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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: MO-2014-008-SI-04Halon system
Number: MO-2014-008-SI-04
Description: MO-2014-008-SI-04:Marigold’s shipboard procedures for crew induction, familiarisation, fire drills and safety training were not effectively implemented. As a result, the ship’s senior officers were not sufficiently familiar with the Halon system’s operation. They did not identify its partial failure and did not activate the override function
Who it affects: All persons responsible for the maintenance of equipment
Issue owner: Korea Leading Company of Ship Management (KLCSM)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 20 Apr 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-008-SI-03Fixed fire suppression system
Number: MO-2014-008-SI-03
Description: MO-2014-008-SI-03:Marigold’s Halon gas fixed fire suppression system for the engine room was not fully operational. The multiple failures of the system at the time of the fire were not consistent with proper maintenance and testing.  
Who it affects: All persons responsible for the maintenance of equipment
Issue owner: KLCSM
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 20 Apr 2016
Status: Partially addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MO-2014-008-SI-02Ventilation closedown
Number: MO-2014-008-SI-02
Description: MO-2014-008-SI-02:The maintenance of the opening/closing arrangements for Marigold’s engine room fire dampers, ventilators and other openings was inadequate. A number of these could not be closed, resulting in the inability to seal the engine room to contain and suppress the fire.
Who it affects: All persons responsible for the maintenance of equipment
Issue owner: Korea Leading Company of Ship Management (KLCSM)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 20 Apr 2016
Status: Adequately addressed
Issue, description, who it affects
Issue: MO-2014-008-SI-01Fire doors
Number: MO-2014-008-SI-01
Description: MO-2014-008-SI-01:A number of Marigold’s engine room fire doors were held open by wire and/or rope. The open doors allowed the smoke to spread across the engine room and into the accommodation spaces.
Who it affects: All persons responsible for the maintenance of equipment
Issue owner: Korea Leading Company of Ship Management (KLCSM)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 20 Apr 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-012-SI-02 Smoking risk controls
Number: MO-2014-012-SI-02
Description: MO-2014-012-SI-02 :The smoking policy and associated risk controls on board Ocean Drover were not effectively managed. While use of designated smoking rooms was identified as the preferred option, smoking was permitted in cabins. In addition, approved ashtrays were not always used to extinguish and dispose of cigarettes.
Who it affects: All persons responsible for shipboard operations
Issue owner: Korkyra Shipping, Croatia
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 11 Mar 2016
Status: Adequately addressed
Issue, description, who it affects
Issue: MO-2014-012-SI-01 Bridge deck stairwell fire door
Number: MO-2014-012-SI-01
Description: MO-2014-012-SI-01 :Ocean Drover’s bridge deck stairwell fire door was fitted with a holdback hook in contravention of international regulations. The door was hooked open, which allowed the fire to spread to the bridge deck from the deck below. 
Who it affects: All persons responsible for shipboard operations
Issue owner: Korkyra Shipping, Croatia
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 11 Mar 2016
Status: Adequately addressed
Issue, description, who it affects
Issue: MO-2014-011-SI-01 Implementation of SMS procedures
Number: MO-2014-011-SI-01
Description: MO-2014-011-SI-01 :Cape Splendor’s safety management system (SMS) procedures for working over the side of the ship were not effectively implemented. As a result, the ship’s crew routinely did not take all the required safety precautions when working over the side. Further, they did not consider that any such precautions were necessary ...
Who it affects: All persons responsible for shipboard operations
Issue owner: U-Ming Marine Transport, Singapore
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 09 Feb 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-011-NSA-025Safety culture
Number: MO-2014-011-NSA-025
Description: MO-2014-011-NSA-025:The safety culture on board Cape Splendor was not well developed and the ship’s managers had identified it as such. A consequence of this inadequacy was the ineffective implementation of working over the side procedures, including the general belief by its crew that safe work practices applied only when working, ...
Who it affects: All persons responsible for shipboard operations
Issue owner: U-Ming Marine Transport, Singapore
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 09 Feb 2016
Status: Adequately addressed
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2015-010-SI-01Unique indications for E Frame on Network control system screens
Number: RO-2015-010-SI-01
Description: RO-2015-010-SI-01:The ARTC Network Control centre procedures did not address the unique operation of the Singleton E Frame equipment to ensure correct and consistent interpretation of the indications provided on the Phoenix display.
Who it affects: Infrastructure managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 05 Jan 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-003-SI-01Planned and other maintenance
Number: MO-2014-003-SI-01
Description: MO-2014-003-SI-01:The poor condition of Royal Pescadores’ anchoring equipment was indicative of inadequate maintenance. The shipboard management team were not aware of the equipment’s maintenance history nor able to provide relevant documents from the ship’s planned maintenance system. 
Who it affects: All persons charged with maintaining equipment
Issue owner: Shih Wei Navigation
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 13 Oct 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-003-SI-02Bitter end securing arrangement
Number: MO-2014-003-SI-02
Description: MO-2014-003-SI-02:The International Association of Classification Societies (IACS) recommendation for having a means of slipping the anchor cable bitter outside the chain locker had not been provided on board Royal Pescadores. Further, the ship’s classification society, ClassNK, does not consider that the IACS recommended slipping arrangement is necessary for reducing safety ...
Who it affects: All persons responsible for ship and crew safety
Issue owner: Shih Wei Navigation and ClassNK
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 13 Oct 2015
Status: Partially addressed
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2014-003-SI-03Weather related matters
Number: MO-2014-003-SI-03
Description: MO-2014-003-SI-03:While the Fremantle vessel traffic service (VTS) operational procedures were aimed at having precautionary measures in place for adverse weather conditions, the triggers specified in the procedures only referred to BoM-issued severe weather and gale warnings. As no wind speed limits were specified, the gale force winds experienced at Fremantle ...
Who it affects: All ships operating in the Port of Fremantle
Issue owner: Fremantle Port Authority (Fremantle Ports)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 13 Oct 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-006-SI-01Proper lookout
Number: MO-2014-006-SI-01
Description: MO-2014-006-SI-01:Kota Wajar’s safety management system procedures with regard to posting a dedicated lookout were not effectively implemented.
Who it affects: All persons responsible for navigation
Issue owner: Pacific International Lines, Singapore
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 30 Jul 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-006-SI-02Passage planning
Number: MO-2014-006-SI-02
Description: MO-2014-006-SI-02:Brisbane Marine Pilots’ standard passage plan and master-pilot exchange did not ensure that a ship’s bridge team is provided adequate information with respect to local traffic and areas where attention must be paid to other vessels, including small craft.
Who it affects: All persons responsible for navigation
Issue owner: Brisbane Marine Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 30 Jul 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-006-SI-03Collisions between ships and small vessels
Number: MO-2014-006-SI-03
Description: MO-2014-006-SI-03:Over the past 26 years, investigations into 41 collisions between trading ships and small vessels on the Australian coast have identified that not maintaining a proper lookout and taking early avoiding action, in accordance with the collision regulations, has been a consistent and continuing contributor to such collisions.
Who it affects: All persons responsible for navigation
Issue owner: Master, owners, operators and skippers of all vessels
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 30 Jul 2015
Status: Partially addressed
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2014-002-SI-01Lack of visual indication for the resetting of the release segment
Number: MO-2014-002-SI-01
Description: MO-2014-002-SI-01:While the design of the on-load release system allowed the reset position of the hook to be visually confirmed, it did not allow for visual confirmation that the release segment and mechanism had been correctly reset. Consequently, the hook device could appear to be properly reset when it was not.
Who it affects: All ships with this type of on-load release arrangement
Issue owner: Jiangsu Jiaoyan Marine Equipment Company
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 19 May 2015
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: MO-2014-002-SI-02On-load release safety pin
Number: MO-2014-002-SI-02
Description: MO-2014-002-SI-02:An equivalent, alternative arrangement to the safety pin had not been provided to prevent inadvertent tripping of the freefall lifeboat’s on-load release during routine operations, such as inspections and maintenance.
Who it affects: All ships with this type of on-load release arrangement
Issue owner: Jiangsu Jiaoyan Marine Equipment Company
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 19 May 2015
Status: Safety action pending
Type: Proactive Action
  Recommendation
  Proactive Action
  Recommendation
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2014-002-SI-03Simulation wire calculation
Number: MO-2014-002-SI-03
Description: MO-2014-002-SI-03:The manufacturer’s calculations did not take into account the shock load imposed on the simulation wires or the lifeboat and launching frame mounting points.
Who it affects: All ships with this type of launch simulation system
Issue owner: Jiangsu Jiaoyan Marine Equipment Company
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 19 May 2015
Status: Safety action pending
Type: Proactive Action
  Recommendation
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2014-002-SI-04Simulation wire approval by a recognized organization
Number: MO-2014-002-SI-04
Description: MO-2014-002-SI-04:The Recognized Organization’s process for the approval of the simulation wires for ‘maintenance and testing’ had not taken into account the shock loading that would be experienced during testing.
Who it affects: All ships with this type of launch simulation system
Issue owner: Bureau Veritas and the International Association of Classification Societies
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 19 May 2015
Status: Safety action pending
Type: Recommendation
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2014-001-SI-02Manufacturer’s instructions
Number: MO-2014-001-SI-02
Description: MO-2014-001-SI-02:The manufacturer’s instruction manual for Seven Seas Voyager’s waste incinerator contained no specific instructions for ash grate maintenance or replacement. Such instructions would have provided useful information for the ship’s crew to plan and safely complete periodic ash grate maintenance.
Who it affects: All persons charged with maintaining equipment
Issue owner: ISIR Impianti Srl
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 23 Jan 2015
Status: Not addressed
Type: Recommendation
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