A second engineer on the Spirit of Tasmania I suffered serious injuries that required surgery after he fell during engine maintenance in March. An investigation revealed that safety management procedures were not properly followed during the incident.
The accident took place on March 6, 2025, while the ship was docked in Geelong, Victoria. The crew was performing a routine oil change on one of the main engine turbochargers when complications arose. They decided to replace the turbocharger's bearing housing cover plate, which meant that crew members had to climb on and off the engine multiple times.
While coming down from the engine, the second engineer fell and injured his knee severely enough that he needed surgery.
The Australian Transport Safety Bureau (ATSB) conducted an investigation and found several major safety issues. Although there should have been regular access to the top of the main engine, no safe route had been established.
“After working on the main engine, the second engineer walked along its rocker covers, and while trying to step over the railing, he slipped and fell,” said Stuart Macleod, Director of Transport Safety at ATSB.
The investigation noted that deciding to replace the bearing housing cover plate significantly altered the original work plan, but the safety protocols were not updated to reflect this change.
“Even with this major change, the Job Safety Analysis was not reviewed, nor did the team complete a new pre-start safety checklist. This was due to perceived time pressure and the belief that the work was low risk. As a result, they did not properly assess the risks of slips and falls associated with the task,” Macleod explained.
The ATSB report indicated that the safety management procedures for Job Safety Analyses on the Spirit of Tasmania I were not effectively applied during the incident.
“This meant that there was no Job Safety Analysis for replacing the main engine turbocharger’s bearing housing cover plate, and the JSAs for other work on the engine did not address the access risks involved,” added Macleod.
After the incident, TT-Line, the ship's management company, took corrective actions, including installing removable work platforms for safer access to the engines on both the Spirit of Tasmania I and its sister ship, the Spirit of Tasmania II. They also updated JSAs related to turbocharger and exhaust manifold work to include access risks.
MacLeod stressed the broader lessons from the investigation, noting that the ATSB has looked into many incidents involving unsafe practices on ships.
“A common factor in these incidents is that the workers do not recognize the hazards or consider the work to be low risk,” he said.
“This investigation underlines the importance of effective risk management, requiring participation from staff both on board and onshore in applying the ship's safety management system effectively,” Macleod concluded.
You can find the full report on the ATSB website.