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A 20-year-old engineer cadet died from severe head injuries after falling seven metres while working in a ship's engine room, according to an Australian Transport Safety Bureau (ATSB) investigation report released today.

The ATSB report into the incident states that, at about 0920 (local time) on 16 May 2005, the engineer cadet on board the South Korean bulk carrier Golden Bell was working with other engine room staff when he fell through an open section of deck grating. The cadet landed seven metres below, on the engine room's bottom deck plates. He suffered severe head and internal injuries.

The cadet had apparently failed to see that a section of deck grating had been removed, in order to facilitate the placement of a ladder. The opening was not physically guarded in any way and only had an inappropriately placed sign to warn engine room staff of the danger that existed.

The ship was at anchor of the Western Australian port of Dampier when the incident occurred.

The cadet was evacuated by helicopter to the Nickol Bay Hospital in Karratha (20 km from Dampier), and despite the efforts of medical staff at the hospital, he died later that afternoon.

The report concludes that the open section of grating was not roped off or otherwise protected, and the danger sign was poorly sited and manifestly inadequate. Additionally, the ship's operating procedures did not specify that any open areas of deck grating should be roped off or otherwise protected.

The report's recommendations include that ship owners, managers and masters should revise operational procedures to reflect the need to ensure that open deck areas on board their ships are adequately safeguarded.

Copies of the report can be downloaded from the ATSB's internet site at www.atsb.gov.au.