Department of Transport and Regional Services

Australian Transport Safety Bureau

Navigation Act 1912Navigation (Marine Casualty) Regulations

investigation into the serious injury to a crew member on board the Bahamas flag bulk carrier

CSL Pacificat sea, south of Portland Victoria

on 18 February 2002

Report No 175

January 2003

ISSN 1447-087XISBN 1 877071 24 2

Investigations into marine casualties occurring within the Commonwealth's jurisdiction are conductedunder the provisions of the Navigation (Marine Casualty) Regulations, made pursuant to subsections425 (1) (ea) and 425 (1AAA) of the Navigation Act 1912. The Regulations provide discretionarypowers to the Inspector to investigate incidents as defined by the Regulations. Where an investigationis undertaken, the Inspector must submit a report to the Executive Director of the Australian TransportSafety Bureau (ATSB).

It is ATSB policy to publish such reports in full as an educational tool to increase awareness of thecauses of marine incidents so as to improve safety at sea and enhance the protection of the marineenvironment.

To increase the value of the safety material presented in this report, readers are encouraged to copy orreprint the material, in part or in whole, for further distribution, but should acknowledge the source.Additional copies of the report can be downloaded from the Bureau’s website www.atsb.gov.au

Australian Transport Safety BureauPO Box 967Civic Square ACT 2608 AUSTRALIA

Phone: 02 6274 64781800 621 372

Fax: 02 6274 6699E-mail: marine@atsb.gov.au

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Contents

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Sources of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

CSL Pacific . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Ship history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Self unloading system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

The incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Comment and analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

The incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Shipboard safety management system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Isolation procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Works committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

The hand-over of management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Audits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

The mate’s hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

The deck mechanic’s hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Fatigue analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Submissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

CSL Pacific . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Figures1. CSL Pacific alongside in Melbourne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v

2. Inside number 1 cargo control room showing bucket circuit breaker and the control panel . . . . .4

3. Longitudinal and transverse reclaimers in hold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

4. Two views of the top of number one bucket elevator, and one view inside . . . . . . . . . . . . . . . . . .6

5. CSL Pacific: Events and causal factors chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

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SummaryAt 1800 on Sunday 17 February 2002, the bulkcarrier CSL Pacific sailed from Melbourne afterdischarging a cargo of furnace slag. The shipwas bound for Adelaide to load a cargo ofpowdered cement.

At 0750 on Monday morning, the chiefengineer, deck mechanic and deck fitters met todiscuss their major work for the day which wasto repair some of the buckets on number onebucket elevator.

Prior to starting work, the deck mechanic wentto number one control room and checked thatthe circuit breaker for the main electric motoron the bucket elevator was open. He did notplace a danger tag on the circuit breaker.

The same morning, the boatswain and seamenhad started to prepare cargo holds one and twoto receive the powdered cement cargo inAdelaide. The seamen were sweeping theresidue of the slag cargo from the bottom of theholds into the bucket elevators. This work wasbeing performed under the supervision of themate who was periodically running number twobucket elevator for short periods to provide themen with empty buckets to fill.

At about 1100, the boatswain, working in thebottom of number two hold, requested that themate rotate number two bucket elevator. At thistime a deck fitter was working inside the top ofnumber one bucket elevator. He was lying withhis torso inside the bucket with one foot restingon one of the drive chains as he was welding.

The mate went to number two control room andran the bucket elevator for a couple of seconds.He then went to number one control room tocheck on the cleaning in number one hold.While there he decided to run the bucketelevator to provide an empty bucket for the manworking there and went to the circuit breaker forthe drive motor. Finding no danger tag, heclosed the breaker and then ran the motor for2–3 seconds. Although he had been told about itearlier, he had forgotten about the work beingperformed at the top of number one bucketelevator.

The fitter welding inside the bucket elevatorsustained serious injuries when the bucketelevator moved. His right hip had beendislocated, his pelvis and a vertebrae had beenfractured, two ribs were broken and he had someligament damage in the groin area.

Help was quickly at hand and the injured fitterwas lifted out of the bucket elevator and takenon a stretcher to the ship’s hospital where hewas examined by the second mate. It wasevident that the fitter’s injuries were serious.The master organised a telephone consultationwith a surgeon from the Royal AdelaideHospital who advised him to land the fitter assoon as possible. After speaking to the ship’smanager and the Adelaide agent the decisionwas made to divert the ship to Portland,Victoria.

CSL Pacific arrived off Portland at 1740. At1800 the injured fitter was transferred to a pilotlaunch and then to Portland base hospital. Thedeck fitter spent the next six weeks in Portlandbase hospital recovering from his injuries beforebeing repatriated on 2 April 2002.

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Sources ofInformationThe officers and crew of CSL Pacific

The Australian Maritime Safety Authority

ASP Ship Management

V.Ships U.K.

Intercontinental Ship Management

Det Norske Veritas, Sydney

ReferencesThe International Convention for the Safety ofLife at Sea, 1974, and its Protocol of 1988(SOLAS), the International MaritimeOrganization (IMO).

The International Management Code for theSafe Operation of Ships and for PollutionPrevention (International Safety Management(ISM) Code) as adopted by IMO resolutionA.741(18).

Guidelines on implementation of theInternational Safety Management (ISM Code)by Administrations as adopted by IMOresolution A.788(19).

The International Convention on Standards ofTraining, Certification and Watchkeeping forSeafarers 1974/1995 (STCW), IMO.

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Narrative

CSL PacificCSL Pacific (figure 1), (formerly River Torrens -2000, Selwyn Range -1985) is a Bahamas flag,handysized, self unloading bulk carrier of31 921 deadweight tonnes at its summer draughtof 11.021 m. CSL Pacific is classed � 100A1,with � LMC1 and UMS2 notations, with Lloyd'sRegister.

CSL Pacific was built at the State Dockyard inNewcastle, Australia in 1977. The ship served asa conventional bulk carrier until it waslengthened in 1985, and fitted with selfdischarging equipment for the three holdsforward of the accommodation superstructure. Ithas an overall length of 181.8 m, a beam of24.84 m and a depth of 13.30 m. Propulsivepower is provided by a Hitachi B&W 6K74EFslow speed, single acting, direct reversing dieselengine of 8 653 kW which drives a single, fixedpitch, propeller to give the vessel a servicespeed of 14.5 knots.

At the time of the incident, CSL Pacific had acrew of 25. The deck department consisted ofthe master and three mates, boatswain and fiveseamen. The engineering department comprisedthe chief and four engineers (including anelectrical engineer), an engine room fitter, adeck mechanic and two deck fitters, anelectrician and two engine room ratings. Therewas also a catering staff of three. The matesmaintained a traditional ‘four on, eight off’watchkeeping routine at sea. In port, when cargooperations were being performed, the secondand third mates worked ‘six on, six off’ and themate was on call at all times. The engineersworked a 24 hour duty roster with the engine

room unmanned outside normal working hours.All of the crew were Ukrainian nationals.

The master of CSL Pacific held an ocean goingmaster’s certificate of competency issued in theUkraine and had 22 years experience at sea, thelast six of which were in command. The mateheld a deep sea navigator certificate ofcompetency issued in the Ukraine and had beenat sea for 19 years. He had previouslycompleted two 4-month contracts on the shipand was two months through his currentcontract. The deck mechanic had also served onthe vessel for two complete contracts and hadjust started his third.

Ship historyCSL Pacific was built for the AustralianNational Line (ANL) in 1977 and was ownedand managed by the company until 1991 whenthe management was passed to ASP ShipManagement (at the time 50 per cent owned byANL). In May 1999 the ship was sold to AuscanSelf-Unloaders, a wholly-owned subsidiary ofCSL International (which together withCanadian Steamship Lines forms the CSLGroup Inc). The management of the vessel wastaken over by Intercontinental Ship Managementof Sydney. Most of the ASP Ship Managementcrew on the ship at the time of the change ofmanagement elected to stay with the ship andaccepted employment with the new managers.After this sale, the vessel continued to tradeprimarily around the Australian coast under theAustralian flag.

In July 2000, the vessel was sold again (a salewithin CSL) to the current registered owner,CSL Pacific Shipping. The management of thevessel also changed at this time to V.Ships U.K(formerly Acomarit). The ship was re-registeredin the Bahamas and the Australian crew werereplaced with Ukrainians. After this sale there

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1 Notation assigned when machinery is constructed and installed under Lloyd’s Special Survey in accordance with Lloyd’s rules. 2 Notation denotes ship may be operated with the machinery spaces unattended.

was a period of hand-over when an Australianmaster and mate remained on the ship for thefirst two months with the new Ukrainian crew.Their role was to provide technical expertise andadvice to the incoming crew, primarily on theoperation and maintenance of the cargo selfunloading system. Many of the Ukrainian crewon the ship at the time of the incident, includingthe master and mate, were on the vessel duringthe hand-over period.

At the time of the incident, CSL Pacific wastrading primarily around the Australian coastusing a continuous voyage permit (CVP) issuedby the Commonwealth Department of Transportand Regional Services.

Self unloading systemIn 1985 CSL Pacific underwent a majorconversion in Nagasaki, Japan, to fit a KvaernerCargo Scooper system. The system has amaximum discharge capacity of 1800 tonnes perhour using scraper reclaimers to discharge thecargo from the holds. This type of system candischarge bulk cargoes up to 100 mm whichmakes it suitable for a wide variety of cargoes.CSL Pacific has carried bulk cargoes including;grain, powdered cement, fly ash, furnace slag,gypsum and cement clinker.

CSL Pacific’s self unloading system is fullyautomated using programmable logic controllerslocated in the three cargo control rooms, oneadjacent to each hold, on the port side of themain deck (figure 2). Each control roomcontrols the operation of the two longitudinalscraper reclaimers, transverse scraper reclaimerand a bucket elevator in each hold. Distributionboards in each control room supply power to theelectric motors which drive the various pieces ofequipment.

FIGURE 2:

Inside number 1 cargo control room showing bucketelevator circuit breaker and the control panel

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The cargo is discharged from each hold fromthe top downward with the reclaimers workingon the surface of the cargo. Each reclaimer ismounted on support beams, suspended by wiresand winches, which allow the reclaimers to beprogressively lowered as cargo is discharged.The longitudinal reclaimers also traverse fromport to starboard and ‘sweep’ the cargo to thetransverse reclaimer mounted athwartships inthe centre of each hold. The cargo is then‘swept’ by the transverse reclaimer to a series ofgates on each bucket elevator housing locatedon the starboard side of the hold (figure 3). Thegates control the admission of cargo to theelevator depending on the level of the cargo inthe hold.

The bucket elevators lift the cargo from theholds and discharge it onto a longitudinal beltconveyor mounted on the starboard side abovethe main deck. The longitudinal conveyortransports the cargo forward to an auxiliaryconveyor, which discharges it onto a boom

conveyor which may be slewed outboard todischarge the cargo to shore receiving facilities.The longitudinal belt conveyor, auxiliaryconveyor and boom conveyor are controlledfrom number one control room adjacent tonumber one hold.

The bucket elevators consist of a steel housing(or trunk) which contains a series of steelbuckets bolted onto two parallel continuousKomatsu chain loops. The chains are driven bysprockets mounted on a common shaft at the topof the elevator. An idler shaft and sprockets arelocated at the bottom of the elevator to providechain tension. The drive shaft is normally drivenby a main electric motor via a reduction gearboxand fluid coupling. An ‘inching’ motor is alsofitted to each bucket elevator to provide slowrotation of the bucket elevator drive shaft formaintenance purposes. Maintenance on thechains and buckets is normally performed at the

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FIGURE 3:

Longitudinal and transverse reclaimers in hold

top of the bucket elevator, access being providedthrough two heavy steel doors in the top of thehousing (figure 4).

On CSL Pacific maintenance of the cargodischarge equipment is the overall responsibilityof the chief engineer. The work is normallyperformed by the deck mechanic and the twodeck fitters with the deck mechanic acting asthe on-job supervisor. The mate has the respon-sibility for supervising all day-to-day activitieson deck involving cargo operations.

The incidentAt 1800 on Sunday 17 February, CSL Pacificsailed from Melbourne bound for Adelaide toload a cargo of powdered cement. The ship wasin ballast after discharging a cargo of furnaceslag in Melbourne. As usual, after the

completion of the discharge, the ship’s electricalengineer went to each cargo control room andopened the circuit breakers on all of the electricmotors for the cargo discharge equipment.

At 0750 on Monday morning, the chiefengineer, deck mechanic and deck fitters met todiscuss the maintenance work which would beperformed that day on the cargo dischargeequipment. The major work for the day was therepair, by welding, of some of the buckets onnumber one bucket elevator, a routinemaintenance task which had been performed onnumerous occasions in the past.

The weather at the time was fine with asoutherly breeze at force four and a southerlyswell of about three metres.

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FIGURE 4:Two views of the top of number one bucket elevator,and one view inside

Top view

Top view

Inside view

Prior to starting work on number one bucketelevator, the deck mechanic went to number onecontrol room to check that the circuit breakerfor the main electric motor on number onebucket elevator was open. He found that thecircuit breaker was open but he did not place adanger tag on the circuit breaker, nor did helock the breaker tripping lever in the ‘off’position.

During the first part of the morning the deckmechanic and two deck fitters carried out sometasks in preparation for repairing the buckets inthe bucket elevator. They were working at thetop of number one bucket elevator housingduring this time.

The same morning, the boatswain and seamenhad started to prepare numbers one and twocargo holds to receive the powdered cementcargo in Adelaide. The hatch covers were openand most of the seamen were clearing theresidue of the slag cargo in the bottom ofnumber two hold. The seamen were sweepingthe slag tailings into the bucket elevator via thebottom gate in the bucket elevator housing. Oneseaman was performing the same work in holdnumber one. The mate was supervising the workin the holds and he was periodically runningnumber two bucket elevator to provide theseamen with empty buckets to fill. During themorning the deck mechanic had spoken to theseaman working in number one hold and toldhim that the buckets could be filled but thebucket elevator must not be turned as the deckfitters would be working on it.

At 1000 the crew on deck stopped work to takea coffee break. During the coffee break the deckmechanic had a discussion with the mate whoasked him if he could repair number nine gateon number two bucket elevator. The deckmechanic answered by saying that he would beworking on number one bucket elevator untilnoon and that they would repair the gate later.The mate later acknowledged this conversation.

Work re-started at 1015 after the morning teabreak. One of the deck fitters climbed into thetop of number one bucket elevator housing andstarted the welding repairs on the buckets. Theother fitter and the deck mechanic set aboutfabricating a new flange for the bucket elevatorgearbox. The deck mechanic was not carryinghis handheld radio at this time, his usualpractice when working on deck, as the batterywas charging.

At about 1100, the boatswain, working in thebottom of number two hold, requested via hishandheld radio, that the mate rotate number twobucket elevator as the bucket in way of thebottom gate had been filled with slagsweepings.

At this time the fitter working inside numberone bucket elevator was lying with his torsoinside the bucket and was welding with one footresting on one of the drive chains. The otherdeck fitter was standing on top of the housingoutside the bucket elevator and the deckmechanic was in the engine room workshop.

The mate went to number two control room,closed the breaker on the bucket elevator drivemotor and ran the bucket elevator for a coupleof seconds. He then went to number one controlroom, walking forward along the port side ofthe main deck. He did not notice the menworking at the top of number one bucketelevator housing.

When he arrived at number one control room,the mate checked on the progress of work innumber one hold from the observation port holeinside the room. While he was in the controlroom, the mate decided that he would turn theelevator to provide the seaman working in thehold with an empty bucket. He could see thatthe seaman was clear of the gate at the bottomof the bucket elevator so he went to the circuitbreaker for the elevator drive motor, closed thebreaker, and then ran the motor for 2–3 secondsmoving the buckets approximately five metres.

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There was no danger tag on the breaker and hehad momentarily forgotten about the work at thetop of the bucket elevator.

When number one bucket elevator moved, thedeck fitter inside the housing was rotated overthe top of the elevator inside the bucket he hadbeen welding, and was then thrown out. He wasleft hanging by the hands on one of the bucketsand the adjacent drive chain crying out in pain.His right hip had been dislocated, his pelvis anda vertebrae had been fractured, two ribs werebroken and he sustained some ligament damagein the groin area.

The other deck fitter saw what had happenedand immediately called to the seamen on deckfor help. He then climbed into the bucketelevator housing and held the injured man’shand until the boatswain arrived. The two menthen lifted the injured deck fitter out of thebucket elevator housing. The boatswain thenused his radio to summon more help. Shortlyafterwards, the deck mechanic and the electricalengineer also arrived at the scene. The four menthen moved the injured deck fitter from the topof the bucket elevator to the platform at the topof the bucket elevator housing.

The mate had also heard the boatswain’s radiocall and came to the bucket elevator. Afterseeing the condition of the injured man hecalled for further assistance using his radio.Receiving no immediate response, he went tofind the second mate, opened the medical lockerand got a stretcher.

The mate and second mate arrived back at thebucket elevator a short time later with astretcher and some first aid equipment. Themaster had also arrived by this time and hadbrought morphine from the safe in his cabin.

After assessing the deck fitter’s condition thesecond mate administered morphine to ease hispain. The deck fitter was then lowered from theplatform in the stretcher and moved aft to theship’s hospital where the second mate made amore thorough examination of his injuries.

During this time the master used the ship’ssatellite telephone to report the incident to thedesignated person at V.Ships U.K. He alsonotified CSL’s office in Sydney and the ship’sAdelaide agent.

After examining the fitter, the second mateconferred with the master. He indicated that hethought the fitter’s injuries were serious, partic-ularly in the groin area, and that the morphinewas not effectively relieving the man’s pain. Themaster told the second mate to administer asecond dose of morphine and then spoke to theagent in Adelaide again to ask him to organise atelephone consultation with a doctor.

A surgeon from the Royal Adelaide hospitalcontacted the ship a short time later. Hediscussed the fitter’s injuries with the masterand advised him to land the man as soon aspossible. After speaking again to V.Ships, CSLAustralia and the Adelaide agent, the decisionwas made to divert the ship to Portland,Victoria.

At 1350, CSL Pacific altered course forPortland. The ship’s Adelaide agent madecontact with an agent in Portland who arrangeda pilot launch for 1800.

CSL Pacific arrived at Portland at 1740. At 1800the injured fitter was transferred to a pilotlaunch and then to Portland base hospital wherehe spent the next six weeks recovering from hisinjuries before being repatriated on 2 April2002.

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Comment andanalysis

EvidenceOn 25 February 2002, two marine investigatorsfrom the Australian Transport Safety Bureauattended CSL Pacific in Melbourne. The sceneof the accident was inspected and the master,mate and deck mechanic were interviewed andprovided accounts of the incident. Copies ofrelevant documents were obtained includinglogs, written statements, accident reports,timesheets, various procedures and maintenanceinstructions.

The injured deck fitter was interviewed, usingan interpreter, on 26 February at Portland basehospital. He was in a stable condition, lucid, andprovided a detailed account of the incident.

ASP Ship Management, V.Ships U.K.,Intercontinental Ship Management and DetNorske Veritas in Sydney were contacted andasked to provide further information relevant tothe incident. This information included;

• reports of past incidents on the vessel,

• procedural information relating to pastmaintenance practices on the vessel,

• information relating to the hand over of themanagement of the vessel in July 2000, and,

• information relating to the InternationalSafety Management Code (ISM Code)certification of the vessel and past audits.

The incidentThe deck fitter working inside CSL Pacific’snumber one bucket elevator, was seriouslyinjured as a result of simple errors on the part ofother members of the crew. The deck mechanicsupervising the deck fitter did not take adequate

steps to prevent the operation of the bucketelevator while the fitter was working on it andthe mate started the bucket elevator, forgettingthat there was maintenance work beingperformed on it.

Prior to starting work on the bucket elevator, thedeck mechanic had checked that the circuitbreaker supplying the drive motor was open, andthus power to the motor was isolated. He didnot, however, take any steps to signify it wasdangerous to operate the motor nor did hephysically or electrically prevent the operationof the motor.

As the immediate supervisor of the work, thedeck mechanic had the first responsibility totake the appropriate measures to make theworkplace safe. However the chief engineer, asthe overall supervisor for the maintenance, wasalso responsible for ensuring that the menperforming the work were taking the appropriatesafety measures. In both cases there was afailure of supervisory duty of care to the deckfitter who was injured.

The deck mechanic did speak to the mate andthe seaman working inside number one hold andtold them of the work being performed on thebucket elevator. He also indicated to the matethat the work on the bucket elevator would notbe finished until midday. Providing the matewith this information, albeit at the informalforum of the morning tea break, was animportant step in ensuring the safety of thefitters working on the bucket elevator.

The mate ran the bucket elevator despite theknowledge that maintenance was beingperformed on it. He stated that, at the time heclosed the circuit breaker and started the drivemotor, he had forgotten about the work at thetop of the elevator. In the few seconds it took toclose the breaker and start the elevator motorthe mate was not cognisant of the risk.

Running the bucket elevators while the cargoholds where being cleaned was an operation the

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mate had performed many times before and,indeed, on at least four other occasions thatmorning. It appears that, at the time he closedthe circuit breaker on number one bucketelevator, his actions were automatic. It was theusual practice on the ship to open the circuitbreakers on the cargo discharge equipment afterthe completion of a discharge. Thus when themate saw the circuit breaker in the ‘open’position, with no warning tag, he would havehad no reason to pause and reconsider hisactions as he expected to find the breaker openand to close it before running the elevator drivemotor.

All ships are required to have a safetymanagement system which, amongst otherthings, safeguards the health and safety of thecrew. That an incident of this kind should occurat all means that there had been a significantfailure of the safety management system on thevessel.

Shipboard safety managementsystemThe ISM Code requires all ships to ‘develop,implement and maintain a safety managementsystem (SMS)…’. The Code states under ‘1.2Objectives’:

1.2.1 The objectives of the Code are to ensuresafety at sea, prevention of human injury orloss of life, and avoidance of damage to theenvironment, in particular to the marineenvironment and to property.

1.2.2 Safety-management objectives of theCompany should, inter alia:

.1 provide for safe practices in ship operation and a safe working environment;

.2 establish safeguards against all identifiedrisks…

CSL Pacific’s safety management systemconsisted of a set of generic safety managementmanuals provided by the ship managementcompany with some ship-specific checklists

which had been generated by the crew for‘Critical Operations’.

Isolation proceduresThe company manuals contained a ‘permit towork’ system which included an ‘EnergyIsolation Lockout/Tagout checklist and Permit-WPAC 2’ with accompanying instructionsstating:

A completed Energy Isolation Permit is requiredwhen performing work on equipment ormachinery where an energy-release incident ispossible.

All pertinent sections of the Energy IsolationChecklist must be completed and presented to theChief Engineer or Authorised Delegate for verifi-cation and issuance of the Energy IsolationPermit.

Only the Chief Engineer or authorised delegatemay approve and issue Energy Isolation Permits.

The instructions contained in the energyisolation checklist were generalised and notspecific to any particular activity, system orship. There was no guidance on specificinstances where an energy isolation permit wasrequired.

The ship’s generic ‘Self Unloading Bulk CarrierManual’ also contained an instruction in section4 ‘General Safety’ under the heading ‘SafeWorking Practices and Environment Protection’which states:

Isolate/lockout power before commencing anymaintenance work

There was no reference to the energy isolationpermit in this procedure.

There was no specific instruction in any of theprocedure manuals as to when circuit breakersare to be opened, tagged and/or locked. Theenergy isolation permit procedure actuallystates:

The Energy Isolation Permit outlines theminimum requirements to work on equipment or

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machinery where an energy release incident ispossible. Additional written procedures must becompiled when special conditions exist.

The intent of these general instructions had notbeen translated into practice on board CSLPacific in the form of a working procedure atthe time of the incident. The deck mechanicstated that it was his usual practice to open therelevant circuit breaker and place a ‘danger tag’on it when working on the cargo dischargeequipment. On this occasion, for whateverreason, he did not place a ‘danger tag’ on thecircuit breaker. An energy isolation permit wasnot issued for the work and the deck mechanicdid not indicate knowledge of any requirementto obtain such a permit. Both he and the matesaid that it was not usual to padlock the circuitbreakers open although they both knew that thishad been the practice on the vessel in the past.

The safety management system on CSL Pacificat the time of the incident was inadequate inrespect of procedures for isolating cargoequipment for maintenance work. There were noprescriptive tagout/lockout procedures relatingspecifically to the ship and it appears that thegeneric instructions contained in the SMSmanuals were not strictly applied on the vessel.Given the well-known risks associated withmaintenance on moving machinery, it would bereasonable to expect that these operations wouldbe identified as ‘critical’ and an appropriate shipspecific procedure formulated.

The proper isolation of equipment beforemaintenance is a fundamental workplacesafeguard which must be ingrained in theworking culture on board every ship.

Following the incident, CSL Pacific’s crew didformulate a new ‘Critical Operation’ checklistwhich contains prescriptive requirements forisolating cargo discharge equipment prior tomaintenance work.

Works committeeCSL Pacific is a busy ship in terms of cargorelated activities, particularly maintenance.Very often crew from different departments areengaged in different work activities which needto be coordinated. It is the practice on manyships to hold periodic ‘works committee’meetings of supervisory personnel from thedeck and engineering departments to discusssuch work. The meetings are usually held in theevenings or mornings prior to the day’s activitiesand provide a forum where information ispassed and the various activities are coordinatedas needed.

The mate indicated that it was the practice onboard CSL Pacific to have a works committeemeeting prior to each cargo loading anddischarge operation. It was not the practice tomeet each day to discuss routine maintenancework. Had there been a more formal exchangeof information at such a meeting prior to theday’s work on 18 February, the mate may havebeen more cognisant of the work beingconducted on number one bucker elevator.

The hand-over of managementWhen CSL Pacific was first operated as a self-discharging bulk carrier by the AustralianNational Line, rigorous lock-out procedureswere implemented for maintenance work on thecargo equipment. Each person on the ship wasissued with a padlock, engraved with their rank.Every person working on a particular piece ofequipment was required to place their padlockon the circuit breaker operating handle, to lockit open, before commencing any work. The lockout procedures were designed specifically toprevent the sort of accident which occurred onCSL Pacific on 18 February 2002.

Records of past accidents on the vessel showthat the lock-out system was effective in asmuch as there were no accidents on the vessel

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involving the inadvertent starting of equipmentbetween 1991 and 1999.

The lock-out procedures were incorporated inthe ship’s safety management system when theISM Code was implemented on the vessel byASP Ship Management in 1998. WhenIntercontinental Ship Management took over themanagement of the ship in 1999, the lock-outsystem was perpetuated with the transfer of thecrew and almost all of the ship’s safetymanagement system.

When V.Ships took over the management of thevessel in July 2000, they implemented their ownsafety management system. There was noformal process whereby proven past practices onthe vessel were incorporated into the new safetymanagement system. Information from themaster and mate from Intercontinental ShipManagement, who stayed on the vessel tofamiliarise the new crew, was passed on in anad-hoc and informal way.

The new crew did generate several ship-specificcritical operation checklists relating to cargooperations, but no checklist for maintenanceactivities. One checklist requires that circuitbreakers must be padlocked when there arepersonnel in the cargo holds during a cargooperation. Another requires that breakers aretagged out when cleaning a blockage in theconveyor system. These procedures areinconsistent as there is no valid reason why oneof these critical operations would rate the lesserprotection of tag-out as the risks are the samefor both activities. Additionally, neither checklistmentions the ‘Energy Isolation Permit’ nor dothey stipulate ‘isolate/lock-out’ and as such theydo not meet the requirements contained in thegeneric procedure manuals.

AuditsThe guidelines for implementing the ISM Code(International Maritime Organisation (IMO)resolution A.788(19)) establishes basicprinciples for verifying that the safetymanagement system of a company responsible

for the operation of a ship complies with theCode. It states under section 2 ‘VerifyingCompliance with the ISM Code’:

2.1.1 To comply with the requirements of the ISMCode, Companies should develop,implement and maintain an SMS to ensurethat the safety and environmental policy ofthe Company is implemented. The Companypolicy should include the objectives definedby the ISM Code.

In practice this means that every ship’s safetymanagement system must make adequateprovisions to provide a safe workingenvironment for the crew and establishsafeguards against all identified risks. To obtainand maintain its ISM Code certification, everyship manager and vessel must demonstrate theadequacy of the safety management system inrespect of these things when audited by theaccreditation authority.

At the time of the incident, CSL Pacific’smanagers had a current Document ofCompliance. The Document of Compliancecertified that the safety management system ofthe company had been audited and found tocomply with the requirements of the ISM Codefor bulk carriers. The safety managementsystem in use at the time of the incident onboard CSL Pacific had also been audited andfound to comply with the requirements of theISM Code, evidenced by a current SafetyManagement Certificate.

The implementation of the ISM Code on thevessel after the change of management in July2000 required that the vessel be initially auditedby Det Norske Veritas prior to receiving itspermanent Safety Management Certificate. Thisaudit was conducted in Japan on 10 January2001. There was no finding made during thisaudit that the ship’s procedures were in any waydeficient with regard to cargo equipmentisolation. Nor was there any check to ensure thatthese fundamental procedures had beenperpetuated from the previous manager’s safetymanagement system.

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The ship management company conductedinternal audits of the ship’s safety managementsystem in November 2000 and November 2001.Like the DNV audit, these audits did not findthat the ship’s procedures, regardingmaintenance work on the cargo equipment, weredeficient or inconsistent with the company’sgeneric procedures regarding energy isolationpermits and isolation/lock-out. Additionally,none of the audits revealed that the company’s‘Energy Isolation Permit’ procedure was notstrictly applied on the vessel. Considering theresults of these audits of the ship’s safetymanagement system, the rigour of the ISMCode implementation process on the vessel mustbe questioned.

FatigueFatigue may be described as a reduction inphysical and/or mental capability as a result ofphysical or emotional exertion which mayimpair nearly all physical abilities including,strength, speed, reaction time, coordination anddecision making. Fatigue may be described asacute or chronic. Acute fatigue occurs in amatter of hours as the result of excessive mentalor physical activity and may be cured by aperiod of rest or sleep. A state of chronic fatigueis reached when the 'normal' period of rest orsleep is insufficient to restore an individual'sworking performance to its usual level.

Chronic fatigue is insidious and usually happensover a period of time. Individuals suffering fromchronic fatigue always perform below theirpersonal best but are often unaware that theirperformance has been significantly degraded.Chronic fatigue has been shown to impairindividual information processing, particularlyin secondary tasks, with increased probability ofslips, lapses and mental blocks.

The mate’s hoursThe mate had been on the ship for the previoustwo months. His overtime sheets show that hehad established a pattern whereby his usualworking day while the ship was at sea consisted

of the morning watch from 0400 to 0800followed by four hours of daywork until midday.He then took a short rest in the afternoon afterlunch and completed his afternoon watch from1600 to 2000. His workday at sea averaged 12hours.

When the ship was in port, the mate’s usual daystarted at 0500 and finished at 2300 or 2400with an hour for lunch between 1200 and 1300.The mate’s work time each day in port wasgenerally 17 or 18 hours.

In the week leading up to the incident the matehad worked 101 hours, 80 hours of which werein the five days before the incident at an averageof 16 hours per day. When he closed the circuitbreaker and ran number one bucket elevatormotor at 1100 on 18 February, he had beenworking for the previous seven hours.

The IMO’s International Convention onStandards of Training, Certification andWatchkeeping for Seafarers 1974/1995 (STCW)has requirements designed to managewatchkeeper fatigue. The Convention states thatall watchkeepers must have rest periods of 10hours in each 24 hour period which may bereduced to six consecutive hours but not formore than two days. The convention alsorequires that there must be not less than 70hours of rest in each seven day period. Themate’s working hours were excessive, withexamination of his overtime sheets revealingthat he was regularly below the STCWrequirements in respect of daily and weeklyminimum rest periods.

The deck mechanic’s hours The deck mechanic had travelled from Odessain the Ukraine to arrive in Melbourne on 12February. He had two days in Melbourne beforejoining the ship four days before the incident.His overtime sheets show that he had averaged12 hours work per day in the four days onboard. During this time the ship was dischargingcargo and he had attended several early morningbreakdowns of the discharge equipment. On 15

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February he was called out at 0400 for sevenhours, on 16 February he was called out at 0300for seven hours and had worked from midnightuntil 0600 and then from 1300 until 2000 on theday prior to the incident.

Fatigue analysisThe mate’s and deck mechanic’s hours of workwere analysed using Fatigue Audit InterDyne(FAID) software developed in conjunction withthe Centre for Sleep Research at the Universityof South Australia. The FAID program enablesthe quantitative assessment of an individual'slevel of fatigue at a point in time based on workhours for the previous seven days. The resultantindividual fatigue 'score' may be used as a guideto indicate what effect fatigue may have had onan individual's performance. The FAID programis in wide use throughout Australia as arostering tool in various transport industriesincluding several pilotage services.

The FAID software indicated that the mate had amaximum fatigue score of 158.6 at 0400 whenhe started his morning watch on 18 February. Atthe time of the incident his fatigue score haddropped to 100 (the FAID software allows for‘time of day’ or circadian effects which dictatethat alertness increases from about 0400onwards).

Research by the Centre for Sleep Researchsuggests that a fatigue score of 40–80 ismoderate, 80–100 is high with scores 100–120being very high. High fatigue scores of 80–100have been shown to produce individualperformance impairment equivalent to a bloodalcohol concentration over 0.05%. The mate’sfatigue score was high at the time of theincident and it suggests that his actions andsituational awareness were to some degreeaffected by chronic fatigue.

The deck mechanic’s fatigue score at the time ofthe incident was 75 having dropped from about90 at the time when he said he had checked thebucket elevator circuit breaker. His maximumfatigue score for the four days he was on theship was 168.8. The FAID software does nottake into account any effects of circadiandysrhythmia (jet lag) that he may still have beensuffering after his long flight from the Ukraine(across nine time zones) before joining the ship.Like the mate, the deck mechanic’s fatigue scoreat the critical time in the morning when hechecked the circuit breaker was high. Thissuggests that his actions may also have beenaffected by fatigue.

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ConclusionsThese conclusions identify the different factorscontributing to the incident and should not beread as apportioning blame or liability to anyparticular individual or organisation.

Based on the evidence available, the followingfactors are considered to have contributed to theserious injury sustained by the deck fitteraboard CSL Pacific on 18 February 2002:

1. The mate started number one bucket elevatorwhile the deck fitter was working inside it.

2. The deck mechanic supervising the work onthe bucket elevator did not place a danger tagon and/or padlock the drive motor circuitbreaker in the open position prior to the fittercommencing work.

3. There was a lack of a suitable ship-specificprocedure, consistent with the managementcompany’s safety policy, detailing steps forisolating cargo equipment prior tomaintenance.

4. The lock out procedure, previously used onthe vessel, was not perpetuated in the ship’snew safety management system after thechange of vessel management in July 2000.

5. The ship’s management company policiesregarding ‘Energy Isolation Permits’ andisolation/lock out during maintenanceactivities on cargo equipment were notrigorously applied on the vessel at the timeof the incident.

6. Although the mate acknowledged that he hadbeen told of the work by the deck mechanicat the morning coffee break, there was no‘works committee’ meeting prior to theincident to formally communicate to themate the fact that work was being conductedinside number one bucket elevator.

7. Audits of the ship’s safety managementsystem prior to the incident failed to ensurethat the procedures for isolating equipmentprior to maintenance were adequate,consistent, and were being followed.

8. The mate was working excessive hours in theweeks leading up to the incident and it islikely that he was suffering from someeffects of chronic fatigue at the time hestarted the bucket elevator.

9. The deck mechanic may also have beensuffering from some effects of chronicfatigue which may have affected his actionson the morning of the incident.

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FIGURE 5:CSL Pacific: Events and causal factors chart

Even

tsCo

nditi

ons

Inci

dent

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It is recommended that:

1. The ship management company ensures thatcargo maintenance activities on board CSLPacific include equipment isolationprocedures which are adequate, consistentand rigorously applied on the vessel.

2. The ship management company monitorsworking hours on CSL Pacific with a view toensuring that crew are adequately rested andare complying with the requirements of theSTCW convention.

3. That ship management companies, classifi-cation societies and maritime administrationsensure that sound safety managementpractices are perpetuated through and afterchanges of vessel management.

Recommendations

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SubmissionsUnder sub-regulation 16(3) of the Navigation(Marine Casualty) Regulations, if a report, orpart of a report, relates to a person’s affairs to amaterial extent, the Inspector must, if it isreasonable to do so, give that person a copy ofthe report or the relevant part of the report. Sub-regulation 16(4) provides that such a personmay provide written comments or informationrelating to the report.

Copies of the complete draft report were sent tothe master, chief engineer, mate, deck mechanic,deck fitter (who was injured), V.Ships U.K.,Intercontinental Ship Management, Det NorskeVeritas and the Australian Maritime SafetyAuthority.

The following was the only submission receivedand is from the Marine Safety and QualityManager of V.Ships U.K.:

We refer to the draft report of the above incident,for which we thank you, and would comment tothe Conclusions as follows:-

1. Accepted

2. Accepted

3. We do not accept that there were not adequateprocedures in place at the time of the incidentbut these procedures were not being followed.

4. Accepted that the previous procedures usedon this vessel were not perpetuated but wouldpoint out that when taking over Managementof a vessel, very often procedures do alterfrom the previous Management. We believethat procedures provided were adequate but,unfortunately, not followed.

5. Similar to Item 4, adequate procedures wereon board at the time of the accident but,unfortunately, not followed.

6. We believe that in this case, the fact that a‘formal works committee’ was not convenedprior to commencing the work was notmaterialistic in causing the accident due to thefact that the Mate was told of the work.

7. As you are aware, audits are a ‘spot’ checkonboard as the audit is constrained by timeelements and it would be unrealistic toperform a total audit of ALL shipboardsystems and procedures. DNV had audited thevessel on 10/01/01 and Internal audits carriedout on 10/11/00 and 20/11/01 and we believethat these audits were carried out effectively.

8. As pointed out, time sheets were completedfor the Mate and we concur that in fact he hadbeen working hours in excess of STCWConvention but would point out that we relyon the on-board Management Team to ensurethese hours of work are complied with.Unfortunately in this case, it appears theywere not. We would comment that the FAIDfigures quoted in the report are indeed‘suggested scores/levels of fatigue’ and thedraft report indicates that the system ofindicating these ‘scores’ is in the researchstage. As such we do not believe these figuresshould be included in an ‘Official Report’.

9. As per Item 8 above.

We trust that the above is helpful in addressingthe ‘Conclusions’ contained in the draft report butshould you require any clarification please do nothesitate to contact us.

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CSL PacificName CSL Pacific (formerly River Torrens-2000, Selwyn Range-

1985)

IMO Number 7420716

Flag Bahamas

Classification Society Lloyd’s Register

Ship Type Self Discharging Bulk Carrier

Cargo Discharge Equipment Kvaerner Cargo Scooper System

Builder NSW Government Engineering and Shipbuilding, Newcastle, Australia

Owners CSL Pacific Shipping

Ship Managers V.Ships U.K.

Gross Tonnage 21 047

Net Tonnage 9 980

Deadweight (summer) 31 921 tonnes

Summer draught 11.021 m

Length overall 181.8 m

Breadth 24.84 m

Moulded depth 14.48 m

Engine Hitachi B&W 6K74EF, 6 cylinder, 2 stroke, single acting, direct reversing

Engine power 8653 kW

Service speed 14.5 knots

Crew 25 Ukrainian nationals

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