Hyundai Dangjin: Upsidedown Ladder Aided 2M’s Death

 Accident Investigation, Accident report, ATSB, Australia, falls, fatality, lifejacket  Comments Off on Hyundai Dangjin: Upsidedown Ladder Aided 2M’s Death
Jan 192016

Simple, straight-forward jobs often become dangerous ones when safety procedures are overlooked or inadequate. In the case of the ore-carrier Hyundai Dangjin a second mate died after falling into the water from a rope ladder while the vessel was alongside at at Port Walcott, Western Australia.

It was 4.50am and the chief mate and surveyor were on the wharf checking the draught marks. Unable to see the midships draught mark the chief called the second mate by radio and told him to check the mark on the outboard, port side where a rope ladder had already been rigged. Mates are trained to read draught marks.

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Jun 092014

wiresConcerns have arisen regarding the dangers of a hydraulic ram not being properly reset after use in Chinese-made JX-4 release mechanisms from Jiangsu Jiaoyan Marine Equipment Company after a freefall lifeboat launched during a maintenance inspection seriously injuring the occupant. Simulations wires which should have restrained the lifeboat and prevented the launch also failed below their safe working load and are being investigated.

The issue has come to light in a preliminary report by Australia’s Transport Safety Board on the inadvertent launch of a lifeboat from the gearedbulk carrier Aquarosa in March this year.

In Singapore, 5 days before the incident, the second engineer was involved with multiple checks of the lifeboat release hook operation. During these checks, he noticed that the hydraulic system was low on oil and he topped it up. He also noted that the activation of the hook release required between 10 and 15 operations of the hydraulic pump handle. Continue reading »

Don’t Blame Us For Blame Says ATSB Chief

 Accident Investigation, ATSB, Australia, maritime safety news  Comments Off on Don’t Blame Us For Blame Says ATSB Chief
Dec 262012
ATSB's Dolan: "...we are in the business of explaining what happened so we can minimise the chance of it happening again. In shorthand, we say we’re a ‘no blame’ organisation..."

ATSB’s Dolan: “…we are in the business of explaining what happened so we can minimise the chance of it happening again. In shorthand, we say we’re a ‘no blame’ organisation…”

“I’ve seen more headlines than  I’d like that start with the words ‘ATSB blames’. We don’t.” Says the Australian Transport Safety Bureau Chief Commissioner Martin Dolan in his latest blog. While he explains the actual no-blame position of the ATSB he opens the question of whether his, and other investigation agencies are doing enough education of the public and the media about what they actually do.

As we all know there are two flavours of accident investigation – those intended to uncover the root causes of an incident and the other basically aimed at hanging whoever can be blamed, usually the master.

As Dolan says: “This approach has major benefits for improving transport safety. Our acting consistently in accordance with the ‘no blame’ principle ensures people are willing to give us lots of sensitive information without fear that the information will be used against them. This helps us understand dimensions of an accident or incident that might otherwise be unknown to us.”

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Fire: BBC Baltic – Half-hearted Hot-Work Procedures

 Accident, Accident report, ATSB, Australia, fire  Comments Off on Fire: BBC Baltic – Half-hearted Hot-Work Procedures
Jul 202012

BBC Baltic burns

All too often there seems to be a disconnect between what procedures are supposed to achieve in terms of safety and the place of paperwork. So it was with a fire aboard BBC Baltic.

Procedures and permits are safety nets. When they become merely a paper exercise bad things happen.

At about 1605 on 26 January 2012, a fire broke out in the number one cargo hold of the general cargo ship BBC Baltic while it was discharging cargo in Port Hedland. At the time, workers from Cervan Marine, a local engineering company, were gas cutting in the cargo hold using an oxy-acetylene torch. The ship’s crew assisted by the local emergency services fought the fire and, by 1625, had extinguished it. There were no injuries as a result of the incident and damage to the ship and its cargo was not serious.

In carrying out the hot work on board BBC Baltic, neither the ship’s crew nor the Cervan Marine workers properly considered and mitigated the risk of fire. All the precautions listed on the ship’s hot work permit were not taken nor was the permit completed properly. Similarly, all the measures listed on Cervan Marine’s job safety analysis were not taken. Furthermore, a tool box meeting was not held to discuss the work and risk, define roles and responsibilities, and the action to take in case of a fire. 

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Universal Gloria Burn Injuries: 3O Didsn’t know His O2

 Accident, Accident report, ATSB, Australia, explosion, maritime safety news  Comments Off on Universal Gloria Burn Injuries: 3O Didsn’t know His O2
Apr 182012

Australia’s Transport Safety Bureau found that an injured third officer aboard the K-Line woodchip carrier Universal Gloria was so poorly trained that he was unaware of the difference between oxygen and air. The officer, on his first assignment as third, was badly burned when the air compressor he was using to fill a cylinder for an oxygen breathing apparatus, OBA, set, exploded.

During routine checks the third officer found that the pressure in one of the OBA cylinders in the fire locker was about 7 MPa, well below the normal 20 MPa, so he decided to remove the cylinder and take it to the steering compartment so he could use the compressor to re-fill it.

The third mate tried to screw the compressor discharge hose connector into the OBA cylinder, but it did not fit. He found an adaptor in the box next to the compressor that fitted both the OBA cylinder and the compressor discharge hose connector. He fitted the adaptor to the hose connector and then fitted it to the OBA cylinder.

The third mate checked all the connections and opened the OBA cylinder valve. Then, as he reached over the compressor to switch it on, the compressor discharge tube exploded. During this process, it is likely that the temperature of the oxygen-rich environment within the discharge hose and tube had dramatically increased due to adiabatic compression.

The heat of the oxygen rose beyond the auto-ignition temperature of the oil in the system, resulting in the explosion. The third officer was engulfed in a ball of flame. He jumped to his feet, regained his composure, and ran out of the steering compartment.

The AB reported the fire, which continued to burn on and around the compressor, to the bridge watchkeeper. He then went to the engine room to get a portable fire extinguisher. He quickly returned with an extinguisher and discharged its contents onto the fire, extinguishing it.

There are internationally recognised colour schemes used in industry so that high pressure cylinders containing different gases can be easily identified.

There are also a number of different types of engineering controls that prevent a high pressure cylinder from being connected to an incompatible system. An oxygen/acetylene welding set is an example where such engineering controls are used. The threads on the oxygen cylinder are right handed, whereas the threads on the acetylene cylinder are left handed. Therefore, the cylinders cannot be incorrectly connected to the welding set.

All ‘K’ Line ships were supplied with Kawasaki OBA sets and either Sabre or Kawasaki BA sets. The cylinders used in all these sets were colour coded. The BA cylinders were pale green in colour, signifying that they contained air and the OBA cylinders were black, indicating that they contained oxygen. The OBA cylinders were also labelled ‘oxygen’ (in Japanese only) and stamped with the molecular formula for oxygen ‘O2’.
The Sabre cylinders had a European standard threaded connection that was different to that of the Kawasaki air and oxygen cylinders. Therefore, the Kawasaki air and oxygen cylinders could not be connected to a Sabre BA set or an air compressor fitted with a European standard connection.
The Kawasaki cylinders were manufactured to conform to the Japanese standard for high pressure gas cylinder valves. However, the threaded connections on both types of Kawasaki cylinders were the same and there were no other engineering controls in place to prevent a Kawasaki oxygen cylinder from being connected to a Kawasaki BA set or an air compressor fitted with a Kawasaki type threaded connection.

Therefore, it was possible for a Kawasaki OBA cylinder to be inadvertently connected to an air compressor fitted with a Kawasaki type threaded connector.

The third mate did not understand that the pale green colour of the BA cylinders signified that they were filled with air, or that the compressor would re-fill them with air. Furthermore, he did not understand that air is a mixture of 78% nitrogen, 21% oxygen and other trace gases. In fact, he thought that oxygen and air were the same thing.

The ATSB investigation found that the explosion occurred as a result of a fire that started within the compressor when oil ignited in the hot oxygen-rich environment.

The investigation identified three safety issues. The crew were not appropriately trained or drilled in the operation and maintenance of the ship’s OBA sets; the ship’s safety management system did not provide the crew with appropriate guidance in relation to the operation and maintenance of the OBA sets; and there were no engineering controls in place to prevent the inadvertent connection of an OBA cylinder to the air compressor.

Fortunately, Universal Gloria had not suffered a serious fire: The ship’s fire fighting manual referred exclusively to fire fighting in the vehicle decks of a car carrier and, hence, was of little assistance to the crew on board a woodchip carrier.
ATSB Report

Mar 082012

At about 1918 on 28 March 2010, a stevedore was crushed between two containers during loading operations on board the container ship Vega Gotland, while it was berthed at the Patrick Terminals’ Port Botany terminal. The stevedore, who was the lashing team leader, died instantly from the injuries he received in the accident.

The ATSB investigation found that the lashing team leader had placed himself in a position of danger and that when a twistlock foundation unexpectedly failed during the repositioning of the container, he was unable to get clear of the swinging container.

The investigation also found that the failure of the twistlock foundation was brought about by an attempt to reposition the container and was consistent with its exposure to gross overstress conditions as a result of the leverage forces applied to it by the container and the unsecured hatch cover.

The investigation identified that while the dangers of working between a moving container and a fixed object were taught to Patrick Terminals’ new employees during their induction training, the issue was not specifically covered or reinforced in the company’s safe work instructions, the hazard identification and associated risk control processes nor, in some instances, followed in practice by stevedores on board the ships in the terminal. Continue reading »

ATSB Launches Investigation Into Tug Breakdown

 Accident, ATSB, Australia  Comments Off on ATSB Launches Investigation Into Tug Breakdown
Nov 092011

Australia’s Trasnsport Safet Board has launched an investigation into the breakdown of the tug Tuahine south of Fraser Island, Queensland, Australia.

The vessel’s crew activated the tug’s 406 mHz EPIRB, thus declaring an emergency, about 80 nm ENE of Cape Moreton after the tug’s steering failed and couldn’t be fixed. The crew of 3 were airlifted off to safety and a tug from Gladstone was sent to take it in tow.

On 1 November 2011, the ATSB commenced a safety investigation into the incident.

British Sapphire FRC: Interlock “Could not work as designed”

 Accident, Accident report, ATSB, Australia, Fast Rescue Boat/Craft, maritime safety news  Comments Off on British Sapphire FRC: Interlock “Could not work as designed”
Jul 262011

A fail safe interlock device should have prevented the drop

Incorrect electrical installation of a ‘fail-safe’ interlock and early activation of a wave compensator led to a fast rescue craft being dropped 18 metres while being deployed in an emergency, says Australia’s Transport Safety Bureau. The chief engineer, who was being medically evacuated, second mate and fourth engineer were injured in the incident on board the Isle of Man registered liquefied natural gas tanker British Sapphire.

ATSB says that that, in the process of lowering the rescue boat, the wave compensator mechanism on the fast rescue boat’s davit was activated early, before the rescue boat had reached the water. A fail safe interlock device should have prevented this by placing the wave compensator into standby mode, only becoming operational when the fast rescue boat was waterborne. However, the electrical installation of the interlock was incorrect and meant it could not work as designed, allowing the wave compensation unit to always operate and the fast rescue boat to make the uncontrolled descent to the sea.

The investigation identified safety issues relating to the commissioning, maintenance, testing, operating instructions and procedures for the fast rescue boat’s wave compensator and its safety interlock system. Further safety issues were identified relating to the job hazard analysis for the use of the fast rescue boat, crew resource management principles and approved training courses for fast rescue boats.

Tests were carried out on board the three sister ships, British Sapphire, British Emerald and British Ruby. with the wave compensator not working correctly on any of them. However, a crucial discovery was made when the engineers on board one of the ships noticed that the electrical drawings had been altered in red pen. As a result of this finding, BP Shipping asked Davit International to supply a set of ‘original’ electrical drawings. These drawings were then forwarded to the ships for further checking.

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Bulk Carrier Polska Walczaca Fatality: Work At Height + Confined Space

 Accident, Accident report, ATSB, Australia, confined space, enclosed space, falls, fatality, SafeSpace  Comments Off on Bulk Carrier Polska Walczaca Fatality: Work At Height + Confined Space
Jul 212011

Work at height remains work at height when it is carried out in a confined space, as a report into a fatality aboard the Vanuatu-registered bulk carrier Polska Walczaca from the Australian Transport Safety Board.  The fatality occured while the victim was intalling a repaired safety handrail on a platform 5 metres above the tank bottom of a cargo hold.

The victim did have a safety harness but was not wearing it, it was found on the platform from which he fell. He also appears not to have worn his hard hat properly, it was found without signs of impact damage some distance from the victim.

The two most obvious lessons are: wear a safety harness, wear a hardhat properly. However, there are other issues worth looking at.

The OS could only see as far as the second platform.

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