Safety issue

Safety issue description

While the risk of aluminium ingot stacks toppling over had been identified by the stevedoring company as a result of past incidents, its procedure for loading aluminium products had not evolved to adequately address this risk. Furthermore, the implementation of basic precautions such as using ladders to climb between ingot tiers was not effectively monitored or enforced.
Issue number MO-2012-010-SI-02
Issue owner Newcastle Stevedores
Transport function Shore operations
Date issue released 04/06/2013
Issue status justification Safety action taken is adequate and reduces risk to minor.

Safety action

Action type Proactive action
Action number MO-2012-010-NSA-007
Organisation Newcastle Stevedores
Action date 04/06/2013
Action description

Newcastle Stevedores advised the ATSB of a number of actions that it has taken to address the safety issue, which in summary are:

  • Immediately after the accident, the risks involved in loading ingots were re-assessed and control measures to address the risk of an ingot lift toppling were identified and documented. The measures primarily comprised establishing a 3 m exclusion zone adjacent to a lift.
  • The procedure for loading ingots was revised to describe the risk and control measures, including exclusion zones and the use of a ladder when climbing between tiers.
  • Enforcement of exclusion zones and the pre-requisites for zone entry (permitted only after securing the ingot lift with strap slings, ratcheted back to prevent toppling, in accordance with a specific, new procedure).
  • Increased monitoring of loading operations by the company staff and a number of updates to the revised loading procedure.
  • An independent review of company procedures and committing to an ongoing review of its policies and procedures in consulatation with the Maritime Union of Australia and the company’s occupational health and safety representatives.
  • Retraining of senior grade stevedores in hazard identification and assessment.
  • Audits and independent testing of ingot strapping and developing a process for rejecting substandard lifts.
  • Recommending improved lift configurations to Patrick Ports and Stevedoring (Patrick).

As of 1 March 2013, Patrick took over the stevedoring for Gearbulk ships in Newcastle. The company advised the ATSB that it has implemented risk control measures to address the risk of ingot stacks toppling over through a job safety analysis, and provided its stevedores with training in applying these measures. The measures are equivalent to those implemented by Newcastle Stevedores after the accident and include establishing exclusion zones and enforcing zone entry conditions.
ATSB response

The ATSB is satisfied the action taken adequately addresses the safety issue.
Action status Closed

Safety action

Action type Safety advisory notice
Action number MO-2012-010-SAN-010
Organisation All stevedoring companies
Action date 04/06/2013
Action description

The Australian Transport Safety Bureau advises that all stevedoring companies should consider the risk of aluminium ingot stacks and similar break-bulk cargoes toppling over during handling.
Action status Closed