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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: MO-2014-009-SI-01Fremantle Ports’ risk assessment
Number: MO-2014-009-SI-01
Description: MO-2014-009-SI-01:Fremantle Ports’ assessment of risks associated with a ship contacting the Fremantle Rail Bridge as a result of a breakaway, particularly from berths 11 and 12, was limited. Preventing a breakaway from berths where the wind was likely to be on a ship’s beam had not been considered. Similarly, the ...
Who it affects: All users of Fremantle’s Inner Harbour, including the Fremantle Rail Bridge
Issue owner: Fremantle Port Authority (Fremantle Ports)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 04 May 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-008-SI-09Ship firefighting cache
Number: MO-2014-008-SI-09
Description: MO-2014-008-SI-09:The large size and weight of the ship firefighting cache made it difficult for the duty Port Hedland volunteer firefighter to transport it to the wharf. 
Who it affects: All agencies charged with shipboard firefighting
Issue owner: Department of Fire and Emergency Services (DFES)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 20 Apr 2016
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: MO-2014-008-SI-08Professional firefighters in Port Hedland
Number: MO-2014-008-SI-08
Description: MO-2014-008-SI-08:The limited professional firefighting capability in Port Hedland restricted the ability to launch an effective response to the fire on board Marigold.   
Who it affects: All agencies charged with shipboard firefighting
Issue owner: Department of Fire and Emergency Services (DFES)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 20 Apr 2016
Status: Not addressed
Type: Recommendation
Issue, description, who it affects
Issue: MO-2014-008-SI-07Access control
Number: MO-2014-008-SI-07
Description: MO-2014-008-SI-07:Suitable atmospheric testing equipment was not available in Port Hedland to ensure safe entry to fire-affected spaces on board Marigold. Access to these areas was not controlled until 53 hours after the fire.  
Who it affects: All agencies charged with shipboard firefighting in regional ports
Issue owner: DFES
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 20 Apr 2016
Status: Not addressed
Issue, description, who it affects
Issue: MO-2014-008-SI-06Incident control
Number: MO-2014-008-SI-06
Description: MO-2014-008-SI-06:The emergency response plans for a ship fire in Port Hedland did not clearly define transfer of control procedures for successive incident controllers from different organisations or contain standard checklists for their use. 
Who it affects: All agencies charged with shipboard firefighting
Issue owner: BHP Billiton, Pilbara Ports Authority and Department of Fire and Emergency Services (DFES)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 20 Apr 2016
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MO-2014-008-SI-05International shore connection
Number: MO-2014-008-SI-05
Description: MO-2014-008-SI-05:Port Hedland’s emergency response teams did not use the ship’s international shore fire connection. As a result, Marigold’s fire main was not pressurised with water from ashore.
Who it affects: All persons charged with shipboard firefighting
Issue owner: BHP Billiton and Department of Fire and Emergency Services (DFES)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 20 Apr 2016
Status: Partially addressed
Type: Recommendation
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
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