Marine safety investigations & reports

Fatality in the elevator trunk on board OOCL Kuala Lumpur, 8.5 nautical miles south-east of Port Botany, New South Wales, on 3 June 2018

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

On 3 June 2018, OOCL Kuala Lumpur’s electro-technical officer (ETO) was testing the ship’s personnel elevator after completing mechanical repairs. While driving the elevator from the cage top, the ETO became trapped between the moving cage and the bulkhead, and was fatally injured.

What the ATSB found

The ATSB investigation found that the ETO was last seen alone, on top of the elevator cage, in the prescribed safe zone with the elevator control in ‘MANUAL’. The exact circumstances explaining how and why the ETO then came to be trapped while the elevator moved between floors could not be determined. For the accident to have occurred, however, the ETO had to have moved from the safe zone, the elevator control had to have been changed from ‘MANUAL’ to ‘AUTO’ and the elevator called.

The investigation also found that safety barriers prescribed in the electrical work permit were not put in place before the work commenced. All ship’s crew were not warned against using the elevator as there had been no warning announcement and there were no warning signs posted at all elevator access doors. This allowed an elevator call to be made while the work was underway. Aspects of the supervision and communications throughout the task were ineffective, which meant that opportunities to stop or alter the method of work were missed.

What's been done as a result

Following this accident the ship’s management company instigated an education programme throughout the company and fleet which addressed its safe work practices, permit to work system, risk assessment, and elevator maintenance. The company safety management system was also amended to more clearly define and detail elevator maintenance responsibilities, processes and procedures.

Elevator maintenance and risk identification training has been provided to all shipboard and shore‑based technical staff. This training will be ongoing and required prior to joining a ship equipped with an elevator. In addition to this, all fleet elevators have been assessed to ensure they meet current elevator cage top control station standards for functions and access. A process for modification, if necessary, has also been implemented.

Safety message

Elevator accidents continue to occur around the world and result in about one fatality per year. Many of these accidents involved the failure to apply existing safety management procedures and/or identified safety barriers that have proven effective in reducing the risks associated with elevator maintenance. These include procedures related to communications, supervision and machinery isolation/lockout. Furthermore, the injured person was often working alone and riding the elevator cage. For any task that is performed on multiple occasions without any adverse consequence, there is the potential for an individual’s perception of risk (or expectancy of a problem) to decrease. This makes it all the more important to always follow documented procedures and safe working practices, even when the operation is considered safe.

It is imperative that close and careful supervision is maintained for any elevator testing and tasks. Supervisory oversight provides an opportunity for experienced, senior technical staff to scrutinise and assess the plans and intentions of those completing the task. This provides an external check and safety barrier before, and during, the work.

Download final report
[Download  PDF: 1.42MB]

The occurrence


Safety analysis


Safety actions

Additional details

Sources and submissions


General details
Date: 03 June 2018   Investigation status: Completed  
Time: 0930 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): 8.5 nautical miles south-east of Port Botany   Investigation phase: Final report: Dissemination  
State: New South Wales    
Release date: 03 June 2020   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Vessel details

Vessel details
Operator Synergy Marine, Singapore  
Vessel OOCL Kuala Lumpur  
Flag Singapore  
IMO 9367176  
Sector Container  
Type of operation Fully cellular container ship  
Damage to vessel Minor  
Departure point Fremantle, Western Australia  
Destination Sydney, New South Wales  
Last update 20 July 2020