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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Jul 292014

lifejacketgasAn autoinflating lifejacket that doesn’t auto-inflate when needed can ruin your whole day. It might be a good idea to check that the gas cylindre on yours is properly screwed in, says MarineSafe Australia Forum

On 7 June, 2014 a worker fell about four metres from the lower landing of an
offshore platform into the sea. He was retrieved from the water without delay by
the crew on a support transfer vessel and transferred to the site clinic for medical treatment.

The  Type 1 Inflatable Personal Flotation Device, PFD. the worker was wearing did not automatically inflate on contact with water despite being equipped with this capability. Inspection of the PFD after the incident identified that the gas canister was not fully screwed into the inflation tube fitting. Continue reading »

Jul 032014

wisdomFire drills ensure  that officers and crew know how to fight a fire efficiently, at least in an ideal world. In the case of the bulk log carrier Taokas the reality was that shipboard fire drills were of little value when a real fire occurred in the accommodation.

Australia’s Transport Accident Investigation Commission was unable to determine how the fire started in an AB’s cabin on 11 July 2013 because the crew had started cleaning it after the blaze was extinguished. True, the crew did extinguish the fire after 25 minutes but showed that some basic firefighting knowledge was lacking.

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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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Oct 152012

Graph depicting number of groundings prior to, and after, the introduction of REEFVTS.

Australia’s Maritime Safety Authority, AMSA, has issued a new video on the Great Barrier Reef and Torres Strait Vesel Traffic Service, REEFVTS,  available for viewing on the AMSA website. Several high-profile groundings have led to installation of VTS and new procedures for the environmentally-critical area.

Located in Townsville, REEFVTS is a joint initiative of Maritime Safety Queensland (MSQ) and AMSA. It is one of the largest coastal vessel traffic services in the world, monitoring from Cape York to Sandy Cape.

The Great Barrier Reef is recognised all over the world for both its stunning beauty and its environmental diversity. That’s why the International Maritime Organization declared the Great Barrier Reef and Torres Strait particularly sensitive sea areas. This means extra care needs to be taken to safeguard the reef from the potential impacts of shipping. Continue reading »

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.