness to participate in any additional study to investigate the benefit of high-visibility markings on gliders. BASI will encourages the GFA and others to continue research on this subject.

Civil Aviation Safety Authority response

A response was received from the Civil Aviation Safety Authority (CASA) on 19 September 1997. This response disagreed with some of the recommendations and instead suggested some alternatives.

Following the GFA/BASI meeting, a copy of the letter to the GFA, summarising the agreements reached at that meeting, was sent to CASA.

The following response was received from CASA on 6 April 1998:

"Thank you for your letter of 3 February 1998 with the results of a meeting between BASI and the GFA at which the BASI report on the Tocumwal and Horsham glider mid air collisions were discussed.

CASA concurs with the recommendations resulting from this meeting and will instigate action to implement the reduction in the size of the Tocumwal and Benalla CTAFs".

Response classification: CLOSED - ACCEPTED

LOCAL SAFETY ACTION

As a result of this occurrence, Sportavia Soaring Centre of Tocumwal, wrote to BASI on 27 August 1997, advising:

"Having read your Air Safety Recommendation on No R970092, we are in full agreeance with the report and also fully agree with the recommendations put forward.

It is our intention to implement immediately the recommendations outlined in the report: They are:

1. A mandatory 15nm inbound radio transmission by all gliders.
2. A 3nm inbound transmission by all gliders entering the circuit area.
3. A radio call on executing the circuit entry.
4. 80 knots indicated airspeed maximum for all gliders inside the circuit area, except during official competitions.
5. The circuit is defined as below 2000 AGL and 3nm radius.

We believe these actions will reduce the possibility of a repeat accident of this nature. Trusting that this is to your satisfaction".

1. The aircraft was flown before necessary certification processes were completed.
2. The aircraft performed a barrel roll or similar manoeuvre for reasons undetermined, and the engine stopped during the manoeuvre.
3. The engine stoppage was most probably due to fuel starvation.
4. The pilot lost control of the aircraft and was unable to regain control before the aircraft struck the ground.

Summary

The small general cargo/container vessel, Arktis Grace arrived in the port of Townsville on 16 August 1996 after a voyage from Papua New Guinea. The voyage had been at reduced speed due to machinery problems. It had no cargo to discharge and remained in Townsville to complete repairs. On 12 October 1996 the ship was still lying at no. 6 wharf in Townsville, awaiting spares for the main gearbox.

The 53-year-old Master was due to pay off from the ship on 15 October and to return to his home in Denmark for leave. On the evening of Saturday 12 October, he and his friend of long standing, the Chief Engineer, went ashore for a farewell dinner. They started the evening with drinks at an hotel near the docks, then went into town for dinner and finally to another hotel before returning on board Arktis Grace at about 2145 that evening.

The Chief Engineer boarded the ship first, while the Master paid the taxi driver. Shortly afterwards, the crew heard a loud crash and felt the ship shudder. The gangway was found tipped on its side and the Master was seen floating face down in the water between the shipís side and the wharf.

The Chief Engineer and a crew member jumped into the water in an attempt to save him. The Master was a big man weighing about 140 kg and, despite their efforts, he was later found to have drowned.

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 Master of Arktis Grace died by drowning, after falling from the vesselís gangway into the gap between the shipís side and the wharf.
2. The hand-ropes of the gangway were sufficiently slack to allow the Masterís centre of gravity to move outside the edge of the narrow gangway and for his weight to tip it over.
3. The hand-ropes had not been tended and tensioned regularly by the deck watch as the vessel rose and fell with the tides.
4. The Chief Engineer and the ordinary seaman in the water did all they could to try to save the Master.
5. There was an excessive delay before an ambulance was called, explained in part by the fact that none of those on board knew the emergency number to call, and the number was not displayed in a prominent position adjacent to the telephone.
6. The Inspector considers that the consumption of alcohol in the hours preceding his death, which led to an apparent blood alcohol level of .291%, was a significant factor in the impairment of the Masterís sense of balance on the gangway.
7. Had a safety net been rigged underneath the gangway, as required by the Port of Townsville By-laws during the weeks immediately preceding the incident, it may have prevented the Master from falling into the water.

Summary

Early in the morning of 6 September 1996, the Malaysian cargo ship Alam Tenggiri was about 65 miles east-by-south of the Queensland port of Mackay, en route from Bing Bong, in the Gulf of Carpentaria, to Newcastle, New South Wales. The weather was fine, the visibility clear and the sea calm.

At about 0120 Eastern Standard Time, the officer on watch saw the light of a vessel ahead on the port bow. Alam Tenggiri was making good a speed of about 12.8 knots, with High Peak Island about 20 miles on the starboard bow. After watching the other vessel, he deduced that the vessel was on a parallel or nearly parallel course and that his ship was the overtaking ship and had a duty to keep clear. He started an ARPA plot and determined the closest point of approach of the other vessel.

The fishing vessel Galaxy was relocating from fishing grounds off Mackay to grounds further south, to the west of the Capricorn Group. The Skipper handed over the watch to the vessel's Cook, who maintained a lookout and a check that the vessel followed the course displayed on the vessel's plotter, which was connected to the GPS. The Cook saw no other vessels.

At about 0240, collision seemed imminent and Alam Tenggiri's rudder was put hard to starboard. As the starboard trawl boom of the fishing vessel came into contact with the port side railing of Alam Tenggiri the cargo ship's rudder was put hard to port. The smaller fishing vessel passed down the port side of the cargo ship.

The Alam Tenggiri started to slow its engine in readiness for turning about to render assistance. After about 20 minutes VHF radio contact was established and information was exchanged. The fishing vessel reported that it had sustained damage to its boom but did not require assistance.

The collision occurred in approximate position 2150.5' South 15048' East. Alam Tenggiri continued on its voyage to Newcastle. Galaxy abandoned the voyage to the new fishing ground and set a course to return to its home port of Caloundra.

Conclusions

These conclusions identify the different factors contributing to the collision between Alam Tenggiri and Galaxy and should not be read as apportioning liability or blame to any particular ship or individual.

It is considered that the fishing vessel Galaxy was on a steady course of about 150 and the following factors contributed to the collision:

• The Second Mate on Alam Tenggiri, having seen the light of the vessel being overtaken, did not keep a proper lookout in that he did not make a full and effective appraisal of the situation and of the risk of collision.
• The Second Mate placed too great a reliance on ARPA without a full appreciation of its possible inaccuracies.
• A prolonged period of overtaking involving no immediate risk of collision reduced awareness of the potential danger of eventual collision.
• Given the extent of open water available, Alam Tenggiri did not give sufficient sea room to the vessel being overtaken.
• The person on lookout on board Galaxy did not keep a proper lookout and did not detect the overtaking vessel by sight or radar.
• Although the manning of Galaxy met the requirements of the Australian Transport Advisory Council's Uniform Shipping Law Code, the person on lookout on board Galaxy was not qualified, had no training in the use of radar and did not have the knowledge to maintain a watch.

Summary

On the morning of 17 August 1996, the 25,093 gross tonne Hong Kong flag container ship Matilda Bay was crossing the Great Australian Bight, on passage from Melbourne to Fremantle in Western Australia. At 0800, the ship was in the position 3722'S, 13150'E, approximately 240 nautical miles WSW of Kangaroo Island. At about 0800, the Second Engineer reported to the bridge that sunlight could be seen coming into the forecastle through the small 'booby' hatch on the forecastle head.

The Chief Officer, after leaving the bridge, made his way forward along the main deck to investigate, taking the Bosun and two Able Seamen (ABs) with him. He had not advised the Third Mate, now on watch on the bridge, nor anybody else, that he was going to the forecastle. He had no radio with him. The four men went onto the forecastle where they found the lid of the booby hatch had been torn off. Attempts to replace it proved fruitless, as it was distorted, so the Chief Officer sent the Bosun to get materials with which to improvise a hatch cover.

Shortly after this, a green sea swept the forecastle, carrying one AB right over the top of the windlass and the other AB against the front of it. The Chief Officer was swept underneath the windlass. The AB who had been swept over the windlass, stunned, called out to the other two who did not reply. He, thinking they had been washed overboard, made his way off the forecastle and told the Bosun what had happened. The Bosun sent the duty AB to the bridge to inform the Officer of the Watch of a man overboard situation.

The Officer of the Watch commenced a Williamson turn and sounded the 'man overboard' alarm. Shortly before 0900, while the vessel had started searching for the men believed overboard, the other AB, recovering on the forecastle, found the Chief Officer under the windlass. Making his way aft he told the Bosun that the Chief Officer was still on the forecastle. The Chief Officer was stretchered aft to the ship's hospital. He had suffered severe head and chest injuries and a broken leg. It was found later that the two ABs had not sustained serious injury. At 0945, the MRCC in Canberra was contacted asking for medical advice and for the nearest port for a medevac of all three.

Those tending the Chief Officer were unable to stem the profuse bleeding from his head injuries. In spite of prolonged CPR and the administering of oxygen, all vital signs had disappeared by 1330 and it was concluded that he had died at some time before that. The ship resumed its course to Fremantle where it arrived on the evening of 19 August.

The incident was investigated by the Marine Incident Investigation Unit on behalf of the Hong Kong Marine Department.

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. The Chief Officer died as a result of multiple injuries received when he was swept underneath the windlass by an unexpectedly high sea coming over the forecastle.
2. The ship, at the time of the incident, having slowed down on the previous evening, was proceeding at an appropriate speed for the prevailing weather conditions.
3. The forecastle had not been properly secured for sea when the ship sailed from Melbourne, on 15 August, and this resulted in the cover of the booby hatch being torn off by the heavy weather encountered crossing the Bight.
4. The fact that the Chief Officer had not informed the bridge or the Master of his intention to proceed forward meant that no assessment was made of the risk of working on the forecastle, repairing the hatch cover, in the prevailing sea conditions.
5. The fact that the Officer of the Watch was unaware that men were to work on the forecastle resulted in the course of the ship being maintained into the heavy weather when it could have been changed to run with the weather for the duration of the repairs, thereby making it safer to work forward.
6. Neither the Chief Officer, nor anyone else in the group on the forecastle, had a radio with which to maintain contact with the bridge. This, combined with language difficulties and shock, contributed to the confusion which prevailed for a while after the incident and to the delay before the Chief Officer was found underneath the windlass.
7. The Master and officers of Matilda Bay did everything possible under the circumstances, and with the medical equipment available on board, to save the life of the Chief Officer.

Summary

At approximately 1600 hours on 8 August 1996, the Indonesian cargo vessel Niaga 46, arrived at Christmas Island, about 4.5 miles to the Northwest of Flying Fish Cove. The ship was due to berth at 0600 the following morning to load 7,600 tonnes of rock phosphate.

Christmas Island is "steep to" and ships do not anchor but drift while waiting to berth. Niaga 46 hove to in position with North West Point bearing 270 x 2.5 miles, to drift overnight. Sea watches were maintained and the engine was on ten minutes notice of readiness. The wind was blowing from a southerly direction at 17 knots and the anticipated current was west going at about 2 knots.

By 2132, the vessel had drifted west towards North West Point and the Third Mate decided to reposition the ship. At 2323, the vessel was repositioned about 2.5 miles due east of North West Point.

At midnight, the Second Mate had not arrived on the bridge, so the Third Mate handed over the watch to the 12-4 apprentice and left the bridge at about 0005. The Second Mate arrived on the bridge at about 0010 and switched on the starboard radar to check the ship's position. The radar showed Niaga 46 as being close to the land east of North West Point. He rang the duty engineer and requested use of the engine. The engine was ready at 0039, however, before the Second Mate could manoeuvre clear of the land the ship grounded at 0047 about 6 cables east of North West Point.

At 0605, contact was made with the Harbour Master, Christmas Island, and he boarded the ship a little after 0700 on 9 August. The Harbour Master took charge of the refloating operation and, after a number of unsuccessful attempts, the vessel was refloated at 2300 on 9 August.

The vessel suffered extensive damage and was taken in tow to a repair port in Indonesia.

Conclusions

These conclusions identify the different factors contributing to grounding of Niaga 46 and should not be read as apportioning liability or blame to any particular individual or organisation.

It is probable that when the Third Mate left the bridge, Niaga 46 was still making way through the water as a result of the prolonged use of the engine at full harbour speed while repositioning the ship between 2132 and 2323. This, combined with the following factors, contributed to the grounding:

1. The Third Mate absenting himself from the bridge before the Second Mate arrived to take up his watch.
2. The hand over of the watch at midnight to the apprentice, was inappropriate, not thorough and did not reflect the true status of the ship in relation to the status of the navigation equipment and the proximity of the land.
3. A complete lack of acceptable watchkeeping standards and an absence of basic seamanship practices.
4. A lack of any realistic assessment by the Master or deck officers of the risks involved while drifting off Christmas Island, together with the lack of planning and determination of sensible safety margins.
5. A lack of clear direction and control over the conduct of the watchkeeping officers by the Company and Master.
6. Poor general management of the ship, and its operation.

Summary

On the morning of 13 May 1996, the 152,308-tonne dwt. Liberian flag bulk carrier Docebay was on ballast passage from Japan to Dalrymple Bay in Queensland. At 0400, the ship was at the position 1347.7' S, 153 56.8' E, approximately 500 nautical miles north-east of Townsville.

Shortly before 0400, the Second Engineer had left his cabin for his 0400-0800 watch in the engine room. At about 0405, the First Engineer, in the cabin adjacent to that of the Second Engineer, heard the sound of a fire and felt heat through their common bulkhead. He telephoned the engine room, and the Second Engineer returned to his cabin, where, upon unlocking and opening the door, he was met by a blast of heat and black smoke. The ship's fire detection system went into alarm. The fire very quickly gained a hold in the cabin as the ship's crew started to tackle the fire from the Chief Engineer's cabin, at the forward end of the alleyway, and from the external door at the aft end of the alleyway. The ventilation was shut down and boundary cooling was applied to the decks above and below the Second Engineer's cabin.

At 0432 the Master broadcast a Mayday message which was received and acknowledged by the Maritime Rescue Co-ordination Centre in Canberra.

After 1 hours the fire was extinguished, and the Mayday was cancelled. The fire had gutted the Second Engineer's cabin and caused extensive smoke damage to other areas on the same deck. Nobody had been injured during the incident.

The vessel anchored at Hay Point on 14 May before loading its cargo of 130,000 tonnes of coal for Praia Mole in Brazil.

Before the ship arrived at Hay Point, the cabin was completely cleaned out. This action, unfortunately, removed any evidence which would have assisted in determining the cause and origin of the fire. Nevertheless, the investigation revealed that in other cabins on the vessel there were electrical extensions, made up by crew members, to provide power from the scarce power points to televisions, VCRs and sound systems situated some distance from them.

Although the lack of available evidence prevented any conclusion being reached on the cause of the fire, an extension lead used in the Second Engineer's cabin, the construction of which would not meet Australian Standards, was suspected.

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.

The removal of the contents of the cabin, before the investigation started, prevented any definite conclusion being reached regarding either the point of origin or the cause of the fire.

With the lack of available evidence to indicate otherwise, the timing of the start of the fire and the Second Engineer's arising in the morning and leaving his cabin must be regarded as purely coincidental.

The fire took hold quickly and for this to have happened there must have been a supply of combustible materials near the source of the fire.

It is concluded that:

1. The port after corner of the Second Engineer's cabin appears to have had the most significant concentration of combustible materials together with the television, VCR, and sound system all connected to a power board on an extension lead at this point. On balance of probability, it is likely that the fire started in this area.
2. The extension lead used would not meet Australian Standards, being unearthed, having below minimum size conductors, having no sheath and the power board being poorly made of flammable, non-impact-resistant plastic. In addition, the power points in the vessel, of American two-pin type, are not switched and therefore appliances cannot be totally isolated from the supply without withdrawing the plugs. This left the extension and power board live at all times.
3. Although it cannot be stated conclusively, the most likely source of ignition would have been either a fault in the television set while in the 'stand by' condition or a short circuit in the power board of the extension lead.
4. There was no policy in place on the ship for checking temporary wiring in cabins, installed by members of the crew, to ensure that it was electrically safe. It is understood that, since the fire, this is being addressed.
5. On the evidence available it is unlikely that arson was the cause of the fire.
6. The response of the ship's crew to the fire was quick and, on the whole, effective. The fire was well contained by the fire-fighting operations although it would have been better contained had the cabin door been kept closed at the beginning of the incident, until fire hoses had been rigged in place and a water curtain was available.

Summary

The Panamanian flag refrigerated cargo vessel Peacock, on a ballast passage from Singapore to New Plymouth, New Zealand, embarked a licensed pilot off Goods Island at 1630 AEST on 17 July 1996 for the passage through the Torres Strait and the Inner Two Way Route of the Great Barrier Reef.

At about 0155 on 18 July 1996, the vessel grounded on Piper Reef at full speed, in a position 100 metres eastward of the light beacon. Initial attempts to refloat the vessel by going astern on the engine were unsuccessful.

Peacock remained stranded on Piper Reef until the late afternoon of 26 July 1996, when salvors successfully refloated the vessel after having transferred some of the fuel oil bunkers to a barge.

The vessel's hull was not breached, and no pollution occurred. However, machinery tests showed that only one steering motor was fully functional, therefore Peacock was towed to Cairns for necessary 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.

Peacock grounded on Piper Reef as a result of the vessel's course not being altered, from 175 to 149, as it approached from the north with the reef right ahead.

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

1. The Pilot's loss of situational awareness, the balance of probability being that he fell asleep.
2. The Pilot's sitting with his chin cupped in his left hand, making him more susceptible to falling sleep.
3. The warm, stuffiness of the wheelhouse atmosphere, in association with the sleep-inducing factors of time of day and background environmental noises.
4. Chronic fatigue as a result of the Pilot's recent work schedule, particularly the high proportion of nights of disrupted sleep.
5. The lack of a strategy on the part of the Pilot to counter the effects of foreseeable fatigue during periods of reduced activity.
6. The lack of proper bridge management and lack of interaction between the Pilot and the Watch Officer.
7. The lack of proper monitoring of the vessel's progress by the Watch Officer.
8. The attitude of the Watch Officer in assuming the Pilot was solely responsible for the navigation and his prolonged absence from the wheelhouse.
9. The absence of a formal control framework, to monitor a coastal pilot's nights of disrupted sleep, to prevent the development of chronic fatigue.

Summary

On 12 June 1996, the barquentine rigged STS Leeuwin was cruising in the Timor Sea. On board, in addition to the permanent and volunteer crew, were 31 trainees, mainly young unemployed persons, drawn from all over the Northern Territory and sponsored by the Commonwealth Employment Service.

Shortly after 0830, a team of three trainees, led by their Watch Leader, climbed aloft on the mainmast, to release the gaskets securing the main gaff topsail, so the sail could be set. The second of the three trainees, a woman in her late twenties, fell as she negotiated the futtock shrouds. Although she had clipped on her safety line, the free end of her safety belt slipped through the buckle, and she fell 18 m to the deck.

Fortunately, the fall was partially broken by the nock sail sheet. Even so, the trainee suffered severe multiple fractures to her knees and to her thighs, also a collapsed lung. A helicopter medivac was arranged to transfer her to the Royal Darwin Hospital, where she remained in intensive care for 16 days.

Conclusions

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

The trainee fell from the futtock shrouds because, although very frightened, she intentionally let go her hand hold in the belief she would be all right.

The main contributing factors to the trainee's fall to the deck are considered to be:

• The trainee had not fastened her safety belt properly, so that it came undone instead of preventing her from falling further.
• The absence of a safety check system, which meant that the trainee was able to climb aloft with an improperly fastened safety belt.
• The onboard philosophy and procedures that removed the safety barrier of safety belt checks before trainees ventured aloft.

Other factors that are considered to have contributed to the accident are:

• The onboard procedures that allowed a trainee to climb aloft for the first time on the mainmast.
• The absence of an onboard philosophy or procedure whereby a trainee with a slow learning capability is afforded supplementary attention.

It is also considered that the shiny surface of the well-worn, fine-weave webbing created difficulty in the tight fastening of the safety belt, which may have contributed to the trainee not fastening the belt correctly.

It is further considered that the trainee's death was averted only by her left arm hooking over the nock sail sheet.