Marine safety investigations & reports

Fatality on board Skandi Pacific, off the Pilbara coast, Western Australia on 14 July 2015

Investigation number:
Status: Completed
Investigation completed

Final Report

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What happened

In the early hours of 14 July 2015, the offshore support vessel (OSV) Skandi Pacific was loading cargo containers from the semi-submersible oil rig Atwood Osprey at its offshore location, about 90 miles north-west off Dampier. Shortly after 0505, cargo transfer was stopped due to worsening weather conditions. Skandi Pacific was moved 30 m away from the rig with the rough seas still on its port quarter. Two crewmembers then began securing cargo on the vessel’s aft deck.

While securing the cargo, the crewmembers slackened the securing chain they had used to secure the containers on the starboard side to better secure the entire stow. At about 0523, two large waves came over Skandi Pacific’s open stern, shifting the unsecured containers forward. One of the crewmembers was trapped between the moving containers, chains and a skip and suffered fatal crush injuries.

What the ATSB found

The ATSB investigation found that the risks associated with securing the cargo in the prevailing weather conditions on 14 July had not been adequately assessed. The fatally injured man was standing in a dangerous location near the unsecured cargo containers when they shifted.

The investigation identified that Skandi Pacific’s safety management system (SMS) procedures for working/securing cargo on deck in poor weather were inadequate with no clearly defined weather limits. Further, there were no clearly defined limits for excessive water on deck that necessitated stopping operations, leaving individuals to make difficult, and necessarily subjective, decisions about whether or not to stop work.

The ATSB also found that Skandi Pacific’s managers had not adequately assessed the inherent high risks associated with seas coming over the vessel’s open stern when work, including cargo handling operations, was being undertaken on its aft deck.

What's been done as a result

Proactive safety action by Skandi Pacific’s managers to avoid a similar accident includes improved cargo handling practices across its OSV fleet. Amongst these measures are updated procedures for working in adverse weather and cargo loading, including specific weather condition limits. In addition, existing risk assessments for offloading deck cargo at installations have been updated to include a section on risks associated with securing cargo.

The safety action taken by the vessel’s managers has adequately addressed the safety issues related to cargo handling/securing in adverse weather. The action taken has partially addressed the safety issue with regard to open stern vessels.

Therefore, the ATSB has issued a safety recommendation to the vessel’s managers to undertake further work to better address the risks associated with the use of vessels with open sterns. The ATSB has also issued a safety advisory notice to shipmasters, owners, and operators of OSV’s to highlight the risks posed by the open stern vessels to the industry more broadly.

Safety message

Offshore support vessel operations are inherently high risk because they often occur in exposed locations in a particularly dynamic environment. Multiple factors, including the weather conditions, schedule requirements, time of day, limited crew numbers, restrictions due to vessel design and systems, amongst others, add complexity to operations. Therefore, risk assessments are critical, with the weather and its impact on factors, such as an open stern, invariably a vital consideration.

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The occurrence


Safety analysis


Safety issues and actions

Sources and submissions

Safety Issues

Go to MO-2015-005-SI-01 - Go to MO-2015-005-SI-02 - Go to MO-2015-005-SI-03 -

Cargo handling procedures

Skandi Pacific’s safety management system (SMS) procedures for cargo handling in adverse weather conditions were inadequate. Clearly defined weather limits when cargo handling operations could be undertaken and trigger points for suspending operations were not defined, including limits for excessive water on deck.

Safety issue details
Issue number: MO-2015-005-SI-01
Who it affects: All owners and operators of offshore support vessels
Status: Adequately addressed

Cargo securing procedures

Skandi Pacific’s safety management system (SMS) procedures for cargo securing were inadequate. There was no guidance for methods of securing cargo in adverse weather conditions.

Safety issue details
Issue number: MO-2015-005-SI-02
Who it affects: All owners and operators of offshore support vessels
Status: Adequately addressed

Open stern offshore support vessels

Skandi Pacific’s managers had not adequately assessed the risks associated with working on the aft deck of vessels with open sterns, including consideration of engineering controls to minimise water being shipped on the aft deck.

Safety issue details
Issue number: MO-2015-005-SI-03
Who it affects: All owners and operators of offshore support vessels
Status: Partially addressed
General details
Date: 14 July 2015   Investigation status: Completed  
Time: 0525 WST (UTC +8)   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Northwest Shelf, 167 km north-west off Dampier    
State: Western Australia    
Release date: 23 November 2016   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Vessel details

Vessel details
Operator DOF Management  
Vessel Skandi Pacific  
Flag Bahamas  
IMO 9447653  
Sector Offshore industry  
Type of operation Securing cargo in adverse weather conditions  
Damage to vessel Nil  
Last update 14 November 2018