Coronial
WAother

Inquest into the Deaths of Shaun Damian Smith, Phillip John Carroll, Megan Anne Pelly, Bradley John Meek

Deceased

Shaun Damian Smith, Phillip John Carroll, Megan Anne Pelly, Bradley John Meek

Demographics

unknown

Date of death

1998-05-05

Finding date

2003-12-19

Cause of death

Acute Smoke Inhalation

AI-generated summary

On 5 May 1998, four Royal Australian Navy personnel—Shaun Damian Smith (29), Phillip John Carroll (23), Megan Anne Pelly (22), and Bradley John Meek (25)—died from acute smoke inhalation in the engine room fire aboard HMAS WESTRALIA. The fire resulted from failure of flexible fuel hoses installed just 36–39.5 hours earlier to replace rigid metal pipes prone to leaking. The hoses failed due to spill pulse pressures they were never designed to withstand. The coroner found multiple systemic failures: the navy used an incorrect TM200 procedure instead of the proper TM187 configuration-change process, bypassing required engineering review; ignored manufacturer warnings about spill pulse pressures; failed to comply with Lloyd's Register certification requirements; inadequately supervised the contractor (ADI); and appointed personnel lacking sufficient technical qualifications. The contractor ADI failed to monitor its subcontractor and installed hoses that were not those specified and not Lloyd's-approved. The coroner emphasised that no engineering assessment was conducted before installing these hazardous modifications near an exposed indicator cock capable of reaching ignition temperature. The fire was entirely preventable had correct procedures and proper engineering oversight been followed.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Error types

proceduralsystemcommunicationdiagnostic

Contributing factors

  • Failure of flexible fuel hoses due to spill pulse pressure fatigue
  • Installation of hoses without engineering assessment
  • Use of incorrect TM200 maintenance procedure instead of required TM187 configuration-change process
  • Failure to comply with Lloyd's Register certification requirements
  • Inadequate naval supervision of contractor ADI
  • Inadequate technical qualifications of contract manager (Warrant Officer Jones) and technical specialist (Mr Morland)
  • Contractor ADI failed to monitor subcontractor Enzed adequately
  • Wrong hoses supplied and installed (SST-12 instead of Parflex 919 TFE)
  • Ignition source: exposed unlagged indicator cock near failed hose at extremely elevated temperature

Coroner's recommendations

  1. In future outsourced maintenance and refit contracts, there should be a suitably qualified superintendent representing the navy with sufficient engineering knowledge to identify safety issues and knowledge of applicable classification requirements to adequately monitor and supervise the contract
  2. The Commander, Chief Engineer and Deputy Chief Engineer of a ship subject to an outsourced maintenance and refit contract should have sufficient knowledge of the working of their ship and of any applicable classification requirements to provide meaningful input into the navy's contract supervision
  3. The Royal Australian Navy should ensure correct navy procedures for configuration changes are adopted in every case
  4. The navy should conduct ongoing and regular monitoring of configuration change processes to ensure changes can be made within reasonable timeframes with adequate safety assessment
  5. The Royal Australian Navy should consider implementing a mandatory handover/training period for senior officers (Commanding Officer, Chief Engineer, Deputy Chief Engineer) aboard oil tankers before taking up their postings, aligned with merchant shipping and RFA best practices
  6. The navy should review its training systems to ensure personnel on classification-required vessels are familiar with relevant classification society requirements
  7. Procedures for contract management within the defence force should continue to be reviewed, with the Defence Material Organisation maintaining specific focus on managing defence contracts
  8. Lloyd's Rules and Regulations should be kept at the Ordering Authority offices and on the ship, and navy personnel involved in contract processes should receive adequate basic training on certification requirements
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