The inquiry by the Australian Transport Safety Bureau (ATSB) also discovered the ship’s safety features were not fully operational and effective and that emergency services had difficulties finding the location of the accident at the Port of Portland.

The incident occurred on board the Toucan Arrow on October 7 last year when the ship’s assistant electrician was “crushed between the ship’s aft gantry crane and a cargo hold hatch lid”, the ATSB report said.

“There were no witnesses to the accident (and) the investigation was unable to determine exactly what the assistant electrician was doing at the time of the accident,” the report stated, but added it was believed the crew member was replacing a faulty warning light that would have notified him of the danger he was in if it had been working properly.

“The ATSB found that the crew member did not comply with the ship’s safe working procedures and did not ensure that the crane driver was advised ... before he began working in the vicinity of the crane.

“The investigation also found that the audible and visual crane-in-motion warning devices were not fully operational and effective. 

“The ATSB further found that there was a lack of mapping information available to assist the emergency services ‘triple zero’ operator in providing the emergency responders with directions to a defined location within the port area. 

“It was also found that the ambulance service had not ensured that its officers were familiar with the port area and the protocols for opening the locked port access gates.”

The bureau’s report also revealed that the assistant electrician’s crew mates administered first aid and that he “was conscious, able to ask for water and was not complaining of any pain” but died as a result of his injuries at the Portland hospital within an hour of the accident.