SIMIC

Some 550 corroded or worn lashing plates needed replacement inspectors found, along with "significant amounts of deck steelwork and structures." This included wasted steel in locations where containers had been lost over the side, said the report.

"Some of the lashing plates were reduced to less than five millimetres effective cross-sectional thickness from the original 25 milliemeres plate," said the ATSB.

"Our investigators found this condition would have taken several years of poor maintenance to develop. This showed the ship had not received the scrutiny from crewmembers, shore management, or other agencies that a ship of its age or condition required," said ATSB chief Angus Mitchell.

On May 11, 2020, the APL England left Ningbo, bound for Australia. She was partially laden with 3,161 TEU. Before departure, the master and chief mate ran the numbers on the ship's load computer and found that the ship had nine lashing force exceedances. Since the vessel's changing ballast and fuel condition would reduce these numbers to an acceptable range during the voyage, they carried on without making any changes.

On May 22, as she neared Australian waters, a weather system began to develop off New South Wales, generating swells of about 15-20 feet. On the morning of the 23rd, as APL England passed off the coast of Port Macquarie, the weather deteriorated and the master reduced speed to seven knots to reduce rolling. All lashings were checked by the crew.

That night, winds increased to about 45 knots and waves to about 18-25 feet. The ship rolled heavily for hours, enough to wake up sleeping crewmen and set off engine room alarms.

At about 6 in the morning, the ship rolled through about 25 degrees each side. The rolling continued, and it was so severe that the main engine lost lube oil suction and shut down automatically due to loss of oil pressure.

The conditions were bad enough that the master and chief mate opted to turn around and head north, with the weather. As dawn broke, the mate noticed that a stack of boxes had toppled aft of the accommodations block and another forward of the wheelhouse.