Marine safety investigations & reports

Independent investigation into the serious crew member injury on board the Panamanian registered bulk carrier Universal Gloria, at sea off Eden, NSW on 11 October 2011

Investigation number:
288-MO-2011-007
Status: Completed
Investigation completed

Summary

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At about 1450 on 11 October 2011, the third mate on board the Panama registered woodchip carrier Universal Gloria suffered burns to his hands and face when the air compressor he was using to fill an oxygen breathing apparatus (OBA set) cylinder exploded.

The ATSB investigation found that the explosion occurred as a result of a fire that started within the compressor when oil ignited in the hot oxygen-rich environment.

The investigation identified three safety issues. The crew were not appropriately trained or drilled in the operation and maintenance of the ship's OBA sets; the ship's safety management system did not provide the crew with appropriate guidance in relation to the operation and maintenance of the OBA sets; and there were no engineering controls in place to prevent the inadvertent connection of an OBA cylinder to the air compressor.

 

Download Final Report
[Download  PDF: 502KB]
 
 
Alternate: [Download  DOC: 2.96MB]
 

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Safety Issues

Go to MO-2011-007-SI-01 - Go to MO-2011-007-SI-02 - Go to MO-2011-007-SI-03 -

Oxygen breathing apparatus training

The ship’s crew were not appropriately trained or drilled in the operation and maintenance of the oxygen breathing apparatus.

Safety issue details
Issue number: MO-2011-007-SI-01
Who it affects: All ship owners, operators, managers and seafarers
Status: Partially addressed

Oxygen breathing apparatus documentation

The ship’s safety management system documentation provided the crew with no guidance in relation to the operation and maintenance of the ship’s oxygen breathing apparatus.

Safety issue details
Issue number: MO-2011-007-SI-02
Who it affects: All ship owners, operators, managers and seafarers
Status: Not addressed

Cylinder design

The threaded connections on the Kawasaki air breathing apparatus and oxygen breathing apparatus cylinders were the same and there were no other engineering controls to prevent an oxygen cylinder from being connected to the air compressor.

Safety issue details
Issue number: MO-2011-007-SI-03
Who it affects: All seafarers
Status: Partially addressed
General details
Date: 11 October 2011   Investigation status: Completed  
Time: 1450 (UTC+11)   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): at sea off Eden    
State: New South Wales    
Release date: 05 April 2012    
Report status: Final   Occurrence category: Serious Incident  
  Highest injury level: Serious  

Vessel details

Vessel details
Vessel Universal Gloria  
Flag Panama  
IMO 9286877  
Type of operation Bulk carrier  
Damage to vessel Nil  
Departure point Iwakuni, Japan  
Destination Eden, NSW  
Last update 14 November 2018