Summary

On the morning of 2 June 1994, the Australian Maritime Safety Authority navigational aids service vessel, Cape Grafton was anchored off Dent Island in the Whitsunday Group, Queensland. Cape Grafton, a diesel/electric powered vessel, had arrived in Australia in March, having been built and fitted out in Spain. The vessel was on its first operational deployment and was scheduled to carry out routine maintenance on Dent Island lighthouse.

At about 0740, Cape Grafton started to weigh anchor to move closer to the lighthouse and to make a lee for the work boat, which was used to convey men and materials to the land.

Anchor was weighed at 0752 and the Master manoeuvred towards the lighthouse turning to starboard, away from the island, before making the necessary lee. At about 0755 the vessel suffered a total loss of power for a few seconds, this 'blacked out' all means of propulsion and instrumentation for a critical period. Although electrical generating power was restored within a few seconds and machinery was restarted, control was not restored in time to prevent the vessel running aground, despite letting go the anchors.

The grounding was relatively minor in nature and Cape Grafton refloated without assistance on the afternoon tide. Nobody was injured and no pollution resulted from the grounding.

Such vessels are required to routinely operate close to the shore or navigational hazards, where commercial vessels would not normally navigate.

While the investigation established operational factors which contributed to this particular incident, significant defects in the ship's systems meant that the vessel was vulnerable to loss of control. Put simply, if the accident had not occurred on 2 June, there is a strong probability that it would have occurred at some time in the future due to incorrect control settings, the configuration of interfaces between the main units in the vessel's propulsion system and deficiencies in the supply of emergency power to essential navigational instruments, as they existed at the time.

The report outlines the background to the incident and considers the contributory factors.

Conclusions

These conclusions identify the different factors contributing 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 Inspector concludes:

1. The grounding of Cape Grafton was the chance coming together of a number of factors at a time when the vessel was close to shore in a vulnerable position and reaction time was limited.

2. There is little doubt that, had those on the bridge and in the engine room worked together properly, had the Master thoroughly understood the operation of the propulsion system and the steering, had the secondary systems and local controls available in an emergency been appreciated and had these been utilised, the grounding could have been prevented. This lack of operational knowledge, however, was compounded by significant systems defects and management deficiencies.

3. The investigation found a general lack of understanding, throughout the AMSA Ship Operations staff, of the operation of the ship's systems, control equipment and protective devices, in particular the interfaces between the various units comprising the propulsion system and its controls, the overload protection system, the engine room data-logger and printout, and the emergency generator and switchboard. This was due, in part, to the absence of any instructions or manuals explaining how the different components worked as a system or detailing the interconnections between each unit, the bridge and engine room control centres. This general lack of understanding, and the lack of any drawings of the overall propulsion machinery system, led to the commissioning of the Novamarine report on the functioning of these systems.

4. Both the absence of accurate 'as fitted' drawings and those defects that were factors in the grounding, together with problems experienced in wiring circuits and other systems not directly related to this report, call into question the quality control regimen followed by the various parties involved and the validity of quality assurance in the face of such defects.

It is further concluded that the following factors contributed directly to the grounding of the Cape Grafton:

1. The Master's lack of understanding of the propulsion system and the fact that he:

(a) did not take early action to stop the propulsion motors, or

(b) declutch the propeller shaft, or

(c) utilise the backup pitch and emergency steering controls.

2. The auto slow down system, intended to protect the generators on overload was defective:

(a) it was disconnected at the propeller pitch control central unit;

(b) there had been a failure to ensure that the system was reconnected after defective sensors had been replaced in Brisbane;

(c) it is possible that, even had these wires remained connected, the system would have failed as the overload trips were set too low and the time setting between the overload signal from the generators and the tripping of the generator circuit breaker was incorrectly set.

3. There was a loss of emergency electrical power to the navigational instruments, particularly the rudder angle and pitch indicators, through:

(a) the design of the emergency generator auto-start system, in that it was able to sense that a main generator was running, although the tie breaker between the main and emergency switchboards was open;

(b) the division of the emergency switchboard into essential and non-essential supplies and the supply of power to the bridge instrumentation, pitch control and one steering system, from the non-essential bus.

4. The wiring of the zero pitch interlock between the KaMeWa system and the propulsion motor starters was not properly connected and allowed the propulsion motors to be started with pitch on the propeller.

5. The lack of interlocks requiring the clutches to be disengaged before a propulsion motor could be started.

6. Defects in the management system leading to:

a) the installation of equipment that was not thoroughly tested in all respects;

b) the installation of systems not thoroughly understood by management or ship staff;

c) ineffective quality control during the installation of electrical and control systems;

d) the failure to undertake a suitable risk assessment for the new vessel, relating to its frequent operation close inshore in hazardous waters.

7. The failure of the ship's emergency generator and associated electrical circuits, to comply with Marine Orders Part 20.6.5.1 (d) (ii), in respect of the maintenance of a power supply to the shipborne navigational equipment, which includes indicators for rudder angle, pitch and the operational mode of the propeller.

8. The lack of clear, uniform operational instructions and procedures, common to bridge and engine room, for starting and operating the ship's propulsion and associated machinery.

9. The absence of any contingency planning for the passing of machinery control from the bridge to the engine room under emergency conditions or plans to utilise the backup pitch control and the emergency steering in the steering flat.

10. The absence of any structured training for the operation of Cape Grafton that would have provided an overall concept of the elements of the propulsion system and how they interfaced with each other.

Summary

On 3 March 1994, the Australian flag tanker Australian Achiever arrived off the floating production storage offloader Griffin Venture off the north-west coast of Western Australia and drifted, during the morning, while awaiting a pilot.

Before morning tea, the Extra Second Engineer showed the Engineer Cadet, the forward domestic fresh water pump and gave him instructions on how to remove the pump to the workshop for overhaul, a task that the Cadet was to undertake after the morning tea break. The Extra Second, in preparation for removal of the pump, ensured that the pump starter isolator and selector switches were in the "off'" position. As the Extra Second was quite clear in his mind that the job involved no electrical work, the fuses were not removed and no "danger" tag was attached to the starter.

During the morning tea break, the Fifth Engineer who was the duty engineer for the day, responded to an engine room alarm which indicated a fault on the vessel's 24 volt DC system, a common cause for alarms.

Shortly after the tea break, the Fifth Engineer again responded to an alarm which he took to be another 24 volt DC earth fault, but which cleared as soon as he "cancelled" the alarm. Later evidence showed that it had been an earth fault on the 440 volt system, in all probability caused by the Cadet having come into contact with a "live" terminal within the starter box for the forward fresh water pump.

At approximately 11 13, some 34 minutes later, the Third Engineer came across the Cadet lying on the deck between the fresh water pumps and the calorifiers. He was not breathing and no pulse could be detected. The door to the starter box for the forward fresh water pump was open and the isolating switch was in the "on" position. The vessel's emergency team was called and resuscitation techniques were applied but without success.

A helicopter, attending the Griffin Venture, was tasked to land on the deck of Australian Achiever and to airlift the Cadet to hospital at Exmouth. Resuscitation techniques were applied throughout the flight but, shortly after arrival, the Cadet was declared dead by hospital staff.

Conclusions

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

1. The findings of the Coroner's inquiry were that the Cadet died by electrocution following contact between his right hand and a live terminal within the starter box for the motor on the forward domestic fresh water pump.
2. The Cadet had been given the task of removing the forward fresh water pump for overhaul, a task which was well within his mechanical abilities. It is considered likely, although it cannot be stated with certainty, that he considered the fuses should be removed prior to commencing work and he was about to do this when he accidentally touched a live terminal with his hand.
3. In order to open the front cover of the starter box to gain access to the fuses, it is necessary to turn the isolating lever to the "off" position. It seems that the Cadet, having opened the front cover, must have turned the isolating switch back into the "on" position, possibly using the spring-steel clip on his key-ring to obtain sufficient leverage.
4. The reason for the Cadet having turned the isolating switch back to the "on" position is unclear. It may have been done during a momentary lapse in concentration or he may have been investigating the function of the interlock. The isolating switch is clearly marked showing the "on" and "off" positions of the small T-bar through the end of the spindle.
5. The alarm for channel 212, recorded on the alarm print-out at a time equivalent to 1039 (ship's time), indicating an earth on the vessel's 440 volt system, was probably initiated by the contact between the Cadet and some live part of the starter for the forward domestic fresh water pump.
6. The Fifth Engineer acknowledged the alarm four minutes later at 1043. As the alarm channel cleared as soon as the "cancel" button was pushed, he was uncertain as to which alarm had been activated and assumed that it was a repeat of the earlier alarm for an earth fault on the 24 volt DC system. The Inspector considers that, as the earth fault was shown as having cleared, there was not cause for further immediate action on the part of the Fifth Engineer.
7. It is not known with certainty whether the Cadet's hand contacted a point in the starter which was at 440 volts or at the control circuit voltage of 110 volts. It is likely, in view of the 440 volt earth alarm recorded at 1039, that it was at 440 volts. In either case, however, heat and humidity in the engine room cause considerable perspiration which would have increased the current flow through his body and, particularly in the case of 440 volts, could possibly have aided in the initiation of an electrical arc. It is not known, either, exactly how long he was in contact with the supply of current as the alarm print-out indicates only the time between the initiation of the earth fault and the time that the alarm was "cancelled" in the control room.
8. The procedures detailed in ASP Ship Management's "Safety and Emergency Procedures Manual", relating to machiney isolation, were not followed. The Extra Second Engineer stated that he had checked that both the selector switch and the isolator for the forward pump starter were in the "off" position. The job of removing the pump was not of an electrical nature and, for this reason, he had not carried out the usual precautions required before undertaking electrical work, such as removing the fuses and "tagging" the starter.
9. The reason for the Cadet having opened the door of the starter cannot be known but, in order to do so, the isolator switch had to have been turned to the "off' position. If, as is possible, he opened it to remove the fuses then under these circumstances, whether or not a safety tag had been attached to the equipment would have had no bearing on the outcome of the incident.
10. The Cadet was found lying on the deck shortly before 1113. No resuscitation techniques were applied before the Emergency Team arrived some minutes later. It was not known at that time that he was dead and, in the absence of a pulse or respiration, CPR should be applied immediately. It is acknowledged, however, that if the alarm at 1039 indicated the time he received the fatal shock, the outcome would have been no different.

Summary

On 19th April 1994 the New Zealand flag ro-ro vessel Union Rotoma was on passage from Nelson in New Zealand to Port Botany in NSW when, at 1835, alarms were sounded by the vessel's automatic fire detection system indicating a fire in the engine room. The duty engineer quickly reported that the aft end of the port main engine was on fire. The fire was spreading very rapidly and the decision was taken to evacuate the engine room and to flood it with the ship's fixed carbon dioxide extinguishing system. A "Mayday" message was transmitted by Inmarsat C and was acknowledged by the Maritime Rescue Coordination Centre in Canberra.

While the crew were shutting down the engine room, the bulk CO was released. The main engines had been stopped from the bridge. Shortly after the release, the running generator stopped, indicating that it had been stifled by the CO. Approximately one and a half hours after the release of CO, two engineers wearing breathing apparatus made an inspection of the engine room and reported that the fire had been extinguished and there were no remaining hot spots.

The engine room was purged of CO before a further inspection was made and the generators were started to restore full electrical power. The inspection revealed that oil, spraying from a fractured pipe on the starboard engine, had ignited on the hot exhaust manifolds of the port engine. The pipe, carrying lubricating oil to the engine's overspeed trip mechanism and to the camshaft bearings, had been fractured by the movement of the camshaft anchor bearing housing moving out of the entablature, into which it had been secured by eight 20mm diameter set bolts, all of which had sheared or worked loose.

Damage caused by the fire was slight, involving mainly instrumentation and wiring. The ship was able to proceed on its voyage to Port Botany using only the port main engine.

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 contributing to the accident and should not be read as apportioning blame or liability to any particular organisation or individual.

1. The fire in the engine room was caused by a spray of lubricating oil, from a fractured pipe on the starboard main engine, being ignited by the hot exhaust manifolds on the port engine.
2. The lubricating oil pipe was fractured when the housing for the camshaft anchor bearing worked its way out of the entablature, consequent upon the failure of the eight securing set bolts.
3. The set bolts which secured the bearing housing in the entablature had no form of locking and should have had cross-drilled heads and been laced with locking wire.
4. It was not possible to ascertain when the securing set bolts had been fitted, but it appears that they must have been fitted when the vessel was in the hands of previous owners. At the time that they were fitted, they were probably not pre-loaded to the required torque.
5. Engine vibration would have contributed to the failure of the bolts.
6. The response of the vessel's firefighting organisation was both fast and effective. This was due in large part to the fact that all officers and key personnel had personal UHF radios and excellent communications were maintained between all those involved throughout the incident.
7. Realistic fire drills carried out on a regular basis, incorporating such techniques as using radios while wearing breathing apparatus and scenarios such as engine room fires requiring C02 flooding, contributed to the efficiency with which the fire was extinguished.
8. No portable oxygen analysers were available on board with which to test the atmosphere in the engine room after it had been vented to clear the CO. Although not a statutory requirement, had one of these been available it would have minimised the risk to personnel when re-entering a space which had been flooded with CO.

Summary

In the early hours of 24 February 1994, the Norwegian flag (NIS) offshore anchor handling and supply vessel Boa Force was engaged in deploying anchors from the offshore construction barge, Support Station III, about half a mile south of Thevenard Island, 11 miles north-west of Onslow, Western Australia.

Anchor handling vessels do not navigate in the accepted meaning of the term but are directed to go in directions determined by the person controlling the operation on board the parent vessel, in this case, using a differential global positioning system and monitor.

In the immediate area of Boa Force's operation, there was a pipeline, marked at regular intervals with temporary buoys and an unmarked subsea wellhead, standing about 3m high in a general seabed depth of under 8m of water. The well itself was not active and had been capped and suspended for some time. To the west, and about 70m from the wellhead, a new pipeline had been laid, running from oil production platforms to Thevenard Island.

At about 0220 Western Australian Standard Time, Boa Force recovered the barge's number one anchor from close to the wellhead. Those on the barge were concerned with the proximity of the wire to the wellhead. Boa Force was ordered to go in a northerly direction to ensure that the wire was clear, before the barge recovered the wire prior to repositioning the anchor.

At about 0250, while moving stem first towards the barge, Boa Force hit the wellhead and holed the engine room space in the only area where the vessel did not have a double hull.

Despite efforts by the Chief Engineer, the Second Engineer and an Integrated Rating, the vessel's pumps could not keep up with the ingress of water. A launch was sent from the Support Station III to stand by Boa Force. A little before 0345, the Master ordered the crew to abandon Boa Force and by 0345 the complement of eleven were on board the launch.

The vessel sank to the seabed partially supported by the wellhead. A boom was deployed to combat any pollution.

An operation to raise and dispose of Boa Force was completed on 6 April. This involved lifting Boa Force clear of the wellhead, patching the breach in the hull, and recovering all oil and other pollutants. The vessel was then towed beyond the continental shelf and scuttled.

The incident occurred in Western Australian State waters, where shipping is administered by the Western Australian Department of Transport, and the general operation, connected with the petroleum industry, came under the provisions of legislation administered by the Western Australian Department of Minerals and Energy. Boa Force was a "declared vessel" under the provisions of the Navigation Act 1912 and its Australian Master and crew held Commonwealth qualifications. Therefore, in addition to the flag State, three Australian administrations had jurisdiction to investigate the incident (Commonwealth Department of Transport, Western Australian Department of Transport and the Western Australian Department of Minerals and Energy), however, by mutual agreement the authorities agreed to conduct a joint investigation in accordance with the provisions of the Navigation (Marine Casualty) Regulations.

Conclusions

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

The sinking of Boa Force was the result of a series of factors which combined to cause the vessel to make contact with Saladin No.3 wellhead.

These were:

1. The failure to temporarily mark the location of Saladin No.3 wellhead with an adequate buoy.

2. The failure to use adequate and accurate charts, or drawings, or plans to enable the anchor laying operation close to the south of Thevenard Island to be conducted in safety.

3. The provision of bathymetric data which was in error by about 1.6m.

4. The failure to supply a differential global positioning system monitor to Boa Force to provide the Master with a display of the operation upon which known hazards could be plotted.

5. The lack of appreciation on board Support Station III of the problems in manoeuvring an offshore anchor handling vessel in a relatively confined area for a prolonged period without an effective point of reference.

6. The failure of the job safety analysis to properly take into account the operational safety issues of an unmarked subsea well.

7. The lack of local marine knowledge and expert marine advice in the planning and operational stages to address the above issues.

8. The failure of the Master of Boa Force to check known depths on 20 February, following an apparent bottom contact, particularly as it was known that the vessel would have to operate in the same area to retrieve the anchor at a later time.

9. The possibility of fatigue, resulting from the operational program, cannot be ruled out.

Other Conclusions:

10. Boa Force met the requirements of the Navigation Act 1912 and subordinate regulations and orders. All certificates were valid.

11. The provision of plans and documents in the Norwegian language did not facilitate the effort by those on Boa Force to control the emergency.

12. The Master, Deck Officers and Engineer Officers should have considered trying to restrict the extent of the flooding by closing all doors and hatches, consistent with the safety of the engineers in the engine room. Any decision not to close doors should have been based on known effects of flooding of the vessel.

13. The damage stability characteristics of the vessel met the relevant criteria for an offshore supply vessel under the provisions of Marine Orders Part 46 and IMO Resolution A. 469(XII), but the criteria did not allow for penetration of the hull inboard of the line of the inner bulkheads of the side tanks.

Summary

On 14 February 1994, while Searoad Mersey was sailing from Grassy Harbour and making the turn around Grassy Island, fog obscured the leading marks which when in line indicate the centre line of the main channel. The Master continued his manoeuvre onto the correct course, but the ship made contact with the northern end of Omagh Reef.

Although the hull was penetrated in way of three ballast tanks, once the situation had been stabilised the ship was able to continue its voyage to Melbourne.

The Master had been appointed to the ship at short notice and had little experience of the port, where masters have to do their own pilotage. With the leading marks obscured, there were no other visual aids to indicate the ship's location with respect to the centre of the 150m wide channel.

Conclusions

It is considered that the contact with Omagh Reef was brought about by a combination of a number of factors, the most important being:

1. The obscuring by fog of the Grassy Harbour front and rear lead marks, these being the only visual aid to indicate a ship's position relative to the centre of she departure channel.

2. The Master's lack of experience of the port.

3. The Master's conservative use of propeller pitch, giving a reduced rate of turn, together with the delay in the commencement of the turn and wind drift due to the easterly wind, resulted in the turn being too wide.

It is further considered that:

4. The long period between the Master's familiarisation voyages and his appointment to the ship nullified the value of the familiarisation voyages.

5. A beacon located on the 4.2m sounding off Grassy Island would provide a point of reference, other than the leads, for making the tight turn around Grassy Island.

Summary

On the evening of 31 January 1994, the Port of Melbourne Authority's suction dredger A M Vella was operating at the eastern end of the South Channel, Port Phillip Bay. The cargo vessel Searoad Mersey, under the command of a "pilot exempt" master, entered Port Phillip Bay on its regular scheduled service. The vessel had received clearance to enter from Point Lonsdale Signal Station, which also advised of the A M Vella dredging operation.

The weather was fine, with good visibility, however, with the sun having set, the light was fading rapidly.

At 2150, while trying, to pass A M Vella "port to port", Searoad Mersey made contact with No. 15 beacon, on the south side of the channel, then at about 2151, collided with AM Vella, striking the dredger on its starboard side, immediately abaft the forecastle.

Both vessels sustained damage, but no-one was injured, and no pollution occurred as a result of the collision.

Conclusions

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

It is considered that the collision was brought about by a series of factors:

1 . In the first instance, the Master of Searoad Mersey did not ascertain the actual position of A M Vella in the channel.

2. Having acquired A M Vella as a target on the ARPA, the Master conducted Searoad Mersey on an assumption based on the initial information from the ARPA and did not properly monitor A M Vella's movements.

3. In endeavouring to maintain a "port to port" passing., the Master. kept the ship on the southern boundary of the channel with the result that it made contact with No. 15 beacon.

4. When Searoad Mersey made contact with No.15 beacon, the Master lost his orientation, overreacted and applied excessive helm.

It is further considered that:

5. There was no momentary failure of Searoad Mersey's steering gear.

6. The apparent alteration of course to port by A M Vella, observed by the Master of Searoad Mersey; was a momentary swing to port, under port helm, as the dredge head was raised from the seabed.

7. Early VHF contact between Searoad Mersey and A M Vella would have been prudent.

8. The advice contained in the Port of Melbourne Authority's three Notices to Mariners was explicit, however, a chart delineating the three areas to be dredged would have been beneficial.

9. Advice passed to vessels by Point Lonsdale Signal Station should provide full, definitive information regarding any operations or changes in navigational aids.

10. Where a master holds a pilotage exemption, it is of the utmost importance that the officer of the watch fully understands his responsibilities and fully monitors all that is going on.

Summary

On 19 January 1994, the Australian flag tanker Osco Star was loading a cargo of petroleum products at No.2 Jetty of the BP Refinery at Kwinana, near Fremantle, W.A.

At about 1420, aviation jet fuel (AVTUR) was being loaded into No.5 port and starboard wing tanks and nearing, the required finishing, ullage in both tanks when the duty mate in the cargo control room shut No.5 port wing tank filling valve. This action put the full loading rate, of about 1200 m /hour, into No.5 starboard tank and, shortly afterwards, cargo overflowed onto the deck from the pressure/vacuum release valve on No.5 starboard cargo tank.

Immediately, shore pumping was stopped, no.1 centre was opened as a "crash tank" and the manifold valves and all cargo tank filling valves were closed.

When the clean-up of the spilt oil was completed, soundings were taken of all cargo tanks. From these, it was established that the level in No.5 starboard tank was falling, while that in No.4 starboard was increasing - an indication that these two tanks were now common in some way.

The cargo in Nos.4 and 5 starboard tanks was pumped to other tanks in the ship and the two tanks were then cleaned and gas-freed prior to being inspected.

Inspection revealed that there was extensive damage to the structure between the two tanks caused by No.5 starboard tank having been hydraulically over-pressurised. The bulkhead had ruptured, leaving a hole of approximately 1 X 1.5 metres. Various other sections of the corrugated bulkhead were bulging, and a weld fracture was found in the aft bulkhead of No.5 starboard tank.

The vessel was eventually allowed to load its original cargo and to proceed to Sydney and thence Geelong, for temporary repairs.

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 contributing to the accident and should not be read as apportioning blame or liability to any particular organisation or individual.

1. The structural damage to the vessel was caused by hydraulic over-pressurisation of No.5 starboard wing cargo tank during the loading of a cargo of jet fuel. The facility for relief of pressure, i.e. a single "Press-Vac" pressure/ vacuum relief valve is not designed to be able to relieve excess pressure under these circumstances.

2. The over-pressurisation of No.5 starboard wing tank was caused by operational errors on the part of the duty deck officer, the Second Mate, in the Cargo Control Room. These were:

i) Loading at an excessive rate into a single wing, tank.

ii) Not opening, the filling valve to No. 1 centre cargo tank before closing off the filling, valve to No.5 port.

iii) Not switching the digital display readout to no.5 starboard tank immediately after shutting off No.5 port.

iv) A mathematical error in his calculations for "time to go" before topping-off No.5 wing tanks.

v) Not accepting an alarm displayed on the Autronica VDU.

3. The Second Mate was not fully aware of all aspects of the operation of the Autronica ullage monitoring system, in particular, the fact that "unaccented" alarms on the computer screen will inhibit the sounding of any further alarms which may be activated.

4. It is probable that the Second Mate's thought processes and concentration were affected to some degree by both fatigue and personal problems. This may account for his forgetting to open the filling valve to No.1 centre, forgetting to switch over the selector switch on the digital display to No.5 starboard tank after closing off the cargo filling to No.5 port, and his mathematical error when calculating the "time to go" before topping off the wing tanks.

5. Both the training, and experience of the Second Mate appear to the Inspector to be insufficient for the operation in which he was employed and the responsibility which he held at the time of the incident. This was due, in part, to the lack of opportunity for an effective induction into the ship's routines and systems, and in part to the lack of information, concerning the level of his experience, being, passed to the Master by ASP Ship Management.

6. The definition and literal meaning of the responsibilities of a "responsible officer" as detailed in Marine Orders Put 3, Seagoing Qualifications, indicate that it was not appropriate for the Second Mate to take responsibility for critical cargo-handling duties, such as the topping-off of cargo tanks.

7. The position of the cargo valve control console, the Autronica computer VDU screen and the tank digital display unit a-re such as to constitute a poor ergonomic layout for single person operation of the control room.

The aircraft was operating from an agricultural airstrip 600 ft above mean sea level, spreading superphosphate over moderately steep undulating terrain. The duration of each flight was 6-7 minutes. The accident flight was the seventh and probably intended to be the last for the day.

A witness, who was situated under the flight path, reported that the aircraft was tracking east-north-east in what appeared to be normal flight. Her attention was distracted for a few moments and when she next saw the aircraft it was in a near vertical dive with the upper surface of the wings facing her. The aircraft then struck the hillside and burst into flames.

Examination of the wreckage did not reveal any pre-existing defect which may have contributed to the accident. Impact marks on the propeller indicated that the engine was operating at impact.

The superphosphate load remained in the hopper and the emergency dump system actuating lever was in the closed position. Inspection indicated that the dump system was serviceable prior to impact.

Calculations indicated that at the time of the accident the aircraft, although heavily loaded, was operating within the flight manual maximum weight limitation.

A light north-easterly wind was observed at the airstrip. However, at the accident site, which was about 250 ft higher, the wind was a moderate west-north-westerly. Sky conditions were clear with a visibility of 30 km.

The aircraft probably experienced windshear and turbulence as it encountered a quartering tailwind approaching the ridgeline. The result would have been a reduction in climb performance, and it is likely that the pilot attempted to turn the aircraft away from the rising terrain. During the turn it appears that the aircraft stalled and that the pilot was unable to regain control before it struck the ground.

The reason the pilot did not dump the load when the climb performance was reduced could not be determined.

Significant factors

The following factors were determined to have contributed to the accident.

1. Shifting wind conditions conducive to windshear and turbulence were present in the area.

2. The aircraft was climbing at near to maximum allowable weight.

3. Control of the aircraft was lost with insufficient height available to effect a recovery.

Sequence of events

The pilot received an endorsement on the MU2 after completing 3.4 hours on the aircraft type with the operator's check-and-training pilot. The operator's policy was that before being cleared to operate as pilot in command on company MU2 aircraft, pilots were required to accumulate 150 hours in command under supervision (ICUS) on the aircraft type. Company records indicated the pilot had completed this flying.

On the evening of 19 December 1994 the company check-and-training pilot gave the pilot a 45-minute check flight. Following this flight the pilot went on a final route check flight with a senior company training captain, from Bankstown to Melbourne and back to Sydney. These three flights were all conducted in VH-IAM. No instrument landing system (ILS) approaches were undertaken on these flights. After the return to Sydney the pilot was assessed as suitable to act as pilot in command on company MU2 aircraft.

Early on the morning of 20 December 1994 the pilot flew VH-IAM from Sydney to Melbourne International airport on his first company flight as pilot in command. On the approach into Melbourne there were three octas of cloud at 600 ft, three octas at 1,000 ft and an ILS approach was required. After landing at 0410 ESuT he rested at a nearby motel. Following this rest period, the pilot spent the afternoon with a fellow pilot. The only problem he mentioned with VH-IAM was that it did not have a serviceable distance measuring equipment (DME) unit.

Early in the evening of 20 December 1994 a flight plan was submitted for an instrument flight rules (IFR) flight to Sydney, departing Melbourne at 1930, and from Sydney to Melbourne, departing Sydney at 2230. The aircraft did not depart Melbourne until 2215. The ILS for runway 34 left at Sydney was out of service. Due to cloud at 800 feet a runway 34 left VOR/DME approach was flown.

The runway 34 left VOR/DME approach involves a progressive descent to specific altitudes at specific DME distances, but VH-IAM did not have a serviceable DME. The controller offered to keep the pilot advised of the aircraft's distance by radar to facilitate the approach. This offer was accepted. During the approach, the aircraft was noted on radar to descend to 1,000 ft when it should still have been at 1,900 ft. The pilot was advised, and the aircraft was noted to climb back to 1,500 ft, still below the required 1,900 ft. The aircraft landed without any further problems.

The aircraft departed Sydney for Melbourne International airport at 0130 on 21 December 1994. En-route cruise was conducted at flight level 140. Melbourne Automatic Terminal Information Service (ATIS) indicated a cloud base of 200 feet for the aircraft's arrival and runway 27 with ILS approaches, was in use. Air Traffic Control advised the pilot of VH-UZB, another company MU2 that was also en-route from Sydney to Melbourne, and the pilot of VH-IAM while approaching the Melbourne area, that the cloud base was at the ILS minimum and that the previous two aircraft landed off their approaches.

VH-UZB was slightly ahead of VH-IAM and made a 27 ILS approach and landed. In response to an inquiry from the Tower controller the pilot of VH-UZB then advised that the visibility below the cloud base was 'not too bad'. This information was relayed by the Tower controller to the pilot of VH-IAM, who was also making a 27 ILS approach about five minutes after VH-UZB. The pilot acknowledged receipt of the information and was given a landing clearance at 0322. At 0324 the Approach controller contacted the Tower controller, who had been communicating with the aircraft on a different frequency and advised that the aircraft had faded from his radar screen.

Transmissions to VH-IAM remained unanswered and search-and-rescue procedures commenced. Nothing could be seen of the aircraft from the tower. A ground search was commenced but was hampered by the darkness and reduced visibility. The terrain to the east of runway 27 threshold, in Gellibrand Hill Park, was rough, undulating and timbered. At 0407 the wreckage was found by a police officer. Due to the darkness and poor visibility, the policeman could not accurately establish his position.  It took approximately another 15-20 minutes before a fire vehicle could reach the scene of the burning aircraft. The fire was then extinguished.

Wreckage examination

The aircraft had struck the ground on a descent path of about three degrees while banked about five degrees to the left. The ground impact position was about 150-200 metres to the right of the centreline for the 27 ILS approach. The track of the aircraft at the time of the accident was about 245 degrees. Examination of the badly fire-damaged wreckage did not produce evidence of any significant defects. At the time of ground contact the landing gear was extended and the flaps were in the 20-degree position.

The tuning units for the VHF radios and navigation receivers were badly fire damaged. However, it was established that the cockpit selector for the number one VHF navigation receiver was tuned to 109.3 MHz, the frequency for the runway 27 ILS and the number two VHF navigation receiver to 114.1 MHz, the frequency for Melbourne VOR. One glidepath receiver was fitted and although some impact damage was sustained in the accident, no evidence of any pre-existing defect was identified. Examination of the altimeters established that the pilot's was correctly adjusted to a QNH setting of 1008 hectopascals and the co-pilot's was set to 1013 hectopascals.

Weather data

The amended terminal area forecast for Melbourne, issued at 1929, included a prediction of 7 octas of stratus cloud, base 500 ft. The 0100 aerodrome weather report for Melbourne included an observation of 2 octas of stratus at 500 ft and 3 octas of stratus at 1,000 ft. The ATIS current at the time of arrival of VH-IAM, was runway 27, damp, wind light and variable, QNH 1008, temperature 17, 7 octas cloud, base 200 ft, drizzle, expect ILS approach. Flight conditions for the ILS approach were smooth. The Bureau of Meteorology estimated that the low stratus cloud layer extended up to an altitude of 4,500 ft.

ILS approach procedure

The published chart for this procedure showed that the approach commenced at an altitude of 3,000 ft at the Epping locator beacon which was 8.5 NM east of the runway threshold. The specified track was 263 degrees magnetic, and the glideslope angle was 3 degrees.  The outer marker beacon was at 3.8 NM from the runway threshold and the middle marker was 0.6 NM from the runway threshold. The pilot was required to keep the aircraft within two dots of the on glidepath and on track ILS indications to remain within specified tolerances. If the aircraft was on the glidepath at the outer marker the altitude would have been 1,645 ft.

As the aircraft gets closer to the runway the ILS localiser and glide path beams become progressively narrower, requiring increased flying accuracy to remain within limits. The minimum altitude for the approach was 610 ft and this altitude should have been reached at about the position of the middle marker. Provided that the high intensity runway and approach lights were on, the required flight visibility to continue the approach was 800 metres. If this minimum visibility did not exist, a missed approach was required. The missed approach procedure was to maintain a track of 263 degrees magnetic and climb to 4,000 ft.

The ILS chart also provides a table of DME distances against altitudes. This allows pilots to make progressive checks of altitude, independent of the ILS cockpit needle indications, to monitor the progress of the ILS. However, DME is not mandatory for the approach which can be satisfactorily completed by reference to the needle indications and by making altitude checks at the locator beacon, the outer marker and middle marker beacons. The elevation of the runway 27 threshold was 407 ft.

Radar data

A readout of the air traffic control radar data tape for the approach indicated that tracking, altitude, and speed anomalies had occurred during the approach.

Tracking

At 3 NM from the runway threshold the aircraft was about 440 metres left of the runway centreline. A heading alteration to the right of about 30-40 degrees was made and the aircraft passed through the centreline and went about 250-300 metres to the right. At the time of ground impact, the aircraft heading had again been altered, and the aircraft was closing on the centreline from the right.

Altitude

The aircraft had passed slightly north of the Epping locator beacon, which marks the start of the ILS final approach, at an altitude of about 2,800-2,900 ft. This altitude was maintained until 2 NM past Epping, when the aircraft was about 200 ft above the glidepath. The descent was then started and continued with the aircraft descending through the glideslope at about 5 NM from touchdown. The descent continued with displacement below the glidepath increasing. Between approximately 2 NM and 1.5 NM from touchdown the descent temporarily stopped at about the minimum altitude for the approach. (This minimum altitude was 610 ft but the radar data only reads out in increments of 100 ft.)  At this stage the aircraft was about 400-450 ft below the glidepath. Descent then recommenced, probably at an increased rate. The last altitude recorded was at approximately 400 ft in the vicinity of the accident site.

Speed

Radar data records calculations of ground speed.  From 10 NM into 6 NM the speed was about 145-150 knots. It then increased and at 5 NM peaked at about 170 knots. The speed then decreased to about 120 knots at 2.5 NM. It briefly increased to about 138 knots at 2 NM then decreased to 120 knots at the accident area. During the ILS approach the wind at 3,500 ft was estimated to be a south-easterly at 20 knots. This varied moderately to be a southerly at 7 knots at 1,000 ft. This indicated that the winds were mainly from abeam and that most of the ground speed fluctuations were probably associated with pilot handling.

Pilot/aircraft handling information

The pilot's logbook was not located after the accident. Most of his experience was on twin piston-engine aircraft such as the Cessna 310 and the Piper PA 31. He also had some time on Nomad aircraft. His last instrument rating renewal was carried out on a Cessna 310 aircraft. The renewal for conduct of an ILS or VOR approach was not covered on that flight but was completed separately in a synthetic trainer.

Advice on the aircraft handling characteristics was obtained from a pilot who was very experienced on the type. He indicated the MU2 was a faster, more difficult type to fly in comparison to general aviation twin piston-engine aircraft on which the accident pilot had gained most of his experience.  After inspecting the radar readout data, he said that VH-IAM was never stabilised on the ILS approach.

The MU2 is an aerodynamically clean and pressurised aircraft. This means that unlike piston engine types the pilot had flown, there would not have been the audible changes in wind noise associated with airspeed changes which provide clues to the changing situation. The experienced pilot consulted during the investigation indicated that with changes in airspeed and/or engine power it is very easy for the MU2 to quickly develop a rate of descent. This can only be detected by close monitoring of the cockpit instruments.

Medical/Fatigue

There was no medical evidence of any condition that might have contributed to the accident.

Specialist advice provided to the investigation indicated that persons involved in night shift work experience circadian disruption. This is because of the disruption of normal sleep and the quality of sleep gained. The main factor known to regulate the sleep/wake cycle is core body temperature. The best quality of sleep is gained when the core body temperature is at its lowest point, which usually happens between 0200 and 0600. As body temperature increases during the day, sleep quality and duration decreases.

Research shows that even where people are exposed to long periods of night shift the human circadian rhythm does not adjust. However, if the individual forms a routine of night shift that is consistent, they can partially compensate. Techniques to assist include the use of heavy drapes and air conditioning and buffering of outside noise.

The pilot was on the second night of night operations. Flying at night is a normal situation for pilots engaged in these type of freight operations. The pilot spent the afternoon before the accident with a pilot friend who had also flown the night before. The friend understood the pilot had slept through to 1300 after the previous night of flying and did not feel fatigued.

ANALYSIS

Because of the specialist advice that the effect of changing to night operations inevitably affects the quality of sleep achieved, it is likely that some fatigue effect existed.

No evidence was found to suggest any aircraft malfunction existed or contributed to the accident.

The cloud base being at the approach minimum altitude would have required the pilot to fly the aircraft to the minima in cloud, at night. Even so, the smooth conditions in the cloud should have made the flying task relatively easy. The knowledge that other aircraft had landed off an ILS approach may have given the pilot an expectation that he should also be able to land.

The evidence indicated that the pilot flew an erratic and unstable approach, in terms of airspeed, track, and glidepath maintenance. The safe operation of the aircraft on the approach required keeping it within specified limits for tracking and glidepath and not going below the permitted minimum. This was not done. The reason for descent below the glideslope and the minimum altitude at a late stage of the approach was not determined but was very likely unintentional.

The MU2 is a faster and more demanding type to fly compared to general aviation piston engine twin-engined aircraft on which the pilot had gained most of his experience. Anecdotal evidence suggests that to minimise costs, many pilots undertake the flight segment of their instrument rating renewal in relatively low-performance aircraft and complete the balance in a synthetic trainer. Therefore, a pilot may be endorsed and operate a high-performance aircraft in IMC yet not have practised instrument flying in that type of aircraft.

Civil Aviation Regulations 5.81 and 5.108 require non-instrument rated private and commercial pilots to undertake Biennial Flight Reviews. The Biennial Flight Review must be conducted in an aircraft type in which the pilot flew the greatest number of hours as pilot in command during the 10 flights before the review.

The Bureau believes that a similar criterion should apply to instrument-rated pilots. It would be appropriate for flight segments of instrument rating renewals to be conducted on a complex, high-performance aircraft, representative of the types that the pilot wishes to operate.

Considering the length of the pilot's ICUS training on the MU2, the approach into Sydney and the accident approach indicated a deficiency with his instrument flying skills. The company training system had not detected this situation, but the specific reasons for this were not determined.

SIGNIFICANT FACTORS

1. The company's training system did not detect deficiencies in the pilot's instrument flying skills.
2. The cloud base was low at the time of the accident and dark night conditions prevailed.
3. The pilot persisted with an unstabilised approach.
4. The pilot descended, probably inadvertently, below the approach minimum altitude.
5. The pilot may have been suffering from fatigue.

SAFETY ACTION

As a result of the investigation, the Bureau issued Safety Advisory Notice 960032 to the Civil Aviation Safety Authority on 02 September 1996.

"SAN 960032

"CAO 40.2.1 lays down the requirements when synthetic trainers are used for instrument rating renewals. This allows for the instrument rating renewal to be undertaken on a category B synthetic trainer except for the renewal of one aid which shall be conducted in flight. However, the CAO does not stipulate the type of aircraft that must be used. The renewal therefore can be carried out on a relatively low-performance aircraft.

"The Civil Aviation Safety Authority should note the safety deficiency identified in this report."

The following response was received from the Civil Aviation Safety Authority on 19 November 1996.

"I refer to your Safety Advisory Notice SAN 960032 concerning the accident involving Mitsubishi MU2B-30, VH-IAM during an instrument approach at Essendon, Victoria on 21 December 1994. The following comments are forwarded for your consideration.

"It can only be speculated that the accident occurred due to the pilot's lack of currency on type. The accident could equally have been caused by distraction, fatigue, or the like. It is current CASA policy that the multi-engine command instrument rating is a generic rating for multi-engine aeroplanes. Given that there are several thousand command instrument rating tests undertaken each year there does not appear to be an accident trend to suggest that the associated flight test provisions are deficient.

"The desirability, or otherwise, of reviewing Civil Aviation Order 40.2.1 will be raised as an issue under the Regulatory Framework Review program. The Personnel Licensing Technical Committee will be responsible for this issue. The suggestion to align flight test aircraft requirements with similar provisions that exist for flight reviews has merit and will be referred to this committee.

"We shall keep BASI appraised of the outcomes of this, and other committee deliberations."

The helicopter had been hired to spray noxious weeds on steep, hilly terrain and had sprayed several local properties in the two days prior to the accident.  On the day of the accident, the pilot began his preparations at 0410 local time but did not begin spraying until 1030 because of fog in the treatment areas.  He then sprayed three sites before arriving at about midday over the property where the accident occurred.

The pilot conducted an aerial inspection before commencing to spray a very steep rocky area at the northern end of the property.  He systematically flew about ten short spray runs north of the powerline then crossed to the southern side of the powerline and flew two spray runs over a small paddock. Ground witnesses then observed the helicopter flying north at about 100 ft towards a previously treated area. They became very concerned that it was flying towards the powerline at about the same height as the wires.  One witness used hand signals in an attempt to prompt the pilot to climb but the aircraft struck the powerline. It pitched steeply nose-down and began breaking up before impacting the ground, inverted, about 70 m beyond the powerline, then rolled 15 m before coming to rest. There was no fire.

At the time of the accident, the temperature was about 24 degrees Celsius, there was a light breeze but no cloud or turbulence, and visibility was at least 20 km.

The wreckage was subsequently examined by engineers.  Evidence was found in the engine compressor and the combustion chamber to confirm that power was still being produced at ground impact.  No pre-existing faults were found with the aircraft which may have contributed to the accident.

Wire strike marks on the helicopter showed that it first contacted the powerline with the forward right fuselage at about cabin floor level.  Two wires then slid down the chin and snagged on the right spray boom which then separated from the aircraft.  The helicopter pitched nose down so severely that the tail boom, along with much of the airframe directly above the engine, was severed by the main rotor blades, one of which detached from the aircraft.

The helicopter carried fuel sufficient for the flight and was within its approved centre of gravity and gross weight limits at the time of the accident.

The pilot was endorsed on the Hughes 396HS helicopter and held an Agricultural Rating Class 2.  His total agricultural flying experience was 1079 hours. He had been provided with detailed maps of the treatment areas.

The pilot was seen wearing a crash helmet minutes before the accident, but it came off during the accident sequence. Damage to the seat belt inertia reel housing was consistent with the pilot wearing the full harness at ground impact.

The helicopter was equipped with a survival beacon which did not transmit a distress signal because it had not been either armed or switched on by the pilot.

The powerlines did not carry markers on the wires. Treatment areas were either side of the powerline and not far apart so the pilot should have been aware of the powerline even though it traversed the valley with a span of 478 metres between poles. However, due to poor contrast between the powerline and the terrain, the pilot probably found it difficult to detect the two wires in time to avoid them. It could not be determined if the pilot applied an appropriate method of identifying the position of the wires from the air before he began spraying.

VH-YEA was not fitted with a wire-strike protection system (WSPS).  The Hughes 500 may be fitted with a WSPS as an optional extra. A standard helicopter WSPS includes one wire-cutter fitted forward on the roof of the cabin and a second cutter forward on the belly, plus devices to guide the wires into the cutters.  VH-YEA was fitted with a Simplex agricultural spray kit which included a belly tank, pressure pump and boom.  When fitted, this particular model Simplex tank protruded so far forward that there was not enough available space for a lower wire-cutter to be installed on the fuselage.  Other helicopter spray tanks are available which, when installed, allow space for both cutters to be fitted.

Had an approved WSPS been fitted to VH-YEA, the lower cutter would probably have severed both wires and the helicopter may have received minor wire-strike damage.

Significant Factors

The following factors were considered relevant to the development of the accident:

1. the powerline was probably difficult to detect due to a lack of contrast with the background terrain; and
2. the helicopter was not fitted with wire-strike protection equipment.

Safety Action

Helicopters are not specifically designed for agricultural work, unlike most modern agricultural aeroplanes which come with re-enforced cabin and wire deflectors/cutters. Helicopters have been adapted for agricultural operations and have approved spray kits or spreaders attached. However, most helicopters used for agricultural operations do not have added crashworthiness built into their cockpits; nor do they have WSPS fitted.

WSPS have been developed and approved for several helicopter types, mostly as a result of low-level military roles. However, rescue operators, fire bombers, medical retrieval helicopters and particularly agricultural helicopters are often in the low-level environment where powerlines exist.

Analysis of Bureau records indicate that, wire-strikes account for about 9% of helicopter accidents in Australia. Since 1984 there have been 73 reported occurrences of wire strikes by helicopters. Of these approximately 50% may have benefited by having an approved WSPS fitted, including 12 occurrences that resulted in fatalities. It is probable that had a WSPS been fitted to this helicopter, the accident would not have occurred.

Recommendation R950120

The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority:

1. require the fitment of approved wire-strike protection system kits for all helicopters engaged in low flying activities for which a kit exists; and,
2. that only agricultural spray kits compatible with wire-strike protection systems be approved for fitment to these helicopters.