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Fatality While Storing the Products Tanker British Beech in Brisbane, Queensland, on 15 December 2011

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Fatality While Storing the Products Tanker British Beech in Brisbane, Queensland, on 15 December 2011 InsertFatality documentwhile storing title the products tanker British Beech Locationin Brisbane, | Date Queensland | 15 December 2011 ATSB Transport Safety Report Investigation [InsertMarine Mode]Occurrence Occurrence Investigation Investigation XX-YYYY-####291- MO -2011- 011 Final – 7 March 2013 ATSB TRANSPORT SAFETY REPORT Marine Occurrence Investigation MO-2011-011 No. 291 Final Fatality while storing the products tanker British Beech in Brisbane, Queensland 15 December 2011 Released in accordance with section 25 of the Transport Safety Investigation Act 2003 - i - Published by: Australian Transport Safety Bureau Postal address: PO Box 967, Civic Square ACT 2608 Office: 62 Northbourne Avenue Canberra, Australian Capital Territory 2601 Telephone: 1800 020 616, from overseas +61 2 6257 4150 Accident and incident notification: 1800 011 034 (24 hours) Facsimile: 02 6247 3117, from overseas +61 2 6247 3117 Email: [email protected] Internet: www.atsb.gov.au © Commonwealth of Australia 2013 In the interests of enhancing the value of the information contained in this publication you may download, print, reproduce and distribute this material acknowledging the Australian Transport Safety Bureau as the source. However, copyright in the material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you want to use their material you will need to contact them directly. ISBN and formal report title: see ‘Document retrieval information’ on page vii - ii - SAFETY SUMMARY What happened On 15 December 2011, British Beech was berthed in Brisbane, Queensland, and its crew was taking on stores from a barge. During the return of a stores container from the ship to the barge, the container came free of its slings. It fell to the barge below, striking the master of the barge. The master was attended to by the barge crew and shore paramedics but he died from his injuries while being transported to hospital. What the ATSB found The ATSB found that the container had not been appropriately rigged on board the ship and the ship’s crew had not warned the barge crew of its return. The ship’s crew did not view the storing operation as dangerous and had, over time, removed identified safety barriers which would probably have prevented the accident. Compliance auditing processes had not identified and minimised such routine violations of the shipping company’s procedures. The ATSB also found that the barge master had placed himself in a position of danger under the suspended load, and that the barge crew had not followed their company’s procedures for storing operations. The ATSB further found that the company had not adequately implemented compliance auditing or incident reporting schemes. As a result, the company had not acted on, or learnt from, previous less serious incidents. What has been done to fix it The method used for handling containers of this type in Brisbane has been altered so that the containers are top lifted and slings are no longer used. The ship’s manager, BP Shipping, implemented a requirement to have the lifting point fixed and above the centre of gravity of loads. A thorough review of lifting and slinging processes, practices, procedures and equipment was conducted as well as a review of lifting and slinging job hazard analyses. A fleetwide review and training workshop for lifting and slinging was also completed. The barge’s operator, Bowen Tug and Barge, undertook a review of its operations and work practices. On 1 July 2012, the company ceased ship storing operations and sold all associated vessels and equipment to another operator. Safety message Lifting operations, even when they are routine, involve inherent risks. Therefore, established procedures must be followed, reinforced and audited to ensure vigilance is maintained and complacency avoided. The basic precaution of standing well clear of suspended loads must always be taken. - iii - - iv - CONTENTS SAFETY SUMMARY ........................................................................................... iii THE AUSTRALIAN TRANSPORT SAFETY BUREAU ................................. ix TERMINOLOGY USED IN THIS REPORT ..................................................... xi 1 FACTUAL INFORMATION ........................................................................ 1 1.1 British Beech......................................................................................... 1 1.1.1 Stores crane ................................................................................ 2 1.2 The stores barge .................................................................................... 3 1.3 The stores container .............................................................................. 4 1.4 The accident .......................................................................................... 5 2 ANALYSIS .................................................................................................... 11 2.1 Evidence ............................................................................................. 11 2.2 Slinging of the stores container .......................................................... 11 2.2.1 Previous method of slinging the container .............................. 13 2.2.2 Upsetting force ......................................................................... 14 2.2.3 Container handling changes after the accident ........................ 14 2.3 Communications ................................................................................. 15 2.4 Safe operations ................................................................................... 16 2.4.1 British Beech ............................................................................ 16 2.4.2 Bowen Tug and Barge (BTB) .................................................. 17 2.4.3 Personal protective equipment ................................................. 19 2.5 Reporting of risk-related events within BTB ...................................... 20 2.6 Individual actions ............................................................................... 22 2.6.1 Violations at the skill-based level ............................................ 22 2.6.2 Complacency ........................................................................... 23 3 FINDINGS ..................................................................................................... 25 3.1 Context ............................................................................................... 25 3.2 Contributing safety factors ................................................................. 25 4 SAFETY ACTION ........................................................................................ 27 4.1 Bowen Tug and Barge ........................................................................ 27 4.1.1 Stores container handling......................................................... 27 4.1.2 Safety management system adequacy ...................................... 27 4.1.3 Compliance auditing ................................................................ 28 4.1.4 Reporting culture ..................................................................... 28 - v - 4.2 BP Shipping ........................................................................................ 28 4.2.1 Compliance auditing ................................................................ 28 APPENDIX A : SHIP INFORMATION ............................................................ 31 APPENDIX B : SOURCES AND SUBMISSIONS ............................................ 33 - vi - DOCUMENT RETRIEVAL INFORMATION Report No. Publication date No. of pages ISBN ISSN 291-MO-2011-011 7 March 2013 46 978-1-74251-308-9 1447-087X Publication title Fatality while storing the products tanker British Beech in Brisbane, Queensland, on 15 December 2011. Prepared By Australian Transport Safety Bureau PO Box 967, Civic Square ACT 2608 Australia www.atsb.gov.au Acknowledgements The cover photograph and Figures 5 and 7 courtesy of the Queensland Police Service, Brisbane Water Police. Figure 4(a) courtesy of Xactics International. Figure 6 courtesy of the master of British Beech. Figure 10(a) courtesy of Australian Providoring & Trading Company. Figures 8 and 10(b) courtesy of Workplace Health and Safety Queensland. - vii - - viii - THE AUSTRALIAN TRANSPORT SAFETY BUREAU The Australian Transport Safety Bureau (ATSB) is an independent Commonwealth Government statutory agency. The Bureau is governed by a Commission and is entirely separate from transport regulators, policy makers and service providers. The ATSB's function is to improve safety and public confidence in the aviation, marine and rail modes of transport through excellence in: independent investigation of transport accidents and other safety occurrences; safety data recording, analysis and research; fostering safety awareness, knowledge and action. The ATSB is responsible for investigating accidents and other transport safety matters involving civil aviation, marine and rail operations in Australia that fall within Commonwealth jurisdiction, as well as participating in overseas investigations involving Australian registered aircraft and ships. A primary concern is the safety of commercial transport, with particular regard to fare-paying passenger operations. The ATSB performs its functions in accordance with the provisions of the Transport Safety Investigation Act 2003 and Regulations and, where applicable, relevant international agreements.
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