Safety management system procedures were not effectively implemented when the Spirit of Tasmania I’s second engineer was seriously injured in a fall during engine maintenance earlier this year, said the final report from the Australian Transport Safety Bureau.
What happened
At about 0600 on 6 March 2025, the second engineer of Spirit of Tasmania I began a routine oil change on one of the ship’s main engine turbochargers. Problems were encountered during the oil change, and it was decided to replace the turbocharger’s bearing housing cover plate. This significant change to the scope of work required access to the top of the engine.
The second engineer and another engineer on duty then carried out the work, which took longer than expected and required both to climb on and off the engine top several times. At 0815, while climbing off the engine, the second engineer slipped and fell heavily, resulting in serious injury.
What the ATSB found
The ATSB investigation found that, while access to the top of the engine was regularly required, there was no access ladder or platform nor was a standard safe route defined or used. Consequently, the injured second engineer used an unsafe access route along the engine rocker covers at the time of the accident.
The investigation also identified that although the shipboard safety management system required that the change of work scope necessitated a review of the Job Safety Analysis (JSA) and/or completing a new prestart safety checklist (Take 5), neither was undertaken due to perceived time pressure and a perception that the work was low risk, resulting in the risk of a fall not being properly considered.
In addition, the ATSB found that the JSA procedure was not effectively implemented on board. This resulted in there being no JSA in place for the work being done at the time of the incident. Further, the JSAs covering other work on top of the engine did not address the risks involved in accessing the engine top.
What has been done as a result
The ship’s managers, TT-Line Company (TT-Line), reacted proactively to the accident and put in place several engineering and procedural measures to reduce the risk of falls from the engine top and general access risks.
TT‑line has provided a removable work platform for safe access to the top of the engines for both sister ships, Spirit of Tasmania I and II. The JSAs related to work on turbochargers and the exhaust manifold have been updated to include the access risk. The updated JSA also includes a restriction on routine maintenance of critical equipment during short duration port calls, reducing time pressure constraints in case of unforeseen problems.
Additionally, modifications have been made to the bearing housing cover plates, reducing the need for personnel to access the engine top for ad hoc repairs.
Safety message
The ATSB has investigated numerous occurrences involving unsafe working practices on board ships. Many of these resulted in serious or fatal injury(s) due to falls from height, machinery or equipment falling, explosions and other hazardous occurrences. A recurring factor in such incidents is the people involved in the work not recognising the hazards involved and/or they considered the work routine and low risk. In addition, risk assessment and mitigation are often not done or ineffective.
This investigation highlights the importance of effective risk controls, which requires staff at all levels on board and ashore to contribute towards the effective implementation of the shipboard safety management system.
Download the full report: ATSB-MO-2025-002-Spirit-of-Tasmania-1