Recommendations and Safety Advisory Notices

Significant safety issue

While most flag States have laws in place that implement the UNCLOS requirement for a ship's master to render assistance to the crew of another vessel
following a collision, these laws are not being effectively implemented on board all ships.

Safety advisory notice

The Australian Transport Safety Bureau advises that all flag States should consider the safety implications of this safety issue and take action where considered appropriate.

Minor safety issue

The evidence suggests that Class B AIS transmissions may not be reliably detected by watch keepers on board all ships. Therefore, operators of small vessels fitted with Class B AIS units should be aware that they cannot rely on the AIS unit alone to warn ships of their presence.

Safety advisory notice

The Australian Transport Safety Bureau advises that all owners, operators and skippers of small vessels should consider the safety implications of this safety issue and take action where considered appropriate.

Safety issue

The ship's safety management system working aloft procedure was not effectively implemented on board the ship and was not routinely followed when crew members climbed the emergency ladder to assist with the stowage of the cargo crane hook.

ATSB Safety advisory notice

The Australian Transport Safety Bureau advises that ASP Ship Management should consider the safety implications of this safety issue and take action where considered appropriate.

Safety Issue

The ship's health, safety, security and environment meetings and job hazard opportunity log were not effectively used to raise and discuss safety issues associated with cargo crane operations.

ATSB Safety advisory notice

The Australian Transport Safety Bureau advises that ASP Ship Management should consider the safety implications of this safety issue and take action where considered appropriate.

Safety issue

The design of the cradle for the cargo crane hook did not allow for unassisted stowage of the hook when the ship had a stern trim in excess of 2.1 m.

ATSB safety advisory notice

The Australian Transport Safety Bureau advises that Marlow Navigation should consider the safety implications of this safety issue and take action where considered appropriate.

Safety issue

The International Safety Management (ISM) Code requires ship owners to ensure that each ship's master is given all necessary support to fulfil their duties. However, Jevkon Oil and Gas did not provide the necessary support either before the commencement of the delivery voyage or after the ship's crew began having difficulties using the intermediate fuel oil in the main engine and started drifting in the Indian Ocean.

ATSB safety advisory notice

The ATSB advises that Jevkon Oil and Gas should consider the implications of this safety issue and take action where considered appropriate.

Safety issue

The ship's safety management system was inadequate. Had Jevkon Oil and Gas implemented an effective safety management system on board Breakthrough, the risk of an incident such as the one that occurred on the delivery voyage would have been reduced.

ATSB safety advisory notice

The ATSB advises that Jevkon Oil and Gas should consider the implications of this safety issue and take action where considered appropriate.

Safety issue

The ship's certification was issued by a management company to itself on behalf of the Republic of Sierra Leone, solely with the purpose of allowing the ship to sail on an international voyage and did not represent the ship's actual management or that any effective inspections of the ship or audits of the ship's safety management system had taken place.

ATSB safety recommendation

The ATSB recommends that the Sierra Leone International Ship Registry should address this safety issue.

Safety issue

The operation of the ship's systems and the decisions made by the ship's senior officers suggests that they did not have sufficient relevant knowledge and experience to safely undertake Breakthrough's delivery voyage and they did not effectively use the time spent in China, standing by the ship, to acquire the necessary knowledge.

ATSB safety advisory notice

The Australian Transport Safety Bureau advises ship owners, operators and masters should consider the safety implications of this safety issue and take action where considered appropriate.

Safety Issue

Both the 6 hours on/6 hours off work routine for watchkeepers and the modified work routine for deck ratings used on board Thor Gitta, while
complying with the ILO 180 and STCW requirements for rest, probably resulted in a cumulative level of fatigue in the crew.

Response from the Danish Maritime Authority

The Danish Maritime Authority recognises the use of programs like FAID to indicate the possibility of fatigue, but regards the indications given by such programs only as normative and not as given proof.

It is the opinion of the Danish Maritime Authority that the 6 hours on/off work routine for watchkeepers and the modified routine for deck ratings on board Thor Gitta does not constitute a problem as long as the hours of rest are in compliance with the Order, ILO Convention 180 and part A, Chapter VIII of the STCW code for crewmembers engaged in watchkeeping.

The Danish Maritime Authority disagrees with the statements indicating that the roster of the AB and the work routine for watchkeepers probably results in a cumulative level of fatigue in the crew.

Safety recommendation

The Australian Transport Safety Bureau recommends that the Danish Maritime Authority undertake further work to address this safety issue.

The DMA has, in 2008, established a procedure on examination of rest and work hours, as well as outlook whenever a Danish or Greenlandic ship is involved in grounding or collision or has a very serious accident.

In these cases, the Investigation Division gather relevant information and evaluate the information before forwarding them to various departments within the DMA for further consideration. The considerations focus on whether there have been violations of rules in force. Consideration is also focusing on questions in relation to the manning of ships and possible need of changes.

Safety Issue

Saldanha's master and crew were not aware of the appropriate first aid treatment required for burn injuries. As a result, the third engineer was not immediately provided with appropriate first aid.

Safety Advisory Notice

The ATSB advises that flag States, owners, operators and masters should consider the safety implications of this safety issue and take action where considered appropriate.

Safety Issue

While the Volcano Company safety bulletin warned of the dangers associated with servicing the VJ type burner, it did not inform operators that the burner could be replaced with a VJP burner (a similar burner fitted with a diesel pilot burner), or recommend that existing oil firing units could be modified.

Safety Recommendation

The ATSB recommends that the Volcano Company takes safety action to address this safety issue.

Safety Action

The Volcano Company has advised the ATSB that they will;

1. Advise all operators of the occurrence on board the bulk carrier Saldanha.

2. Advise all operators of the importance of adhering to the safety bulletin, regardless of the type of burner, and the fact that if the operation and servicing are not done as per our safety bulletin, ship crews will be exposed to the same risks as those seen on board Saldanha.

3. Advise all operators that the "VJ" burner is  a direct ignition type and that there is also another type of burner "VJP" fitted with pilot burner. If operators wish to have their burner fitted with a pilot burner, Volcano will advise them that the existing burner could be replaced with VJP type burner or that it can be modified.

4. We will also put the same advice on our homepage for a period of time.

Safety issue

Iron King's safety management system did not include procedures that adequately ensured that the ship's master and crew were aware of, and drilled in, the emergency steering system change over procedure to be followed in the event of steering control loss.

Safety Advisory Notice

The Australian Transport Safety Bureau advises that owners, operators and masters should consider the safety implications of this safety issue and take action where considered appropriate.

Safety Issue
The work permit system had not been effectively implemented on board the ship. Consequently, most maintenance and repair work was being carried out by ship's personnel without the work permits and 'Danger: Do Not Operate' tags that were required by the ship's procedures.

Safety Recommendation

ATSB recommends that the Parakou Shipping undertake further action to address this safety issue.

Safety Issue

Northern Fortune's third mate did not contact Allena or take any steps to determine if a collision had occurred and did not inform the ship's master of the incident. Therefore, he disregarded his legal and moral obligations to ensure the safety of the fishing vessel's crew. It is a requirement for flag States to ensure that their ships' masters effectively implement the United Nations Convention of the Laws of the Sea (UNCLOS) requirements to stop and render assistance to those who are in danger of being lost at sea.

Safety Advisory Notice

The Australian Transport Safety Bureau advises that ship operators, ship masters and maritime training institutions should consider the safety implications of this safety issue and to take action where considered appropriate.

The review of the draft report evoked affirmative opinions related to the identified safety factor... The ADOMS IID flag State Chief Casualty Investigator intends to focus attention on the identified safety factor related to article 98 of UNCLOS. He will adequately address this issue to raise awareness and to initiate a brought discussion within the Administration and on all her ships and on the Marine Accident Investigator's International Forum (MAIIF) as well. However, it appears to be of paramount importance as well, that fishing companies and skippers, who operate their small fishing vessels in confined waters with busy commercial traffic, understand that safety may also be a two-way road. It can be a lethal attitude to only rely on the help of others. Fishing industry and coastal authorities within their territorial limits are invited to enforce a proactive safety culture including a professional understanding and adherence of the COLREGS by means of elevated surveillance and advanced relevant legal considerations.

Safety issue

It was not a requirement for Allena to be fitted with either a radar reflector or an Automatic Identification System (AIS) unit. Consequently, the vessel was probably difficult to detect electronically in the prevailing weather conditions.

Safety Advisory Notice

The Australian Transport Safety Bureau advises that fishing vessel owners, operators and skippers should consider the safety implications of this safety issue and takes action where considered appropriate.

Safety issue

The Queensland regulations for fishing vessel certificates of competency are ambiguous and are not consistent with the Uniform Shipping Laws Code (USL Code) or the National Standard for Commercial Vessels (NSCV). The regulations allow a fishing vessel to be operated up to 200 miles from the coast by a skipper who may not have been appropriately trained, experienced or qualified for that operational area.

Safety Recommendation

The Australian Transport Safety Bureau recommends that Maritime Safety Queensland takes action to address this safety issue.

Safety Issue

Atlantic Eagle's safety management system procedures for navigation, aimed at ensuring the ships safe progress and safeguarding against single person errors, had not been effectively implemented on board the ship and were not followed on 15 July 2008.

Safety Recommendation

The Australian Transport Safety Bureau recommends that Atlantic Bulk Carriers Management takes safety action to address this safety issue.

Safety Issue

Atlantic Eagle's safety management system procedures for record keeping had not been effectively implemented on board the ship, were not followed with regard to the grounding and its aftermath and no attempt was made by the ships managers to correct the situation.

Safety Recommendation

The Australian Transport Safety Bureau recommends that Atlantic Bulk Carriers Management takes safety action to address this safety issue.

Safety issue

The ship's safety management system provided no guidance to the master or crew regarding the minimum level of bridge manning during periods of pilotage.

Action taken by Reederei Alnwick Harmstorf MO-2008-006-NSA-017

Reederei Alnwick Harmstorf has advised the Australian Transport Safety Bureau that consideration will be given to addressing this safety issue.

Safety Recommendation

The Australian Transport Safety Bureau recommends that Reederei Alnwick Harmstorf takes action to address this safety issue.