The Australian Transport Safety Bureau (ATSB) published its investigation report about fatal fall from the pilot ladder of Formosabulk Clement.
The incident
During the COVID-19 pandemic, the international maritime industry struggled to comply with requirements for the maximum continuous period that a seafarer could serve on board a ship without taking leave. Following a period of grace during which the continuous service period was relaxed to 14 months, in November 2020, the Australian Maritime Safety Authority (AMSA) notified ship owners, operators and seafarers that it would resume enforcing the 11-month continuous service limitation from 28 February 2021.
On 25 July 2021, Formosabulk Clement departed Mailiao, Taiwan, in ballast, bound for Newcastle, New South Wales to load coal. The ship’s trade routes for the preceding 6 months had provided no opportunity for change of crew and 14 of the 25 crew on board had been on board for more than 11 months.
At that time, pandemic-related restrictions on crew changes varied considerably between different States in Australia with Queensland offering the most convenient opportunities. Hence, in early July, Formosabulk Clement’s manager, Formosa Plastics Marine Corporation (FPMC), engaged its local shipping agents in Australia to arrange a crew change off Brisbane, Queensland. The arrangements would involve the ship calling at Brisbane anchorage to rendezvous with a crew change vessel (launch). Eleven crewmembers were to join the ship and 15 were leaving.
At 0912 on 9 August, Formosabulk Clement anchored in the port of Brisbane outer anchorage, about 6 miles east of Point Cartwright. Ashore, pandemic protocols had been completed for the joining crew and arrangements for transfer by launch had been made. The launch service provider (Pacific Tug) notified all parties that, to satisfy requirements, the transfer would require 2 trips by the launch PT Transporter. The launch was to collect the passengers and depart from the quarantine facility at Brisbane Rivergate marina and shipyard.
Pacific Tug requested that Formosabulk Clement be relocated further south in the anchorage area to assist the transfer, and with Brisbane vessel traffic service (VTS) approval, the ship was moved south. During this same information exchange, the ship’s master was requested to have the boarding arrangements located on the opposite side of the ship to the deployed anchor and to provide a good lee for the transfer. At 1436, Formosabulk Clement’s port anchor was let go and at 1500 ‘finished with engines’5 was rung. The ship was now anchored about 5 miles east of Caloundra Head, about 7 miles south of the original anchor location. It was riding easy on the anchor, 7 shackles in the water in a fresh breeze and moderate seas, from the south-east.6 Throughout the afternoon, the ship yawed about the anchor, at the whim of the conditions, its heading varying between about 140° and 80° in about 30-minute cycles.
At 1448, PT Transporter departed the Rivergate marina and shipyard with 2 crewmembers (skipper and deckhand) and 8 Formosabulk Clement joining crewmembers on board. At 1530, it passed to the west of the entrance beacons, 30 miles from the ship, heading north-east making better than 15 knots across Moreton Bay. The passage across the bay toward the ship remained uneventful other than for several of the passengers becoming seasick in the choppy conditions.
At 1600, on board Formosabulk Clement, the departing chief mate (dCM) completed handover of rank to the trainee chief mate who had been on board since early May and was now taking over the position. The new chief mate then took the navigation watch from the second mate. The dCM was to leave the ship on the first launch after supervising the embarkation of the 8 joining crew (and their luggage) and the disembarkation of 7 other crewmembers. In agreement
with the master, the plan was for the dCM to be the last person to disembark. The dCM and the master (on the bridge) would be using handheld UHF radios to communicate.
Analysis
In 2021, the COVID-19 pandemic and the response of international shipping to manage it created challenges for ship crew changes. In the case of Formosabulk Clement, this resulted in the ship diverting to Brisbane to conduct a change of long-serving crewmembers on 9 August 2021. With the ship at anchor, the crew change was being conducted via a combination pilot ladder from the crew transfer launch, a much smaller vessel about 16 m below the ship’s deck.
The transfer was conducted in the early evening on the ship’s starboard side, the leeward side from time to time as the ship yawed at anchor in the rough sea conditions. The ship’s main engine was also used to maintain a lee and, by 1833, the 8 joining crewmembers (and their luggage) had safely boarded the ship.
The launch then moved clear of the ship to wait for the transfer of crew from the ship. While waiting, the launch skipper felt the seas become rougher and, after conferring with shore management, returned the launch alongside. The skipper reported that the deckhand and ship’s master were advised to stand by while they (the skipper) assessed the feasibility of continuing in the conditions. The skipper did not expect to embark anyone at that time and believed permission
would be required before anyone attempted to use the ladder.
Probable cause
Formosabulk Clement’s departing chief mate climbed down the vertical pilot ladder intending to board the crew transfer launch. They did this without the knowledge of the ship’s master or the skipper of the launch.
- After the ship’s master had manoeuvred the ship to create a lee and embark the joining crew from the launch, the ship yawed about the anchor, which exposed the transfer area to the prevailing weather.
- Immediately before the accident, there were difficulties in communicating between the ship’s bridge and the launch. As a consequence, the main engine was not used to re-create a lee before the launch came back alongside the ship, and the transfer location was exposed to the weather.
- A wave, larger than previously encountered, lifted the transfer launch higher than expected and sufficient to make contact with the departing chief mate, knocking them into the water.
- On board Formosabulk Clement, communications plans and protocols for the crew transfer operation had not been sufficiently well implemented and agreed to ensure that deck and bridge personnel maintained awareness and understanding of what was occurring and what was about to occur.
- On board PT Transporter, communications arrangements had not been sufficiently well implemented to ensure that events occurring as the crew transfer process progressed were clearly understood and agreed between its skipper and deckhand.
- Neither vessel’s managers had ensured that the involved personnel had a common and complete understanding of how the personnel transfer would be conducted with respect to aspects including:
- outlining task steps, limits and triggers such as agreed permissions for vessel movements
- setting operational limits
- defining terminology for key transfer-related communications.
The opportunity was not taken to share information well beforehand, which would have allowed differences to have been addressed and a single plan developed and agreed before the task was underway.
Safety action
Pacific Tug (PT) informed the ATSB that the company immediately ceased personnel transfer operations after this accident until a comprehensive review of such operations was conducted. PT sought a system of communication less constrained by language and amenable to being shared beforehand to assist in achieving the shared mental model of the task among all participants.
