Formosabulk Clement: ATSB published investigation report

published on 22 September 2023 94 -

In August 2021, during the COVID-19 pandemic, Formosabulk Clement diverted to Brisbane, Queensland for crew change, to be completed to/from a launch via the combination pilot ladder. At the time, Queensland was the easiest jurisdiction in Australia for ships to conduct crew change due to the State’s extensive quarantine arrangements for transporting and accommodating seafarers. By 1833 on 9 August, 8 persons and their luggage had been successfully transferred from the launch PT Transporter to the ship located at an outer anchorage. The launch skipper then drove the launch a short distance off the ship for a short break.

By this time, the ship had turned about the anchor and the boarding side of the ship came under the influence of the forces of wind and sea. After receiving supervisor advice to attempt the transfer again, the launch skipper took the launch back toward the boarding area to assess whether the conditions were suitable. On board Formosabulk Clement, the departing chief mate (dCM) saw the approaching launch and went down the access ladders and onto the vertical pilot ladder in anticipation of boarding. At about 1838, as the dCM waited on the ladder and the launch came close alongside, a large wave passed down the side of the ship and lifted the launch higher than expected. The dCM was struck by the launch and knocked into the sea. Despite being quickly recovered on board, they received fatal injuries.

The investigation found that the open water conditions at the anchorage, were marginal but, within a lee created by the ship, they were suitable for the transfer to occur. However, as the skipper brought the launch alongside to assess conditions, the transfer area was no longer in a lee and waves were acting against the ship’s side, increasing in height as they passed along it.

Coincident breakdowns in communications between, and within, the ship and the launch resulted in the ship’s master, the dCM, the launch skipper and the launch deckhand having different understandings of the significance and intent of the launch returning alongside the ship.

In addition, the dCM went down the boarding ladders in preparation to board the launch without the knowledge or agreement of either the ship’s master or the launch skipper. The dCM was then in a vulnerable position when the launch was lifted on the higher than expected wave.

The investigation also found that plans and details of how the transfer was to be controlled and progress when the launch was alongside were not adequately shared between all parties in the time available as the launch approached the ship. Neither the shipping company nor the launch company had in place procedures to ensure that such information was shared before the ship arrived at the anchorage.

As a consequence, different interpretations and misunderstandings of the plan and expectations of the people involved in the transfer, particularly those in positions of influence over the progress of the transfer, were not identified and addressed.
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