Oct 222010

image Discrepancies between procedures and shipboard practice may have contributed to the death of an integrated rating aboard the floating storage and offloading tanker Karratha Spirit while untying from a buoy off Dampier, Western Australia says Australia’s Transport Safety Bureau, AMSA. Concern is also raised that vagueness regarding precisely when such a vessel can be termed ‘navigable’ means that there are times when a vessel falls outside the jurisdictions of Australia’s National Offshore Petroleum Safety Authority and AMSA.

Says AMSA: “On 24 December 2008, the Australian registered floating storage and offloading (FSO) tanker, Karratha Spirit, was moored to a Catenary Anchor Leg Mooring buoy, CALM, at the Legendre Oil Field, about 60 miles2 north of Dampier, Western Australia.

imageAt about 18003, the master made the decision to disconnect from CALM buoy and
depart the oil field because of an approaching category four tropical cyclone. The master, chief mate and crew assembled on the ship’s forecastle deck and disconnected the oil import hose and started to fit a blank flange to the hose. At the
same time the master ordered the preventer lines, which stop the hose from drifting
under the mooring hawsers, to be let go.

The master then instructed the chief mate to go to the bridge while he remained on
the forecastle, controlling the operation, as he wanted to experience the operation
first hand from the forecastle. He then ordered the crew to release the mooring
quick release hooks and begin lowering the hawsers and chafe chains using their
pickup lines. However, before the hawsers could be lowered away from the ship,
the import hose drifted under them. At about 1945, the master ordered the main
engine to be run astern for about 1 minute to pull the import hose out from under
the mooring hawsers.


The astern movement resulted in the hose hoist wire, the hawsers and the hawser
pickup lines coming under tension. The hose was still suspended from the hoist
wire and the crew began to lower it using the winch motor. The pickup lines were
lowered away, the port side by releasing the winch brake and the starboard side
using the winch motor.

At about 1954, the hose hoist wire parted suddenly with a loud bang. The master
ordered the crew to, ‘Cut through and let go’.

The starboard pickup line reached its end first and an integrated rating (IR) climbed
under the winch drum, between the drum’s cheek plates, to cut the lashing which
was securing the end of the line to the drum. At about 1958, another IR on the port
winch applied the drum’s brake and stepped between the cheeks of the drum to cut
the lashing at the end of the port hawser pickup line. There were still about three
turns of pickup line, under tension, on the drum and the IR struggled to cut through
them with his knife. When the lashing parted, the pickup line rapidly unwound from
the drum, striking the IR on the head and throwing him under the winch drum and
into the base of a pedestal roller fairlead.

The seriously injured IR was moved to the ship’s hospital where the crew attempted
to resuscitate him. The master and the chief mate tried unsuccessfully to telephone
the emergency services ashore. The master then contacted the Dampier Port
Authority using the ship’s VHF radio requesting assistance and they, in turn,
telephoned the police. The Australian Rescue Coordination Centre (RCC), the
authority best placed to coordinate medical advice and a medical evacuation, was not contacted directly from the ship and the RCC was not informed of the accident
until 2050, almost 1 hour after it had occurred.

At about 2150, after numerous attempts to contact the ship using a satellite
telephone had failed, a doctor ashore was finally able to contact the ship. After
consulting the master, the doctor concluded that the injured IR was deceased and
advised the master that resuscitation attempts could stop.

The ATSB’s investigation identified five safety issues. The report acknowledges the
safety actions already taken by appropriate organisations and issues one
recommendation and one safety advisory notice to address the outstanding safety
• The ship’s procedures for connecting and disconnecting from the CALM buoy
did not provide explicit, succinct and unambiguous guidance and there were
differences between the procedures and the actual shipboard practices that
increased the level of risk associated with those operations. [Minor safety issue ]

• The procedures for connecting and disconnecting the import hose and
disconnecting from the CALM buoy in place on board Karratha Spirit were
signed off as being satisfactory and reflecting shipboard practice, but they had
not been effectively reviewed on board the ship. Consequently, the ambiguities
in the procedures and the discrepancies between the procedures and the ship’s
practices were not identified during any shipboard review or audit and were not
made known to the ship’s managers through any review process. [Minor safety

• The Job Hazard Analysis (JHA) for disconnecting from the CALM buoy did not
provide an accurate assessment of all of the hazards and associated risks in
performing the task. In addition, the crew did not use it to assess the risks
associated with undertaking an unfamiliar operation and it was reviewed without
any involvement from the crew. Consequently, the JHA was not an effective
means for assessing and controlling the risks associated with the operation of
disconnecting from the CALM buoy. [Minor safety issue ]

• The National Offshore Petroleum Safety Authority (NOPSA) does not undertake
the audits necessary for maritime compliance and the Australian Maritime
Safety Authority (AMSA) is only able to do so, while the facility is on station,
with NOPSA’s cooperation. NOPSA had carried out annual occupational health
and safety inspections on board the ship and AMSA had carried out the
necessary third party audits of the system to meet its certification requirements.
However, none of these audits or inspections had identified the discrepancy
between the mooring hawser procedures and actual shipboard practices or that
the ship’s internal review processes had not identified the discrepancy. [Minor
safety issue]

• In this instance, the consensus of the regulatory authorities is that Karratha
Spirit was not in a navigable form at the time of the accident and was therefore
under NOPSA’s jurisdiction according to the Offshore Petroleum and
Greenhouse Gas Storage Act (OPGGSA). However, the point at which Karratha
Spirit became ‘navigable’ is not clearly defined in the OPGGSA and is open to
interpretation. Consequently, during some operations, it is possible that the ship
would not come under the jurisdiction of any Australian safety regulatory
regime. [Significant safety issue]

Read the full report here.


  One Response to “Karratha Spirit Fatality: A Problem of Procedures”

  1. The ATSB report implies that the (injured) seaman cut the lashing holding the end of the hawser pick up line on his own initiative. In fact the master was on the focsle and was in charge of the disconnect operation. The master could see that the port hawser was under extreme tension and yet still ordered the seaman to cut the lashing. He could also see that there were still a few turns of the hawser on the drum. Surely this is a case where a master gives a seaman a direct order to perform a task, and as a result of carrying out this order the seaman is fatally injured.

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