Marine safety investigations & reports

Serious injury on board United Treasure off Port Kembla, New South Wales on 7 July 2009

Investigation number:
Status: Completed
Investigation completed


Download Final Report
[Download  PDF: 422KB]

On 7 July 2009, while United Treasure was anchored off Port Kembla, New South Wales, two seamen fell about 8 m in a cargo hold after the scaffolding on which they were working toppled over. Both men suffered compound fractures and were evacuated from the ship by helicopter and taken to hospital.

The ATSB investigation found that the scaffolding had not been properly assembled or secured to the ship's structure. The investigation also found that an appropriate risk assessment for the work had not been carried out and the relevant ship's procedures were not followed.

To avoid a further occurrence of this type on board their managed ships, United Treasure's managers have taken safety action by revising the relevant shipboard procedures. In addition, the ATSB has issued one safety advisory notice.

Download Final Report
[Download  PDF: 422KB]


To download, click the link, then right-click and select Save As.

Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations and should be credited accordingly.

Safety Issues

Go to MO-2009-005-SI-01 - Go to MO-2009-005-SI-02 -

Permit system

United Treasure’s permit to work aloft system had not been effectively implemented on board the ship. In addition, the standard form for the permit did not ensure that the officer in charge of the work and its authoriser were not the same person and that a risk assessment was formally undertaken by at least two responsible officers.

Safety issue details
Issue number: MO-2009-005-SI-01
Who it affects: All ship owners, operators, managers, masters and crews
Status: Adequately addressed

Tower assembly

The tower was not assembled as designed. The outriggers and intermediate planks, both key components, were missing and the work platform guard rails were not used. The manufacturer’s instructions were also missing but no attempt was made to obtain them, a parts list or the missing parts.

Safety issue details
Issue number: MO-2009-005-SI-02
Who it affects: All seafarers
Status: Adequately addressed
General details
Date: 07 July 2009   Investigation status: Completed  
Time: 1130   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Port Kembla anchorage    
State: New South Wales    
Release date: 17 November 2010   Occurrence category: Incident  
Report status: Final   Highest injury level: Serious  

Vessel details

Vessel details
Vessel United Treasure  
Flag Panama  
IMO 9286607  
Type of operation Bulk carrier  
Damage to vessel Nil  
Departure point Jingjang, China  
Departure time 8 June 2009, 1200 UTC  
Destination Port Kembla  
  Crew Passenger Ground Total
Serious: 2 0 0 2
Total: 2 0 0 2
Last update 14 November 2018