International

Summary

On 12 July 1997, the Indian flag bulk carrier Dakshineshwar was on a loaded, northbound passage through the inner route of the Great Barrier Reef, from Hay Point to the east coast of India with a cargo of coal. A licensed Reef Pilot was in charge of the navigation.

At about 2100, the vessel passed between Alert Patches and OG Rock at the eastern end of the Prince of Wales Channel, Torres Strait, and settled on a course of about 270. The ship's speed over the previous hour had been 12 knots.

At about 2111, the vessel was abeam of Ince Point and the Pilot saw that the Global Positioning System display showed a speed of 10.5 knots. About three minutes later the Pilot, who had moved to the port bridge wing, heard an alarm or some alerting device ringing on the bridge, and he went to investigate. As he got close to the centre line, he glanced at the helm indicator and engine room tachometer. The helm indicator showed that full starboard rudder had been applied and the tachometer showed zero revolutions. The ship's head had been paying off to port and the rate of turn increased rapidly as the ship closed with Wednesday Island to the western side of Ince Point.

The ship's speed had slowed to about 6.5 knots when the engine was restarted. The Pilot had to make a quick decision and decided to maintain full starboard rudder and ordered emergency full ahead revolutions to maximise the rate of turn to starboard. The ship reached a heading of 172, before starting to turn to starboard. At about 2120, Dakshineshwar grounded in position 10 30.4 degrees South 142 17.9 degrees East, with Ince Point Light bearing 100 x 0.85 of a mile.

Conclusions

These conclusions identify the different factors contributing to the incident and should not be read as apportioning blame or liability to any particular organisation or individual. The following factors are considered to have contributed to the grounding:

1. The engine failure which occurred sometime after 2100.
2. Too rapid shut-down of the freshwater generator.
3. The practice of manually adjusting the set point on the jacket cooling water temperature controller.
4. The lack of understanding and knowledge of the proper operation of automated systems and specifically the engine temperature control system by all the engineers.
5. The lack of sufficiently experienced engineers in the engine room while preparing for stand-by.
6. Poor or deficient operational procedures in the MCR.
7. Deficient communications between the bridge and engine room and the failure to use the most basic communication system, the bridge telegraph. It is further considered that.
8. The Pilot had to make an immediate decision and took the best action under the circumstances.
9. The assumption made by the 3rd Mate that the problem was not the engine but the steering, and any confusion that caused, occurred at such a time that his actions did not alter the outcome.

The crew were operating a de Havilland Canada DHC-6 Twin Otter aircraft in Exercise Highland Pursuit 2/97. The purpose of the exercise, which was conducted by No. 173 Surveillance Squadron, 1st Aviation Regiment, Australian Army, was to provide tropical mountainous flying training in Papua New Guinea. There were three trainees and one training pilot on board the aircraft.

On Sunday, 9 November 1997, the third day of flying operations in Papua New Guinea, the crew were conducting a flight from Madang and return via a number of airstrips in the central highlands. When haze and cloud prevented them flying the flight-planned direct track between the Koinambe and Simbai airstrips, they decided to fly north-west via the Jimi River valley and one of its tributaries. Two of the trainees were occupying the cockpit seats, one as flying pilot and the other as navigating pilot using a 1:1,000,000-scale chart. When the crew turned the aircraft to follow a tributary off the Jimi River, the training pilot was in the aircraft cabin.

A few minutes later, their discussion regarding the progress of the flight attracted the attention of the training pilot. By this time, however, the position of the aircraft in the valley, and its available performance, were such that an escape from the valley was not possible. The aircraft collided with trees before impacting steeply sloping ground.

It was subsequently established that when the crew turned from the Jimi River, they entered the wrong valley. Calculations based on the manufacturer's performance data showed that the aircraft did not have sufficient performance to outclimb the increase in terrain elevation from the Jimi River valley to cross the Bismarck Ranges via this valley. There was a low level of experience and corporate knowledge within the Army regarding the operations of fixed-wing aircraft such as the Twin Otter in tropical mountainous areas.

Against this background, deficiencies were identified in the planning and preparation for the exercise, including risk assessment and the selection and briefing of the training pilot.

Local safety action

As a result of their investigation into the occurrence, Aeronautical Radio of Thailand Ltd has proposed to:

1. Issue a local instruction to prevent controllers approving climb and descent for aircraft operating in the area adjacent to the FIR boundary, or in those areas where crews of aircraft conduct frequency changes.
2. Issue a local instruction requiring the inclusion of the KATKI position on flight progress strips for all aircraft using the intersecting routes.
3. Amend the aeronautical charts to have KATKI annotated as a compulsory reporting point for routes G463 and B219.
4. Review all route intersections in the FIR similar to the KATKI position and amend existing procedures if required.
5. Review the procedural control facilities, including the provision of adequate flight progress strip bays, and the capability for continuous control frequency monitoring by the procedural controller.

Summary

At approximately 1600 hours on 8 August 1996, the Indonesian cargo vessel Niaga 46, arrived at Christmas Island, about 4.5 miles to the Northwest of Flying Fish Cove. The ship was due to berth at 0600 the following morning to load 7,600 tonnes of rock phosphate.

Christmas Island is "steep to" and ships do not anchor but drift while waiting to berth. Niaga 46 hove to in position with North West Point bearing 270 x 2.5 miles, to drift overnight. Sea watches were maintained and the engine was on ten minutes notice of readiness. The wind was blowing from a southerly direction at 17 knots and the anticipated current was west going at about 2 knots.

By 2132, the vessel had drifted west towards North West Point and the Third Mate decided to reposition the ship. At 2323, the vessel was repositioned about 2.5 miles due east of North West Point.

At midnight, the Second Mate had not arrived on the bridge, so the Third Mate handed over the watch to the 12-4 apprentice and left the bridge at about 0005. The Second Mate arrived on the bridge at about 0010 and switched on the starboard radar to check the ship's position. The radar showed Niaga 46 as being close to the land east of North West Point. He rang the duty engineer and requested use of the engine. The engine was ready at 0039, however, before the Second Mate could manoeuvre clear of the land the ship grounded at 0047 about 6 cables east of North West Point.

At 0605, contact was made with the Harbour Master, Christmas Island, and he boarded the ship a little after 0700 on 9 August. The Harbour Master took charge of the refloating operation and, after a number of unsuccessful attempts, the vessel was refloated at 2300 on 9 August.

The vessel suffered extensive damage and was taken in tow to a repair port in Indonesia.

Conclusions

These conclusions identify the different factors contributing to grounding of Niaga 46 and should not be read as apportioning liability or blame to any particular individual or organisation.

It is probable that when the Third Mate left the bridge, Niaga 46 was still making way through the water as a result of the prolonged use of the engine at full harbour speed while repositioning the ship between 2132 and 2323. This, combined with the following factors, contributed to the grounding:

1. The Third Mate absenting himself from the bridge before the Second Mate arrived to take up his watch.
2. The hand over of the watch at midnight to the apprentice, was inappropriate, not thorough and did not reflect the true status of the ship in relation to the status of the navigation equipment and the proximity of the land.
3. A complete lack of acceptable watchkeeping standards and an absence of basic seamanship practices.
4. A lack of any realistic assessment by the Master or deck officers of the risks involved while drifting off Christmas Island, together with the lack of planning and determination of sensible safety margins.
5. A lack of clear direction and control over the conduct of the watchkeeping officers by the Company and Master.
6. Poor general management of the ship, and its operation.

Summary

On 12 June 1996, the barquentine rigged STS Leeuwin was cruising in the Timor Sea. On board, in addition to the permanent and volunteer crew, were 31 trainees, mainly young unemployed persons, drawn from all over the Northern Territory and sponsored by the Commonwealth Employment Service.

Shortly after 0830, a team of three trainees, led by their Watch Leader, climbed aloft on the mainmast, to release the gaskets securing the main gaff topsail, so the sail could be set. The second of the three trainees, a woman in her late twenties, fell as she negotiated the futtock shrouds. Although she had clipped on her safety line, the free end of her safety belt slipped through the buckle, and she fell 18 m to the deck.

Fortunately, the fall was partially broken by the nock sail sheet. Even so, the trainee suffered severe multiple fractures to her knees and to her thighs, also a collapsed lung. A helicopter medivac was arranged to transfer her to the Royal Darwin Hospital, where she remained in intensive care for 16 days.

Conclusions

These conclusions identify the factors contributing to the incident and should not be taken as apportioning either blame or liability.

The trainee fell from the futtock shrouds because, although very frightened, she intentionally let go her hand hold in the belief she would be all right.

The main contributing factors to the trainee's fall to the deck are considered to be:

• The trainee had not fastened her safety belt properly, so that it came undone instead of preventing her from falling further.
• The absence of a safety check system, which meant that the trainee was able to climb aloft with an improperly fastened safety belt.
• The onboard philosophy and procedures that removed the safety barrier of safety belt checks before trainees ventured aloft.

Other factors that are considered to have contributed to the accident are:

• The onboard procedures that allowed a trainee to climb aloft for the first time on the mainmast.
• The absence of an onboard philosophy or procedure whereby a trainee with a slow learning capability is afforded supplementary attention.

It is also considered that the shiny surface of the well-worn, fine-weave webbing created difficulty in the tight fastening of the safety belt, which may have contributed to the trainee not fastening the belt correctly.

It is further considered that the trainee's death was averted only by her left arm hooking over the nock sail sheet.

Summary

The South Korean bulk ore carrier Daeyang Honey sailed from Koolan Island, Western Australia on 14 October 1992, with a crew of 28. The ship was loaded with a full cargo of about 122,300 tonnes of low-grade iron ore, bound for the Japanese port of Mizushima.

In the afternoon of 22 October, a signal from a float-free emergency position indicator radio beacon (EPIRB) was detected by the search and-rescue polar orbiting satellite system (COSPAS-SARSAT), about 300 miles east of the Philippine Islands, close to the area of the typhoon Colleen. The EPIRB was identified as coming from the Daeyang Honey.

An initial air search by the United States authorities based on the Island of Guam was hindered by bad weather associated with the typhoon. On 25 October, in better flying conditions, a life raft was located and ships in the area were requested to search for survivors and wreckage.

On 26 October the life raft was relocated and a little later the EPIRB, surrounded by debris, was also sighted. The motor vessel Azalea Everett was diverted to the position of the EPIRB, where debris and the beacon were found, but no survivors. At about the same time, the motor vessel Bum Ju located the life raft and positively identified it as belonging to the Daeyang Honey.

The Daeyang Honey had loaded iron ore on a number of occasions at the Australian ports of Dampier and Port Hedland.

Conclusions

1. Nothing occurred at Koolan Island that contributed to the loss of the vessel.
2. The cargo loaded contained no characteristic that would have involved an increased risk over the normal ore shipped from Koolan Island.
3. The failure to supply the master with a written loading declaration had no bearing on the loss of the ship. The information on Koolan Island iron ore, contained in such a declaration, would not have altered or modified the loading of the cargo.
4. The Daeyang Honey encountered a severe tropical storm (typhoon) during 21 and 22 October. It would seem that the ship foundered from whatever cause in the early afternoon of 22 October 1992. The storm must be considered to have significantly contributed to the loss.

Summary

The Australian registered tanker Australian Achiever, of 127,575 tonnes summer deadweight, cleared the New Zealand port of Whangarei for the port of Brisbane at 2030 on 7 November 1992. The ship had part discharged and retained on board about 35,000 tonnes of crude oil.

At 2230, the exhaust gas uptake high temperature alarm sounded, and the temperature reading was seen to be 10 degrees Celsius above the alarm setting. The engine was slowed to reduce the temperature and the waste heat unit was inspected for hot spots. None were found and the engine speed was increased at 2345.

At 0115 on 8 November, when about 11 miles from the nearest land, the exhaust gas alarm sounded again, and the main engine revolutions were reduced. A further inspection of the waste-heat unit revealed a small area glowing red at the forward, inboard corner. The main engine was stopped, and the crew were alerted.

The fire within the waste-heat unit could not be fought directly and the main firefighting effort concentrated on boundary cooling. After fire burnt a hole through the casing, several portable C02. extinguishers were discharged into the unit through the hole, without effect.

The ship's engineers initiated the proper established procedures and stopped the engine. Although the weather was favourable and the current tended to take the ship offshore, given the proximity of the land and the nature of the cargo, the Master requested that a tug be made available to tow the vessel back to Whangarei.

The fire in the waste-heat unit had reached such an intensity that areas of the generating section's steel tube banks, and a small section of the steel casing reached fusion temperature with resulting meltdown of the materials.

At daybreak, the crew prepared for the tow by hanging off the starboard anchor and ranging the anchor cable. A tug arrived at 0955 and the tow was connected at 1132. By 2100, the ship had been brought safely to harbour and it subsequently anchored in Bream Bay.

The fire was contained throughout 8 November and into 9 November by boundary cooling. It was extinguished by 1515 on 9 November, but it was considered prudent not to open up the unit until the area had cooled further. in all the fire burnt for some 39 hours.

Officers of New Zealand's Ministry of Transport, Maritime Transport Division, were appointed by the Inspector to undertake an initial investigation on behalf of the Australian Department of Transport and Communications.

Conclusions

1 The fire occurred as a result of a combination of factors:

(a) The washing process failed to remove all soot deposits

(b) The dampers isolating the tube banks from the mainstream of exhaust gas did not dose properly, allowing hot low velocity gas to ignite the soot deposit

(c) The lack of water circulating in the generating section may have contributed to the loss of the tubes, as there was no water to carry away the surface heat generated by the soot fire on the external surfaces of the tubes.

2 The original decision to isolate the waste-heat unit tube banks and run with the economiser dry was reasonable and not open to criticism.

3 Design problems related to cleaning of waste-heat units have been known for some years, nevertheless, the unit had operated without a fire since about 1984. The importance of regular washing was well understood by the ship's staff and there was accepted criteria, based on inlet and exit exhaust gas temperatures. governing the necessity of washing the unit. But temperature differential would not indicate the presence of isolated areas of soot compaction.

4 There is no evidence that the failure to wash the unit at Ras Tanura resulted in excessive soot deposits. The only evidence is that sufficient soot remained or had compacted in one area after washing at Whagarei to cause a soot fire. However, the strong possibility that more soot than normal had accumulated cannot be discounted.

5 Neither the maker's nor the owner's/operator's instructions reflected the reality of cleaning the waste-heat unit under operational conditions, but this deficiency is not considered to have contributed to the cause of the fire.

6 The actions taken by the Master to alert the New Zealand authorities and to place tug assistance on stand-by was timely and correct.

7 The actions taken by the Chief Engineer and the engine room staff in stopping the engine and blocking associated apertures was correct and in accordance with the makers instructions.

8 The firefighting operation was efficient and effective, reflecting credit on the organisation of all the ship staff involved.

9 The Master's decision to pump the ship's bilges direct to the sea was a proper decision given the circumstances and priorities relating to Australian Achiever at that time.

Summary

While engaged in seismic operations in Tayabas Bay, Luzon the Philippines, the Australian registered research vessel Rig Seismic grounded on an uncharted reef. The vessel was refloated without assistance. No pollution occurred and the vessel suffered only minor damage.

Conclusions

It is considered that:

1. The reef in which the Rig Seismic grounded was uncharted.
2. The Assistant Manager, Ships Operations and the ship's Master made every reasonable effort to collect available information and to familiarise themselves with the operational areas.
3. The Master's use the African Queen 11 to sound ahead of the Rig Seismic was a sound precautionary measure.
4. The African Queen 11 did not locate the reef on which the Rig Seismic grounded due to its different turn track.
5. The actions of all personnel after the grounding were all carried out in a professional and timely manner.
6. Although the Master, due to his prolonged periods on the bridge, would have been tired to some extent, fatigue is not considered a contributing factor to the grounding.

Summary

In the early hours of 30 November 1991, while on a positioning voyage from Singapore to Cebu City in the Philippines, the Australian registered fishing vessel Northern L caught fire. The six crew were unable to fight the fire and abandoned the vessel in approximate position latitude 8 degrees 03 minutes North, longitude 118 degrees 34 minutes East, taking with them an emergency radio and the vessel's 406mHz emergency position indicator radio beacon (EPIRB). At about 0500 explosions were heard coming from the vessel, which sank shortly after.

At sunrise the crew took stock of their surroundings and activated the vessel's EPIRB.

At about 0830, the Australian Marine Rescue Coordination Centre received a distress alert from the United States MRCC, Washington that a distress beacon belonging to the Australian registered fishing boat had been detected in position 8 degrees 02 minutes North 118 degrees 33 minutes East.

These details were passed to Westpac MRCC in Japan, and Manila MRCC in the Philippines.

At 1130 (UTC+8) the Liberian registered tanker Nagasaki Spirit, en route from Dulang, Malaysia, to Santan, Indonesia, was requested by Westpac MRCC to proceed to a position 08 degrees 03.3 minutes North and 118 degrees 34.3 minutes East to investigate the EPIRB signal. At 1245 the Nagasaki Spirit sighted an orange canopy and by 1340 the six survivors had been taken on board the tanker.

The master of the Northern L (a Philippine national), the mate (an Indian national) and the two engineers (both Indonesian nationals) were landed in Santan. The two Australian crew remained with the Nagasaki Spirit until the ship arrived off Brisbane on 14 December.

Conclusions

1. The circumstances described and without evidence to the contrary it is concluded that the loss of the vessel was due to fire and the unrestricted flooding of the engine-room and the adjacent spaces below the main deck.
2. It is concluded that the fire originated in the engine-room. It is not possible to determine with certainty the cause of the fire or the reason for the sinking. However, the most likely cause may be attributed to the escape of diesel oil from a fractured fuel line spraying on to a hot machinery surface, igniting the oil and causing intense heat in the confined spaces of the engine-room. Fuel from the bunker fed the fire.
3. The outbreak of fire occurred while the engine-room was unattended. Had the person on watch been in the engine-room the fire would have been detected at an early stage and therefore it is probable that it could have been controlled and extinguished.
4. The supply of air to the fire and the fire's rapid unrestrained spread were the direct result of the engine-room not being isolated from the spaces either side of it or above it. It was accepted practice on board to operate with all doors, watertight or not, open.
5. Access to the remote controls to the engine-room fuel supply, the vessel's ventilation units and the engine-room CO2 fire smothering system was cut off by the fire, due to the engine-room not being secured and the access to the engine-room at frame 51 being open.
6. It is not possible to determine the source or sources of the explosions reported by the survivors. It is possible that the explosions were as a result of the rupturing of pressure vessels and/or the fuel in the tanks being heated to a level whereby the oil's flash point was reached.
7. Whatever the level of proficiency of the master and crew, the absence of any water on the fire main, compounded by the inability to secure any breathing apparatus, rendered the crew totally unable to fight the fire. Evacuation of the vessel to await the outcome of the fire was their only option.
8. The quality of the operational procedures and standards practised (or not practised) aboard the Northern L created the conditions in which accidents were more likely to occur, and where emergencies were more likely to get out of hand.
9. The position of the controls for the remote shutting down of the fuel supply from engine-room fuel tanks and the release of the engine-room CO2 fire smothering system were in accordance with the relevant legislation, notwithstanding that on this occasion access to them was cut off by the fire. However, their position within the enclosed main deck was not an optimum position, given the construction of the upper deck at conversion.
10. If the engine-room door at frame 51 had been removed, or was left open as a standard practice, the remote stops for ventilation and engine-room pumps were positioned contrary to the regulations.
11. The controls for the watertight doors were not above the bulkhead deck, as required by the regulations.
12. The diesel gas oil shipped in Singapore was within the declared specifications.
13. The liaison in 1989, between the Department of Transport and Communications, and subsequently the Australian Maritime Safety Authority, and the American Bureau of Shipping was deficient in ensuring that the converted vessel met the letter or spirit of the Australian regulations in respect of fire control and subdivision.

Summary

The Melete sailed from Dampier, Western Australia on 11 August 1991 with 27 persons on board, bound for Port Talbot, Wales with a cargo of 68902 tonnes of iron ore fines.

At 0358Z 24 August the Australian Maritime Safety Authority's Maritime Rescue Coordination Centre in Canberra received a distress call via the Inmarsat A Indian Ocean satellite from the Melete in position 27 41'S 054 13'E. The distress message said that the Melete was in danger of sinking with 27 crew on board. The MRCC advised the Melete to activate their EPERB, shortly after which all contact with the Melete was lost.

Search and rescue operations were coordinated by Marine La Reunion. Aircraft and other ships arriving at the last known position of Melete reported sighting oil slicks and flotsam.

Two crew members of Melete were rescued. Continued searches failed to locate other survivors.

Conclusions

It is considered that:

1. The cargo as presented for loading was in accordance with the Code of Safe Practice for Solid Bulk Cargoes.
2. The cargo loading sequence was in accordance with the Master's instructions.
3. The loading rates were comparable with those normally carried out at the Parker Point berth and not excessive.
4. The pour quantities stipulated by the Master, as percentages of deadweight, were typical of current loading practices. However, this is a subject that requires to be investigated thoroughly.
5. There is no evidence in Australia to indicate that any structural damage may have occurred due to contact with other vessels or the berth whilst Melete was at Dampier.