Marine safety investigations & reports

Fall from height and serious injuries to crewmembers on board Shanghai Spirit near Port Alma, Queensland, on 29 January 2017

Investigation number:
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

During the afternoon of 29 January 2017, the deck crewmembers of Shanghai Spirit were conducting painting and routine touch-up work in the cargo holds. They used a mobile scaffold tower to access areas of bulkhead about 6 to 9 m above the hold bottom. Two crewmembers conducted the work from the upper tiers of the scaffold tower and remained unsecured on it when it was moved.

To access the full length of the hold bulkhead, the work required repositioning the scaffold tower on multiple occasions. After the work on the aft bulkhead was completed, it was decided to paint the hopper tank edge. As the scaffold tower was moved with the unsecured crewmembers, it became unbalanced and toppled forward onto the deck.

The two crewmembers on the scaffold tower were seriously injured in the fall and were evacuated to a hospital ashore for treatment.

What the ATSB found

The ATSB found that, contrary to established procedures, two crewmembers remained on the unsecured scaffold tower in preparation for repositioning, rendering it top-heavy and unstable. Consequently, when moved it toppled and fell. Additionally, neither crewmember on the scaffold tower utilised the required safety harness and associated safety lines which would have prevented them falling when climbing or working on the tower.

Finally, the afternoon work in hold number four was not supervised by an officer as required by company procedure and in contrast to the morning activity. The absence of formal supervision, in combination with a desire to expedite the task in difficult working conditions, probably led to the crewmembers remaining unsecured on the scaffolding as it was repositioned.

What's been done as a result

The scaffolding equipment operating instructions and maintenance manuals/guidelines have been included in the company’s safety management system. Further, there is now a requirement for monthly and quarterly inspection of the equipment.

The use of scaffolding is now specifically classed as ‘working at heights’ and is therefore subject to all planning and precautionary measures such as risk assessment, working aloft permits and precautions.

Personnel Protective Equipment training and awareness has been reviewed and enhanced. Additionally, new crewmembers will be subject to pre-joining training that now includes the use of scaffolding.

Safety message

This accident highlights the importance of adhering to procedures that assure safety as well as the value of effective supervision. Owners, operators and crewmembers are reminded to plan and undertake risk assessments for assigned tasks in order to identify any shortcomings in procedures and required risk-mitigation measures.

Download final report
[Download  PDF: 1.4MB]

The occurrence


Safety analysis


Safety issues and actions

Ship details

Sources and submissions

Safety Issue

Go to MO-2017-001-SI-01 -

Inadequate on-board documentation

Guidelines for the provision, care and use of shipboard equipment were not supported by suitable documentation. The only documentation was for mobile scaffolding equipment of different design and not for that in use on the ship.

Safety issue details
Issue number: MO-2017-001-SI-01
Who it affects: All owners and operators and crewmembers involved in working aloft
Status: Adequately addressed
General details
Date: 29 January 2017   Investigation status: Completed  
Time: 1410 AEST (AEST = UTC +10)   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): 28km NE of Port Alma   Investigation phase: Final report: Dissemination  
State: Queensland    
Release date: 21 February 2019   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: Serious  

Vessel details

Vessel details
Operator Asia Maritime Pacific  
Vessel Shanghai Spirit  
Flag Hong Kong  
IMO 9326328  
Sector Bulk carrier  
Type of operation Cargo  
Damage to vessel Nil  
Departure point Subic Bay, Phillippines  
Destination Port Alma, Queensland, Australia  
Last update 03 April 2020