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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: MO-2016-007-SI-01Steering gear planned maintenance instructions
Number: MO-2016-007-SI-01
Description: MO-2016-007-SI-01:Bow Singapore’s planned maintenance system for the steering gear did not include or contain any schedules for detailed inspections or parts replacement.
Who it affects: All workers on ships managed by Odfjell Management
Issue owner: Odfjell Management
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 05 Oct 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2016-001-SI-03Mooring at Station Pier
Number: MO-2016-001-SI-03
Description: MO-2016-001-SI-03:While TT-Line Company’s standard mooring line pattern for ships at Station Pier had been successfully used for many years, the breakaway indicated the risk could have been further reduced to better prepare for such unusual circumstances.
Who it affects: All ship masters and deck officers
Issue owner: TT-Line Company
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 11 May 2017
Status: Partially addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MO-2016-001-SI-02Melbourne vessel traffic service procedures
Number: MO-2016-001-SI-02
Description: MO-2016-001-SI-02:The Port of Melbourne vessel traffic service (VTS) procedures for adverse weather were not comprehensive and, hence, its response on 13 January was only partially effective. One important consequence was that VTS’s advance warning of storm force winds did not reach all relevant parties, including Spirit of Tasmania II’s master.
Who it affects: Port of Melbourne vessel traffic service and all users of the port
Issue owner: Victorian Ports Corporation (Melbourne)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 11 May 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2016-001-SI-01TT-Line Company procedures
Number: MO-2016-001-SI-01
Description: MO-2016-001-SI-01:The adverse weather procedures for TT-Line Company ships when alongside did not take into account all the necessary factors to provide effective defences against significant, short-term weather events such as thunderstorms and squalls.
Who it affects: All ship masters and deck officers
Issue owner: TT-Line Company
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 11 May 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-005-SI-03Open stern offshore support vessels
Number: MO-2015-005-SI-03
Description: MO-2015-005-SI-03:Skandi Pacific’s managers had not adequately assessed the risks associated with working on the aft deck of vessels with open sterns, including consideration of engineering controls to minimise water being shipped on the aft deck.
Who it affects: All owners and operators of offshore support vessels
Issue owner: DOF Management, Norway
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 23 Nov 2016
Status: Partially addressed
Type: Proactive Action
  Recommendation
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2015-005-SI-02Cargo securing procedures
Number: MO-2015-005-SI-02
Description: MO-2015-005-SI-02:Skandi Pacific’s safety management system (SMS) procedures for cargo securing were inadequate. There was no guidance for methods of securing cargo in adverse weather conditions.
Who it affects: All owners and operators of offshore support vessels
Issue owner: DOF Management, Norway
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 23 Nov 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-005-SI-01Cargo handling procedures
Number: MO-2015-005-SI-01
Description: MO-2015-005-SI-01:Skandi Pacific’s safety management system (SMS) procedures for cargo handling in adverse weather conditions were inadequate. Clearly defined weather limits when cargo handling operations could be undertaken and trigger points for suspending operations were not defined, including limits for excessive water on deck.
Who it affects: All owners and operators of offshore support vessels
Issue owner: DOF Management, Norway (DOF Management)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 23 Nov 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-002-SI-04 Towage procedures
Number: MO-2015-002-SI-04
Description: MO-2015-002-SI-04 :Procedures for harbour tugs to meet inbound ships and for their co-ordinated movement in the Fremantle pilotage area were not clearly defined. On 28 February, inadequate co-ordination of the tugs and ineffective communication between Maersk Garonne’s pilot and the tug masters resulted in both tugs, the second one in particular, ...
Who it affects: All those responsible for navigation
Issue owner: Svitzer Australia; Fremantle Ports; Fremantle Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 17 Oct 2016
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: MO-2015-002-SI-03 Contingency planning
Number: MO-2015-002-SI-03
Description: MO-2015-002-SI-03 :Fremantle Pilots’ procedures did not include any contingency plans, including abort points, for risks identified for the pilotage. 
Who it affects: All those responsible for a ship’s safe navigation
Issue owner: Fremantle Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 17 Oct 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-002-SI-02 Passage plan
Number: MO-2015-002-SI-02
Description: MO-2015-002-SI-02 :Fremantle Pilots’ publicly available information to assist ships' masters with preparing a berth to berth passage plan was inadequate and ineffectively implemented. The information provided consisted essentially of a list of waypoints, which was routinely not followed.  
Who it affects: All those responsible for a ship’s safe navigation
Issue owner: Fremantle Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 17 Oct 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-002-SI-01 Bridge resource management
Number: MO-2015-002-SI-01
Description: MO-2015-002-SI-01 :Bridge resource management (BRM) was not effectively implemented on board Maersk Garonne. The ship’s passage plan for the pilotage was inadequate, its bridge team members were not actively engaged in the pilotage and they did not effectively monitor the ship’s passage.
Who it affects: All those responsible for navigation
Issue owner: Maersk Line Ship Management, Singapore
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 17 Oct 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-009-SI-04Forecast terminology
Number: MO-2014-009-SI-04
Description: MO-2014-009-SI-04:Fremantle Ports’ staff did not understand the significance of some wind and weather terminology used in the BoM forecast. Consequently, port procedures triggered by a BoM ‘gale’ or ‘severe weather’ warning such as preparing the tugs and calling the harbour master were not followed.
Who it affects: Port and ship operators
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-2014-009-SI-03Weather event management
Number: MO-2014-009-SI-03
Description: MO-2014-009-SI-03:Fremantle Ports’ procedures for adverse weather were not adequate for weather that could reasonably be expected to occur. Some procedures could not be reasonably implemented and other were not monitored for compliance.
Who it affects: All ships berthed in Fremantle’s Inner Harbour
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-2014-009-SI-02Bureau of Meteorology weather warnings
Number: MO-2014-009-SI-02
Description: MO-2014-009-SI-02:The Bureau of Meteorology (BoM) marine forecast title of ‘strong wind warning’ understated the ‘damaging winds’ expected during the ‘severe thunderstorm’. The forecast did not use recognised marine weather terms for wind speed, such as ‘gale force’.
Who it affects: Port, boat and ship operators in Australian coastal waters
Issue owner: Bureau of Meteorology (BoM)
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-2014-009-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
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
Issue, description, who it affects
Issue: MO-2013-012-SI-01Planned maintenance
Number: MO-2013-012-SI-01
Description: MO-2013-012-SI-01:HC Rubina’s electronic planned maintenance system did not contain any instructions to ensure that the shaft alternator flexible coupling was maintained in accordance with the manufacturer’s requirements.
Who it affects: All ships
Issue owner: IMM Shipping
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 14 Nov 2014
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: MO-2013-012-SI-02Defect reporting
Number: MO-2013-012-SI-02
Description: MO-2013-012-SI-02:The ship’s managers did not have effective systems to ensure that the defective control system for the controllable pitch propeller was reported to the relevant organisations as required. Consequently, Brisbane’s vessel traffic services, pilotage provider and the pilot remained unaware of the defect and could not consider it in their risk ...
Who it affects: All ships
Issue owner: IMM Shipping
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 14 Nov 2014
Status: Partially addressed
Type: Recommendation
Issue, description, who it affects
Issue: MO-2013-012-SI-03Port entry procedures – Defect notification
Number: MO-2013-012-SI-03
Description: MO-2013-012-SI-03:The ship’s agent’s information questionnaire did not ask for all of the information required to complete the QSHIPS booking form and ensure that defects were reported.
Who it affects: Port operations and vessel’s under pilotage
Issue owner: Asiaworld Shipping Services and Maritime Safety Queensland
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 14 Nov 2014
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: MO-2013-011-SI-01Roles and Responsibilities
Number: MO-2013-011-SI-01
Description: MO-2013-011-SI-01:Bosphorus’ safety management system provided no guidance in relation to the allocation of function based roles and responsibilities to members of the bridge team during pilotage.
Who it affects: All persons charged with navigating a vessel during pilotage
Issue owner: Universal Shipping
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 22 Sep 2014
Status: Not addressed
Type: Recommendation
Issue, description, who it affects
Issue: High risk areas of pilotage MO-2013-011-SI-02
Number: High risk areas of pilotage
Description: High risk areas of pilotage :Brisbane Marine Pilots’ ‘Port of Brisbane Passage Plan’ did not detail any guidance or instructions relating to watch handover or changing the helmsman during high risk areas of a pilotage.
Who it affects: All persons charged with navigating a vessel during pilotage
Issue owner: Brisbane Marine Pilots
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 22 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2013-011-SI-03High risk areas of pilotage
Number: MO-2013-011-SI-03
Description: MO-2013-011-SI-03:Bosphorus’ safety management system did not detail any guidance or instructions relating to watch handover or changing the helmsman during high risk areas of a pilotage.
Who it affects: All persons charged with navigating a vessel during pilotage
Issue owner: Universal Shipping
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 22 Sep 2014
Status: Not addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MO-2013-010-SI-01Crane warning devices
Number: MO-2013-010-SI-01
Description: MO-2013-010-SI-01:The gantry crane in motion warning light nearest to the assistant electrician’s location was not operating and the warning sirens were not audible from his location. As a result, he was not provided with either a visual or audible warning of the crane’s movement.
Who it affects: All ship owners, operators and seafarers
Issue owner: Gearbulk Norway
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 16 Jun 2014
Status: Adequately addressed
Issue, description, who it affects
Issue: MO-2013-010-SI-02Crew familiarisation
Number: MO-2013-010-SI-02
Description: MO-2013-010-SI-02:The on board familiarisation process did not ensure that new crew members were informed of the precautions required when working on deck while the gantry cranes were in operation.
Who it affects: All ship owners, operators and seafarers
Issue owner: Gearbulk Norway
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 16 Jun 2014
Status: Adequately addressed
Issue, description, who it affects
Issue: MO-2013-010-SI-03Emergency response
Number: MO-2013-010-SI-03
Description: MO-2013-010-SI-03:There was a lack of mapping information available to assist the ‘triple zero’ operator in providing the emergency responders with directions to a defined location within the port area.
Who it affects: Emergency service agencies
Issue owner: Port of Portland and the Emergency Services Telecommunications Authority
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 16 Jun 2014
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: MO-2013-003-SI-01Safety Management System
Number: MO-2013-003-SI-01
Description: MO-2013-003-SI-01:Calliope’s safety management system (SMS) did not provide the crew with adequate guidance regarding passage planning, training and familiarisation. Individual crew familiarisation records and risk assessment forms were not retained on board the yacht and there was no system of auditing or checking to ensure the adequacy of the SMS ...
Who it affects: All persons charged with navigating a vessel at sea
Issue owner: Marine Construction Management and the Cayman Islands Shipping Registry
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 12 May 2014
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: MO-2013-003-SI-002Large yacht regulatory requirements
Number: MO-2013-003-SI-002
Description: MO-2013-003-SI-002:The Cayman Islands requirements in relation to a yacht’s compliance with the Large Commercial Yacht Code and other relevant legislation are determined by the yacht’s mode of operation. As a result, a commercially operated yacht in excess of 24 m in length must comply with the requirements of the Code ...
Who it affects: All persons charged with navigating a vessel at sea
Issue owner: Cayman Islands Shipping Registry
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 12 May 2014
Status: Not addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MO-2013-003-SI-003Sydney Harbour pilotage requirements
Number: MO-2013-003-SI-003
Description: MO-2013-003-SI-003:Calliope was not required to carry a pilot during Sydney Harbour voyages because the yacht was considered to be a recreational vessel, even though the risks it posed to the port were the same as those posed by similarly sized commercially operated vessels.
Who it affects: All persons charged with navigating a vessel at sea
Issue owner: Sydney Ports Corporation
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 12 May 2014
Status: Not addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MO-2013-007-SI-01Risk assessment
Number: MO-2013-007-SI-01
Description: MO-2013-007-SI-01:Atlantic Princess’s safety management system provided no guidance relating to actions that should be taken when persons less experienced than a pilot used a pilot ladder to board or disembark the ship.
Who it affects: All masters owners and operators of ships
Issue owner: Santoku Senpaku
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 09 May 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2013-007-SI-02Safe means of access
Number: MO-2013-007-SI-02
Description: MO-2013-007-SI-02:There were no facilities on board the Floating Offshore Transfer Barge Spencer Gulf that could be used to provide a safe means of access for personnel transfers between the barge and the ship. Furthermore, the barge operator’s procedures prohibited such personnel transfers.
Who it affects: Owners and operators of ports and offshore loading facilities
Issue owner: CSL Australia
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 09 May 2014
Status: Not addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MO-2013-007-SI-03Safety management system compliance
Number: MO-2013-007-SI-03
Description: MO-2013-007-SI-03:The examples of non-compliance with the requirements of Whyalla Launch Services’ safety management system indicate that the system was not fully and effectively implemented on board Switcher.
Who it affects: All masters, owners and operators of ships and small vessels
Issue owner: Whyalla Launch Services
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 09 May 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2013-007-SI-05Safety management system guidance
Number: MO-2013-007-SI-05
Description: MO-2013-007-SI-05:Whyalla Launch Services’ safety management system did not provide effective guidance in relation to assessing a passenger’s ability to climb a pilot ladder or positioning of pilot launches while passengers were climbing and descending ladders. The system also referenced superseded SOLAS regulations and IMO resolutions relating to pilot ladders.
Who it affects: All masters owners and operators of ships and small vessels
Issue owner: Whyalla Launch Services
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 09 May 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2013-008-SI-01Visual and manual checking of ladder and manropes by pilots
Number: MO-2013-008-SI-01
Description: MO-2013-008-SI-01:The pilotage company’s procedures did not explicitly require the pilot to check the pilot ladder and manrope arrangements before disembarking the ship.
Who it affects: Pilotage companies
Issue owner: Australian Reef Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 20 Mar 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2013-008-SI-02Communication of readiness for pilot disembarkation
Number: MO-2013-008-SI-02
Description: MO-2013-008-SI-02:The pilotage company’s procedures for positive communication of readiness between the pilot and the launch crew were adequate. However, it was common for employees to vary these communication protocols, leaving perceptions of readiness open to error and misinterpretation.
Who it affects: Pilotage companies
Issue owner: Australian Reef Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 20 Mar 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2013-008-SI-03Use of a deck party to assist with the pilot transfer
Number: MO-2013-008-SI-03
Description: MO-2013-008-SI-03:The ship’s pilot transfer procedures did not specify a requirement for additional crew members to assist the supervising officer. As a result, the supervising officer was actively involved in deploying the pilot ladder and manropes, and transferring the pilot’s belongings to the launch, and could not focus his efforts on ...
Who it affects: Owners and operators of ships employing coastal pilots.
Issue owner: Dorval Ship Management
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 20 Mar 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2013-008-SI-04Communication of requirements for manropes
Number: MO-2013-008-SI-04
Description: MO-2013-008-SI-04:The pilotage company’s procedures did not require pilots to inform launch crews whether manropes would or would not be deployed in advance of the transfer.
Who it affects: Pilotage companies
Issue owner: Australian Reef Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 20 Mar 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2013-008-SI-05Securing of manropes to the deck
Number: MO-2013-008-SI-05
Description: MO-2013-008-SI-05:The ship’s pilot transfer procedures had not been revised to incorporate the most recent SOLAS requirements that manropes be secured at the rope end to a ring plate fixed to the deck.
Who it affects: Owners and operators of ships employing coastal pilots.
Issue owner: Dorval Ship Management
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 20 Mar 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2013-005-SI-01Condensate drainage pot design
Number: MO-2013-005-SI-01
Description: MO-2013-005-SI-01:The condensate drainage pots fitted to Nireas’ main air receivers were not fit for purpose as they were not capable of withstanding the internal pressures that were likely to accumulate in service.
Who it affects: Regulators, classification societies, masters, owners and operators of ships
Issue owner: Laskaridis Shipping / Jiangsu Jinling Shipyard / Lloyds Register / Australian Maritime Safety Authority
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 04 Mar 2014
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
  Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2012-006-SI-01Failure to keep a proper lookout
Number: MO-2012-006-SI-01
Description: MO-2012-006-SI-01:In the past 25 years the ATSB and its predecessor have investigated 39 collisions between trading ships and smaller vessels on the Australian coast. These investigations have all concluded that there was a failure of the watchkeepers on board one or both vessels to keep a proper lookout and that ...
Who it affects: Watchkeepers
Issue owner: Fukujin Kisen and all other operators
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 12 Dec 2013
Status: Adequately addressed
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2012-005-SI-01On board planned maintenance system
Number: MO-2012-005-SI-01
Description: MO-2012-005-SI-01:The ship’s planned maintenance system did not include all of the main engine manufacturer’s maintenance requirements. Furthermore, the maintenance records did not include sufficient detail to confirm that the main engine was maintained in accordance with the manufacturer’s requirements.
Who it affects: Shipboard maintenance management
Issue owner: ID Wallem Ship Management
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 22 Aug 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2012-005-SI-02Class requirements
Number: MO-2012-005-SI-02
Description: MO-2012-005-SI-02:ClassNK did not have in place a system which ensured that updated service advice from the engine manufacturer was being implemented on board ships with engines which its surveyors were routinely and regularly surveying.
Who it affects: Ship and machinery inspection and survey, shipboard maintenance management
Issue owner: ClassNK (Nippon Kaiji Kyokai)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 22 Aug 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2012-010-SI-03Stevedore working hours and fatigue
Number: MO-2012-010-SI-03
Description: MO-2012-010-SI-03:The stevedoring company had not identified stevedore fatigue as a risk to the company or its operations and, as a result, had not implemented a system to manage fatigue. Consequently, its operations were exposed to a level of fatigue-related risk that had not been assessed and treated.
Who it affects: All stevedoring companies and their employees
Issue owner: Newcastle Stevedores
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 04 Jun 2013
Status: Adequately addressed
Type: Recommendation
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2012-010-SI-02Aluminium ingot loading procedures
Number: MO-2012-010-SI-02
Description: MO-2012-010-SI-02:While the risk of aluminium ingot stacks toppling over had been identified by the stevedoring company as a result of past incidents, its procedure for loading aluminium products had not evolved to adequately address this risk. Furthermore, the implementation of basic precautions such as using ladders to climb between ingot ...
Who it affects: All stevedoring companies and their employees
Issue owner: Newcastle Stevedores
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 04 Jun 2013
Status: Adequately addressed
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2012-010-SI-01Stability of aluminium ingot lifts
Number: MO-2012-010-SI-01
Description: MO-2012-010-SI-01:The aluminium ingot lifts in Newcastle, comprising multiple stacks of ingot packs strapped together, with an effective height to width ratio of 5:1 were inherently unstable. Furthermore, handling and stowage of ingot lifts involved the risk of a lift being disturbed and one or more of its packs falling or ...
Who it affects: Cargo handling companies and their employees
Issue owner: Patrick Ports and Stevedoring (Patrick) and Gearbulk Norway (Gearbulk)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 04 Jun 2013
Status: Partially addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: MO-2012-001-SI-03Risk assessment for the inner moorings
Number: MO-2012-001-SI-03
Description: MO-2012-001-SI-03:A risk assessment for mooring a ship at the inner moorings had never been undertaken. As a result, the risks associated with leaving a ship at the inner moorings overnight during the swell season were not properly identified and strategies to minimise those risks were not implemented.
Who it affects: Ships berthed at the inner moorings at Christmas Island
Issue owner: Patrick
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 23 May 2013
Status: Adequately addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MO-2012-001-SI-04Guidance for masters of ships berthed at the inner moorings
Number: MO-2012-001-SI-04
Description: MO-2012-001-SI-04:While the pilot provided limited advice to masters of ships visiting Christmas Island, the port operator did not provide the master of ships intending to berth using the buoys in Flying Fish Cove with any written or verbal guidance regarding berthing and unberthing arrangements and emergency contingencies.
Who it affects: Ships berthed at the inner moorings at Christmas Island
Issue owner: Patrick
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 23 May 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2012-001-SI-02Joining shackle locking pin effectiveness
Number: MO-2012-001-SI-02
Description: MO-2012-001-SI-02:The port operator was aware that the type of locking pin arrangement on the cantilever line joining shackle was not effective in preventing the shackle’s pin from working its way free. However, the operator had not implemented a program of replacing the shackles in the entire mooring system in Flying ...
Who it affects: Ships berthed at the inner moorings at Christmas Island
Issue owner: Patrick
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 23 May 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2012-001-SI-01Inspection of the mooring system in Flying Fish Cove
Number: MO-2012-001-SI-01
Description: MO-2012-001-SI-01:The port operator had not implemented an effective planned inspection and maintenance program for the mooring system in Flying Fish Cove. Consequently, it had been 18 months since the underwater components of the cantilever line had been inspected.
Who it affects: Ships berthed at the inner moorings at Christmas Island
Issue owner: Patrick
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 23 May 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-011-SI-01Bowen Tug and Barge safety management system adequacy
Number: MO-2011-011-SI-01
Description: MO-2011-011-SI-01:Bowen Tug and Barge’s safety management system guidance for barge storing operations did not designate roles or responsibilities to specific individuals and a system for communicating with the ship’s crew was not discussed and established.
Who it affects: All ship storing companies
Issue owner: Bowen Tug and Barge
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 07 Mar 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-011-SI-02Bowen Tug and Barge compliance auditing
Number: MO-2011-011-SI-02
Description: MO-2011-011-SI-02:Bowen Tug and Barge did not have an effective compliance auditing process in place to ensure that its employees were following the training they had received and the guidance contained in the safety management system documentation.
Who it affects: Bowen Tug and Barge
Issue owner: Bowen Tug and Barge
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 07 Mar 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-011-SI-03BP Shipping compliance auditing
Number: MO-2011-011-SI-03
Description: MO-2011-011-SI-03:Compliance auditing on board British Beech had not identified that requirements of the job hazard analysis were not being followed by the crew during the storing operations.
Who it affects: BP Shipping and all ship’s crew members
Issue owner: BP Shipping Ltd
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 07 Mar 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-011-SI-04Bowen Tug and Barge incident reporting
Number: MO-2011-011-SI-04
Description: MO-2011-011-SI-04:The lack of any record of incident reporting by Bowen Tug and Barge, and its employees, indicates an ineffective reporting culture within the company. Hence, the opportunity to learn from previous incidents was lost.
Who it affects: Bowen Tug and Barge
Issue owner: Bowen Tug and Barge
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 07 Mar 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-011-SI-05Bowen Tug and Barge stores container handling
Number: MO-2011-011-SI-05
Description: MO-2011-011-SI-05:Bowen Tug and Barge had identified the need to spread the slings when lifting a stores container. However, there was no process in place to ensure that ships' crews were advised of this to ensure its safe return from the ship.
Who it affects: All ship’s stores handling organisations
Issue owner: Bowen Tug and Barge
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 07 Mar 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-005-SI-01SMS procedures for quick release of hook
Number: MO-2011-005-SI-01
Description: MO-2011-005-SI-01:Adonis’s safety management system did not contain any procedure or guidance in regard to the use and correct setting of the tug’s towing hook quick release arrangements.
Who it affects: All ship owners, operators and managers
Issue owner: Sea Swift, Cairns
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 08 Feb 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-005-SI-02Two tug requirement
Number: MO-2011-005-SI-02
Description: MO-2011-005-SI-02:The requirement in Sea Swift’s Marine Execution Plan to let Adonis go after clearing the Clinton coal wharves was ambiguous and this led to the crews of Adonis and Wolli misinterpreting the requirement.
Who it affects: All ship owners, operators and managers
Issue owner: Sea Swift, Cairns
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 08 Feb 2013
Status: Not addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-005-SI-03Towing hook locking pin positioning
Number: MO-2011-005-SI-03
Description: MO-2011-005-SI-03:The location of the towing hook ‘locking’ pin on the upper part of the quick release lever meant that if the pin was not properly in its ‘unlocked’ slot, it could fall into the locking hole, thereby locking the release lever.
Who it affects: All ship owners, operators and managers
Issue owner: Mampaey Offshore Industries, The Netherlands
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 08 Feb 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-010-SI-01Procedure for work over the side
Number: MO-2011-010-SI-01
Description: MO-2011-010-SI-01:MSC Siena’s safety management system procedure for working over the side required that a risk assessment be carried out, and necessary checks and precautions documented in a work permit. However, the procedure had not been effectively implemented on board the ship.
Who it affects: Allseas Marine ships’ crews
Issue owner: Allseas Marine, Greece
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 05 Feb 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-010-SI-02Permit to work
Number: MO-2011-010-SI-02
Description: MO-2011-010-SI-02:MSC Siena’s permit to work over the side and the associated procedure required that the ship not be underway when working over the side. However, this requirement could not be complied with when working over the side to rig a combination pilot ladder.
Who it affects: Allseas Marine ships’ crews
Issue owner: Allseas Marine, Greece
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 05 Feb 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MI-2010-011-SI-01Marine Orders Part 54
Number: MI-2010-011-SI-01
Description: MI-2010-011-SI-01:The safety framework prescribed by successive issues of Marine Orders Part 54 (MO 54) has not assigned the responsibility for the overall management of the safety risks associated with coastal pilotage operations to pilotage providers or any other organisation.
Who it affects: All ship operators, masters, pilots and pilotage providers
Issue owner: Australian Maritime Safety Authority
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 24 Oct 2012
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: MI-2010-011-SI-04Risk event and incident reporting
Number: MI-2010-011-SI-04
Description: MI-2010-011-SI-04:Risk identification and mitigation in coastal pilotage operations is inadequate as a result of the under-reporting of risk events and incidents by pilots.
Who it affects: All ship operators, masters, pilots and pilotage providers
Issue owner: Australian Maritime Safety Authority, Australian Reef Pilots, Hydro Pilots and Torres Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 24 Oct 2012
Status: Partially addressed
Type: Proactive Action
  Proactive Action
  Recommendation
  Proactive Action
  Recommendation
  Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MI-2010-011-SI-02Pilot training and professional development
Number: MI-2010-011-SI-02
Description: MI-2010-011-SI-02:The coastal pilot training program and ongoing professional development is inadequate.
Who it affects: All ship operators, masters, pilots and pilotage providers Safety
Issue owner: Australian Maritime Safety Authority
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 24 Oct 2012
Status: Partially addressed
Type: Recommendation
Issue, description, who it affects
Issue: MI-2010-011-SI-03Pilot fatigue management plan
Number: MI-2010-011-SI-03
Description: MI-2010-011-SI-03:The coastal pilot fatigue management plan is inadequate.
Who it affects: All ship operators, masters, pilots and pilotage providers
Issue owner: Australian Maritime Safety Authority, Australian Reef Pilots, Hydro Pilots and Torres Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 24 Oct 2012
Status: Not addressed
Type: Recommendation
  Proactive Action
  Recommendation
  Proactive Action
  Recommendation
  Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MI-2010-011-SI-05Check pilot system
Number: MI-2010-011-SI-05
Description: MI-2010-011-SI-05:As a measure to assess the adequacy of the individual systems of coastal pilotage and pilot competency, the check pilot system is ineffective.
Who it affects: All ship operators, masters, pilots and pilotage providers
Issue owner: Australian Maritime Safety Authority
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 24 Oct 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MI-2010-011-SI-06Great Barrier Reef and Torres Strait Vessel Traffic Service
Number: MI-2010-011-SI-06
Description: MI-2010-011-SI-06:The potential for the Great Barrier Reef and Torres Strait Vessel Traffic Service (REEFVTS) to support coastal pilotage and enhance safety is under-utilised. 
Who it affects: All ship operators, masters, pilots and pilotage providers
Issue owner: Australian Maritime Safety Authority and Maritime Safety Queensland
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 24 Oct 2012
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: MO-2011-001-SI-01Port of Brisbane preparedness for incidents
Number: MO-2011-001-SI-01
Description: MO-2011-001-SI-01:Brisbane port authorities had not put in place sufficient procedures, checklists and/or supporting documents to ensure VTS staff were adequately prepared, trained and practiced to handle a predictable incident such as this.
Who it affects: MSQ Port of Brisbane
Issue owner: Maritime Safety Queensland (MSQ)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 05 Oct 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-001-SI-02Burner nozzle assembly and documentation
Number: MO-2011-001-SI-02
Description: MO-2011-001-SI-02:The design of the burner nozzle allowed the nozzle swirl plate and needle valve to be misaligned when being assembled which in turn led to the needle valve stem being damaged during assembly. Furthermore, the maintenance manuals and supporting documentation supplied by Garioni Naval, the thermal oil heater manufacturer, did ...
Who it affects: Garioni Naval SpA
Issue owner: Garioni Naval SpA
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 05 Oct 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-008-SI-01Automatic defences within the ACIII system bypassed
Number: MO-2010-008-SI-01
Description: MO-2010-008-SI-01:When the main engine was operated in engine room control mode, there was no automatic interlock to prevent ‘wrong way’ operation of the engine and no audible alarm to indicate when it was running the ‘wrong way’. As a result, the only system protections to warn the crew of ‘wrong ...
Who it affects: All ship's engineers
Issue owner: Newlead Bulkers
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 13 Sep 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-008-SI-02Flinders Ports passage plan
Number: MO-2010-008-SI-02
Description: MO-2010-008-SI-02:While the Flinders Ports passage plan for Port Lincoln contained information relating to general navigation in the port, such as depths and navigation/channel marks, it did not contain actual passage specific information, such as courses and speeds to be followed. If the plan had contained course and speed information, the ...
Who it affects: All pilotage organisations
Issue owner: Flinders Ports
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 13 Sep 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-008-SI-03Risk assessment and contingencies for manoeuvre
Number: MO-2010-008-SI-03
Description: MO-2010-008-SI-03:Flinders Ports had not undertaken a risk assessment, or developed contingency plans for this specific shiphandling manoeuvre in Port Lincoln. Consequently, the pilot had no guidance regarding what actions to take if the berthing manoeuvre did not progress as he planned.
Who it affects: All pilotage organisations
Issue owner: Flinders Ports
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 13 Sep 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-008-SI-04Procedures for ACIII bridge control system
Number: MO-2010-008-SI-04
Description: MO-2010-008-SI-04:Newlead Bulkers had not implemented any procedures or guidance to inform the crew that extra vigilance was required when operating the main engine in engine room control mode because there was no automatic interlock to prevent ‘wrong way’ operation of the engine and no audible alarm to indicate when it ...
Who it affects: All ship owners, operators and managers
Issue owner: Newlead Bulkers
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 13 Sep 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-008-SI-05Tug masters participation
Number: MO-2010-008-SI-05
Description: MO-2010-008-SI-05:The participation of the two tug masters in the pilotage process was not actively encouraged in Port Lincoln. Consequently, it was not until after the collision that one of the tug masters advised the pilot that the ship's main engine was still running ahead.
Who it affects: All pilotage organisations
Issue owner: Flinders Ports
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 13 Sep 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: Trading ship operations in Gladstone
Description: The analysis of trading ship operations in Gladstone that had been carried out by the relevant authorities had not appropriately considered all that could be done to prevent the grounding of a ship as a result of steering gear or main engine failure. Action taken by Maritime Safety Queensland Maritime Safety Queensland ...
Who it affects: Maritime Safety Queensland
Issue owner:
Operation affected:
Date, status, type
Date: 30 Jul 2012
Original risk: Significant
Status:
Type: Recommendation
Issue, description, who it affects
Issue: MO-2011-004-SI-01Commissioning processes
Number: MO-2011-004-SI-01
Description: MO-2011-004-SI-01:The shipyard commissioning processes did not identify that the ship’s rudder angle indicator transmitter and tiller link-arm were not installed correctly.
Who it affects: All ship owners, operators, managers, masters and officers
Issue owner: Tsuneishi Group Shipbuilding, China
Operation affected: Marine: Other
Date, status, type
Date: 30 Jul 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-004-SI-02Contingency planning
Number: MO-2011-004-SI-02
Description: MO-2011-004-SI-02:There has not been a comprehensive risk based approach to contingency planning for deep draught bulk carrier operations in Gladstone.
Who it affects: All pilotage organisations
Issue owner: Maritime Safety Queensland (MSQ)
Operation affected: Marine: Other
Date, status, type
Date: 30 Jul 2012
Status: Partially addressed
Type: Recommendation
Issue, description, who it affects
Issue: MO-2011-004-SI-03Pilotage safety management system
Number: MO-2011-004-SI-03
Description: MO-2011-004-SI-03:There has not been a comprehensive safety management system implemented in the Port of Gladstone with the aim of identifying, evaluating and controlling pilotage related risk.
Who it affects: All pilotage organisations
Issue owner: Maritime Safety Queensland (MSQ)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 30 Jul 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-007-SI-01 Oxygen breathing apparatus training
Number: MO-2011-007-SI-01
Description: MO-2011-007-SI-01:The ship’s crew were not appropriately trained or drilled in the operation and maintenance of the oxygen breathing apparatus.
Who it affects: All ship owners, operators, managers and seafarers
Issue owner: Taiyo Nippon Kisen
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 05 Apr 2012
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-007-SI-02Oxygen breathing apparatus documentation
Number: MO-2011-007-SI-02
Description: MO-2011-007-SI-02:The ship’s safety management system documentation provided the crew with no guidance in relation to the operation and maintenance of the ship’s oxygen breathing apparatus.
Who it affects: All ship owners, operators, managers and seafarers
Issue owner: Taiyo Nippon Kisen
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 05 Apr 2012
Status: Not addressed
Issue, description, who it affects
Issue: MO-2011-007-SI-03Cylinder design
Number: MO-2011-007-SI-03
Description: MO-2011-007-SI-03:The threaded connections on the Kawasaki air breathing apparatus and oxygen breathing apparatus cylinders were the same and there were no other engineering controls to prevent an oxygen cylinder from being connected to the air compressor.
Who it affects: All seafarers
Issue owner: Water Safety Service
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 05 Apr 2012
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: National and international maritime, cargo and labour organisations
Description: The recognised safe practices of not working under or near a container being loaded is not well reflected published in national and international guidance to assist container terminal operators develop their own safety policies and guidelines.
Who it affects: Patrick Terminals
Issue owner:
Operation affected:
Date, status, type
Date: 19 Dec 2011
Original risk: Minor
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2010-002-SI-01Safe work instructions
Number: MO-2010-002-SI-01
Description: MO-2010-002-SI-01:Patrick Terminals’ safe work instructions for lashing/unlashing did not specifically cover the recognised safe practices of not working under containers or between moving containers and fixed objects. Consequently, there was a discontinuity between the level of awareness regarding these dangers and the training new employees received during their induction period.
Who it affects: All stevedores
Issue owner: Patrick Terminals
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 19 Dec 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-002-SI-02Hazard assessment process
Number: MO-2010-002-SI-02
Description: MO-2010-002-SI-02:Patrick Terminals’ hazard identification process had not identified the dangers of working near or under containers being loaded.
Who it affects: All stevedores
Issue owner: Patrick Terminals
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 19 Dec 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-002-SI-03Risk assessment process
Number: MO-2010-002-SI-03
Description: MO-2010-002-SI-03:Patrick Terminals’ risk assessment process for lashing and unlashing operations had not anticipated a fatal accident resulting from being struck by items falling from a portainer or cargo, or from being struck by a moving container. As a result, while the appropriate risk control for this occurrence had been covered ...
Who it affects: All stevedores
Issue owner: Patrick Terminals
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 19 Dec 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-002-SI-04Safety zone guidance
Number: MO-2010-002-SI-04
Description: MO-2010-002-SI-04:Patrick Terminals had no formalised policy in place to provide clear guidance to its stevedoring employees about where they could or could not work on a ship when cargo was being loaded or discharged.
Who it affects: All stevedores
Issue owner: Patrick Terminals
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 19 Dec 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-002-SI-05Terminal safety management
Number: MO-2010-002-SI-05
Description: MO-2010-002-SI-05:The implementation of Patrick Terminal’s safety management system resulted in an environment where Patrick Terminal management and stevedores were disconnected in relation to the management of some of the day-to-day workplace safety risks. As a result, there was little ownership of the safe work instructions by the stevedores, and some ...
Who it affects: All stevedores
Issue owner: Patrick Terminals
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 19 Dec 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-002-SI-06Safety issues not covered in guides for operators
Number: MO-2010-002-SI-06
Description: MO-2010-002-SI-06:The recognised safe practices of not working under or near a container being loaded is not well reflected in national and international guidance published to assist container terminal operators develop their own safety policies and guidelines.
Who it affects: All stevedores
Issue owner: National and international maritime, cargo and labour organisations
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 19 Dec 2011
Status: Adequately addressed
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2010-002-SI-07Risk-event reporting
Number: MO-2010-002-SI-07
Description: MO-2010-002-SI-07:The culture which existed in the Patrick terminal did not encourage the reporting of non-compliances or unsafe acts. Consequently, two critical parts of an effective safety system, which had a direct impact upon its ability to effectively manage safety in the terminal, the ‘reporting’ culture and the ‘just’ culture, were ...
Who it affects: All stevedores
Issue owner: Patrick Terminals
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 19 Dec 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-007-SI-01Cargo Securing Manual
Number: MO-2010-007-SI-01
Description: MO-2010-007-SI-01:Mimasaka’s cargo securing manual did not contain any information relating to the stowage and securing of timber veneer.
Who it affects: All ship owners, operators, managers and masters
Issue owner: NYK-Hinode Line
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 14 Nov 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-007-SI-02NYK's Operation Manual
Number: MO-2010-007-SI-02
Description: MO-2010-007-SI-02:The Operation Manual for Loading and Lashing of Tasmanian/Malaysian Dry Veneer, developed by NYK-Hinode Line for use by ships carrying timber veneer, did not contain any information relating to the stowage and securing of the timber veneer cargo on deck.
Who it affects: All ship owners, operators, managers and masters
Issue owner: NYK-Hinode Line
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 14 Nov 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-007-SI-03Emailed instructions
Number: MO-2010-007-SI-03
Description: MO-2010-007-SI-03:The instructions that were emailed to Mimasaka’s master by NYK-Hinode Line did not provide the crew with proper guidance about how to stow and secure the packs of timber veneer on deck.
Who it affects: All ship owners, operators, managers and masters
Issue owner: NYK-Hinode Line
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 14 Nov 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-007-SI-04Veneer packaging
Number: MO-2010-007-SI-04
Description: MO-2010-007-SI-04:Ta Ann Tasmania did not follow the recommendations contained in section 2.3 of Appendix A of the International Maritime Organization’s Code of Safe Practice for Ships Carrying Timber Deck Cargo when they packaged the timber veneer for shipment by sea.
Who it affects: All shippers of timber cargoes
Issue owner: Ta Ann Tasmania
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 14 Nov 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-007-SI-05Third party inspection of veneer packaging
Number: MO-2010-007-SI-05
Description: MO-2010-007-SI-05:The Australian Maritime Safety Authority had not inspected the packs of veneer to establish whether Ta Ann Tasmania was packaging the veneer in line with the recommendations contained in section 2.3 of Appendix A of the International Maritime Organization’s Code of Safe Practice for Ships Carrying Timber Deck Cargo.
Who it affects: All regulators, surveyors and inspectors
Issue owner: Australian Maritime Safety Authority (AMSA)
Operation affected: Marine: Other
Date, status, type
Date: 14 Nov 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-002-SI-01Learning from previous events
Number: MO-2011-002-SI-01
Description: MO-2011-002-SI-01:Prior to 2 February 2011, the crew had encountered problems with the lifting wire jamming in the head of the davit when the bucket was hoisted too high. However, nothing had been done to prevent it from happening again in the future.
Who it affects: All seafarers
Issue owner: Hanjin Ship Management
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 02 Aug 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-004-SAN-016
Description: Training institutions delivering approved STCW courses are not keeping up to date with the introduction of wave compensation units to ensure their courses provide students with the knowledge required to safely operate these units.
Who it affects: Ship operators, ship masters and maritime training institutions
Issue owner:
Operation affected:
Date, status, type
Date: 27 Jul 2011
Original risk: Minor
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2010-004-SI-01Incorrect wiring of the interlock
Number: MO-2010-004-SI-01
Description: MO-2010-004-SI-01:It was found that the safety interlocks on the wave compensator systems on board British Sapphire, British Emerald and British Ruby had been electrically by-passed thereby preventing the safety interlocks from functioning.. As a result, the wave compensators on board all three ships could be engaged regardless of whether the ...
Who it affects: All owners operators and managers of ships equipped with Davit International fast rescue craft
Issue owner: d-i Davit International
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 27 Jul 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-004-SI-02Crew training for wave compensator
Number: MO-2010-004-SI-02
Description: MO-2010-004-SI-02:The training provided to the crew did not ensure they were familiar with the function or operation of the wave compensator or its safety interlock
Who it affects: All owners operators and managers of ships equipped with Davit International fast rescue craft
Issue owner: BP Shipping Ltd
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 27 Jul 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-004-SI-03Manufacturers Manuals and procedures for wave compensator
Number: MO-2010-004-SI-03
Description: MO-2010-004-SI-03:Davit International’s fast rescue boat davit manual did not provide sufficient guidance for the crew in the operation of the wave compensator and its safety interlock
Who it affects: All owners operators and managers of ships equipped with Davit International fast rescue craft
Issue owner: d-i Davit International
Operation affected: Marine: Other
Date, status, type
Date: 27 Jul 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-004-SI-04Ship's manuals and procedures for wave compensator
Number: MO-2010-004-SI-04
Description: MO-2010-004-SI-04:British Sapphire’s fast rescue boat davit procedures did not provide sufficient guidance for the crew in the operation of the wave compensator
Who it affects: All owners operators and managers of ships equipped with Davit International fast rescue craft
Issue owner: BP Shipping Ltd
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 27 Jul 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-004-SI-05Job hazard analysis
Number: MO-2010-004-SI-05
Description: MO-2010-004-SI-05:The job hazard analysis for the operation of the fast rescue boat was incomplete and did not include an assessment of the hazards associated with the operation of the wave compensator
Who it affects: All owners operators and managers of ships equipped with Davit International fast rescue craft
Issue owner: BP Shipping Ltd
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 27 Jul 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-004-SI-06Team resource management
Number: MO-2010-004-SI-06
Description: MO-2010-004-SI-06:The crew did not use resource management principles to ensure that they had a shared mental model of the task that they were carrying out. As a result there was confusion amongst the various crew members as to their roles and responsibilities at the time of the incident
Who it affects: All ship owners, operators, managers and seafarers
Issue owner: BP Shipping Ltd
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 27 Jul 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-004-SI-07Installation and acceptance
Number: MO-2010-004-SI-07
Description: MO-2010-004-SI-07:There was no evidence to indicate that the operation of British Sapphire's (or its sister ships) fast rescue boat davit’s wave compensator and safety interlock had been sufficiently tested at the time of the ship's delivery to ensure safe operation
Who it affects: All owners operators and managers of ships equipped with fast rescue craft
Issue owner: BP Shipping Ltd
Operation affected: Marine: Other
Date, status, type
Date: 27 Jul 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-004-SI-08On board maintenance of wave compensator
Number: MO-2010-004-SI-08
Description: MO-2010-004-SI-08:The planned maintenance system on board British Sapphire did not include a specific requirement to maintain or test the wave compensator or its safety interlock on the fast rescue boat davit. As a result, the crew had not identified the issue with the wave compensator safety interlock during periodic maintenance.
Who it affects: All owners operators and managers of ships equipped with fast rescue craft
Issue owner: BP Shipping Ltd
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 27 Jul 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-004-SI-09On board return to service
Number: MO-2010-004-SI-09
Description: MO-2010-004-SI-09:The planned maintenance system on board British Sapphire did not detail a procedure for a recommissioning test following maintenance on the fast rescue boat davit. As a result, any recommissioning test that was done after on board maintenance had not identified the issue with the wave compensator safety interlock prior ...
Who it affects: All owners operators and managers of ships equipped with fast rescue craft
Issue owner: BP Shipping Ltd
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 27 Jul 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-004-SI-10STCW training for wave compensator
Number: MO-2010-004-SI-10
Description: MO-2010-004-SI-10:Training institutions delivering approved STCW courses are not keeping up to date with the introduction of wave compensation units to ensure their courses provide students with the required knowledge to safely operate these units
Who it affects: All maritime training organisations
Issue owner: Licensing authorities
Operation affected: Marine: Other
Date, status, type
Date: 27 Jul 2011
Status: No longer relevant
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2010-006-SAN-015
Description: Global Supplier was built and surveyed as a Uniform Shipping Laws (USL) Code vessel and therefore was not fitted with radar or an AIS unit which would be required under the provisions of the current National Standard for Commercial Vessels. Had these devices been fitted, they would have provided information ...
Who it affects: Small commercial vessels
Issue owner:
Operation affected:
Date, status, type
Date: 19 Jul 2011
Original risk: Minor
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2010-006-SI-01Global Supplier's navigation lights
Number: MO-2010-006-SI-01
Description: MO-2010-006-SI-01:Global Supplier was not fitted with the correct navigational lights for a vessel engaged in towing operations.
Who it affects: All tug owners, operators, managers and masters
Issue owner: Global Marine & Eng Pty Limited
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 18 Jul 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-006-SI-02Ambiguous pilotage direction
Number: MO-2010-006-SI-02
Description: MO-2010-006-SI-02:Dampier Port Authority's pilotage directions are unclear and ambiguous with respect to the requirements for towing vessels or on the use of pilotage exemptions by crew other than the master.
Who it affects: All port authorities and pilotage organisations
Issue owner: Dampier Port Authority
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 18 Jul 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-006-SI-03Global Supplier without radar and AIS unit
Number: MO-2010-006-SI-03
Description: MO-2010-006-SI-03:Global Supplier was built and surveyed as a Uniform Shipping Laws (USL) Code vessel and therefore was not fitted with radar or an AIS unit which would be required under the provisions of the current National Standard for Commercial Vessels. Had these devices been fitted, they would have provided information ...
Who it affects: All regulators, surveyors and inspectors
Issue owner: State and Territory Marine authorities
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 18 Jul 2011
Status: Not addressed
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: Steering gear testing
Description: Preliminary inspections and tests of MSC Basel's steering system did not identify any faults. However, more thorough examinations of the entire steering systems may identify any intermittent defects. Action taken by Reederei F. Laeisz Reederei F. Laeisz has advised the ATSB that the spherical bearing and pin which were found seized ...
Who it affects: Reederei F. Laeisz
Issue owner:
Operation affected:
Date, status, type
Date: 04 May 2011
Original risk: Minor
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2010-009-SI-01Fault finding of steering system
Number: MO-2010-009-SI-01
Description: MO-2010-009-SI-01:Preliminary inspections and tests of MSC Basel steering system did not identify any faults. However, more thorough examinations of the entire steering systems may identify any intermittent defects.
Who it affects: All ship's engineers
Issue owner: Laeisz Reederei
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 04 May 2011
Status: Partially addressed
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: Fatigue management
Description: Significant safety issueThere was no effective fatigue management system in place on board Shen Neng 1 to ensure that the bridge watchkeeper was fit to stand a navigational watch after the loading in Gladstone.   Response from Tosco Keymax InternationalThe ATSB has been advised by Tosco Keymax International that since the incident, ...
Who it affects: Tosco Keymax International Ship Management Co.
Issue owner:
Operation affected:
Date, status, type
Date: 14 Apr 2011
Original risk: Significant
Status:
Type: Recommendation
Issue, description, who it affects
Issue: Passage planning procedures
Description: Significant safety issueThe ship's safety management system did not contain procedures or guidance on the proper use of GPS route plans and their relationship to the ship's passage plans. Response from Tosco Keymax InternationalThe ATSB has been advised by Tosco Keymax International that since the incident, in accordance with the company's ...
Who it affects: Tosco Keymax International Ship Management Co.
Issue owner:
Operation affected:
Date, status, type
Date: 14 Apr 2011
Original risk: Significant
Status:
Type: Recommendation
Issue, description, who it affects
Issue: MO-2010-003-SI-01Fatigue management system
Number: MO-2010-003-SI-01
Description: MO-2010-003-SI-01:There was no effective fatigue management system in place to ensure that the bridge watch keeper was fit to stand a navigational watch after the loading in Gladstone.
Who it affects: All ship owners, operators, managers and masters
Issue owner: Tosco Keymax International Ship management company
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 14 Apr 2011
Status: Partially addressed
Type: Recommendation
Issue, description, who it affects
Issue: MO-2010-003-SI-02Safety management system for passage planning
Number: MO-2010-003-SI-02
Description: MO-2010-003-SI-02:The ship’s safety management system did not contain procedures or guidance on the proper use of GPS route plans and their relationship to the ship’s passage plans.
Who it affects: All ship owners, operators, managers and masters
Issue owner: Tosco Keymax International Ship management company
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 14 Apr 2011
Status: Not addressed
Type: Recommendation
Issue, description, who it affects
Issue: MO-2010-003-SI-03Lack of visual cues for dangers
Number: MO-2010-003-SI-03
Description: MO-2010-003-SI-03:In the 30 minutes leading up to the grounding, there were no visual cues to warn either the chief mate or the seaman on lookout duty, as to the underwater dangers directly ahead of the ship.
Who it affects: All masters, deck officers and pilots
Issue owner: Australian Maritime Safety Authority (AMSA)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 14 Apr 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-003-SI-04Sea area off Gladstone not 'protected'
Number: MO-2010-003-SI-04
Description: MO-2010-003-SI-04:At the time of the grounding, the protections afforded by some of the measures currently employed in the more northern sections of the GBR were not in place in the sea area off Gladstone.
Who it affects: All masters, deck officers, pilots and VTS operators
Issue owner: Australian Maritime Safety Authority (AMSA)
Operation affected: Marine: Other
Date, status, type
Date: 14 Apr 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-005-SI-01Dangers associated with use of grinder
Number: MO-2010-005-SI-01
Description: MO-2010-005-SI-01:The oiler’s actions indicate that he was not aware of the dangers associated with the use of an angle grinder to remove the top of the drum.
Who it affects: All seafarers
Issue owner: NSC Schiffahrtsgesellschaft, Germany
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 17 Feb 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-005-SI-02Knowledge of ship’s safety management system
Number: MO-2010-005-SI-02
Description: MO-2010-005-SI-02:The oiler’s actions indicate that he was likely not aware of the ship’s safety management system hot work permit requirements.
Who it affects: All ship, owners, operators, managers and seafarers
Issue owner: NSC Schiffahrtsgesellschaft, Germany
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 17 Feb 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: Third party inspection of lashing equipment
Description: The Australian Transport Safety Bureau advises that coastal States, flag States and classification societies should consider the safety implications of this safety issue and take action where considered appropriate.
Who it affects: Coastal and Flag States and Classification Societies
Issue owner:
Operation affected:
Date, status, type
Date: 27 Jan 2011
Original risk: Significant
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2009-002-SI-01Condition of lashing gear
Number: MO-2009-002-SI-01
Description: MO-2009-002-SI-01:The poor condition of much of the ship’s container lashing equipment indicates that the inspection and maintenance regime applied to this critical equipment had been inadequate.
Who it affects: All ship owners, operators, managers and maters
Issue owner: Swire Navigation/CNCO
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 27 Jan 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2009-002-SI-02Third party inspection of lashing equipment
Number: MO-2009-002-SI-02
Description: MO-2009-002-SI-02:At the time of the incident, there was no requirement for any third party to inspect or survey the fixed and loose lashing equipment on a ship. Had this been done, the maintenance and replacement regime of such equipment on board Pacific Adventurer might have been more effective.
Who it affects: All regulators surveyors and inspectors
Issue owner: Flag and coastal states
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 27 Jan 2011
Status: Adequately addressed
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2009-002-SI-03Container packaging completed by shipper.
Number: MO-2009-002-SI-03
Description: MO-2009-002-SI-03:The ammonium nitrate prills were not packaged in the containers in accordance with the requirements of the IMDG Code. The containers were packed in a way which allowed the prills to move within the container in a way that may have contributed to the failure of the containers and/or the ...
Who it affects: All shippers of ammonium nitrate
Issue owner: Orica
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 27 Jan 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2009-002-SI-04IMDG Code requirements oversight
Number: MO-2009-002-SI-04
Description: MO-2009-002-SI-04:Before the incident, Orica Australia had advised the Australian Maritime Safety Authority (AMSA) that their packaging method for the prills was fully compliant with the IMDG Code’s provisions. However, AMSA’s IMDG Code compliance audit regime had not detected that the method was not compliant.
Who it affects: All regulators, surveyors and inspectors
Issue owner: Australian Maritime Safety Authority (AMSA)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 27 Jan 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-001-SI-01Planned maintenance system alarm/shutdown testing
Number: MO-2010-001-SI-01
Description: MO-2010-001-SI-01:River Embley’s planned maintenance system did not require routine testing of the compressor high temperature alarm/shutdown.
Who it affects: All ship owners, operators, managers and engineers
Issue owner: ASP Ship Management
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 25 Jan 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-001-SI-02Manufacturers guidance
Number: MO-2010-001-SI-02
Description: MO-2010-001-SI-02:The manufacturer’s maintenance manual did not include a requirement for the routine testing of the compressor high temperature alarm/shutdown.
Who it affects: All machinery and equipment suppliers
Issue owner: CHAMPION COMPRESSORS
Operation affected: Marine: Other
Date, status, type
Date: 25 Jan 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2009-001-SI-01Ship's passage planning procedures
Number: MO-2009-001-SI-01
Description: MO-2009-001-SI-01:Atlantic Blue’s safety management system procedures did not require specific off-track limits to be included in the passage plan or otherwise ensure that limits for effective track monitoring were always defined.
Who it affects: All ship owners, operators, managers, masters and deck officers
Issue owner: Fleet Management Limited, Hong Kong
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 16 Dec 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2009-001-SI-02Pilotage SMS and check pilot regime
Number: MO-2009-001-SI-02
Description: MO-2009-001-SI-02:The pilotage system used by Atlantic Blue’s pilot did not define off-track limits or make effective use of recognised bridge resource management tools in accordance with the Queensland Coastal Pilotage Safety Management Code and regular assessments of his procedures and practices under the code’s check pilot regime conducted over a ...
Who it affects: All pilotage organisations
Issue owner: Australian Maritime Safety Authority (AMSA)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 16 Dec 2010
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2009-001-SI-03Shore monitoring of shallow water areas
Number: MO-2009-001-SI-03
Description: MO-2009-001-SI-03:The ‘shallow water alert’ generated by the Great Barrier Reef and Torres Strait Vessel Traffic Service’s (REEFVTS) monitoring system did not provide adequate warning of Atlantic Blue entering shallow water because the boundary of the defined shallow water alert area was too close to dangers off Kirkcaldie Reef.
Who it affects: All VTS operators
Issue owner: Reef VTS
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 16 Dec 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2009-001-SI-04Shore monitoring of two-way routes
Number: MO-2009-001-SI-04
Description: MO-2009-001-SI-04:The REEFVTS monitoring system did not provide an ‘exiting corridor alarm’ when Atlantic Blue exited the two-way route that it was transiting because the route had not been defined as a navigational corridor.
Who it affects: All VTS operators
Issue owner: Reef VTS
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 16 Dec 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2009-009-SAN-021
Description: While Petra Frontier had undergone an initial flag State inspection on 4 May 2009 and routine class surveys, the most recent being a class survey completed on 12 August 2009, neither authority was aware that the ship was unseaworthy in relation to critical safety equipment when it departed Singapore. Response from ...
Who it affects: American Bureau of Shipping
Issue owner:
Operation affected:
Date, status, type
Date: 14 Dec 2010
Original risk: Minor
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2009-009-SI-01Drill schedule
Number: MO-2009-009-SI-01
Description: MO-2009-009-SI-01:Petra Frontier’s safety management system contained procedures outlining how fire and abandon ship drills should be carried out in accordance with SOLAS and Marshall Islands requirements. However, it also contained a drill schedule that provided some contradictory information.
Who it affects: All ship, owners, operators, managers and masters
Issue owner: Petra Marine Australia
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 14 Dec 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2009-009-SI-02Statutory buy in
Number: MO-2009-009-SI-02
Description: MO-2009-009-SI-02:While Petra Frontier had undergone an initial flag State inspection on 4 May 2009 and routine class surveys, the most recent being a class survey completed on 12 August 2009, neither authority was aware that the ship was unseaworthy in relation to critical safety equipment when it departed Singapore.
Who it affects: All regulators, surveyors and inspectors
Issue owner: Marshall Islands International Registries
Operation affected: Marine: Other
Date, status, type
Date: 14 Dec 2010
Status: Partially addressed
Type: Proactive Action
  Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2009-005-SAN-024
Description: The tower was not assembled as designed. The outriggers and intermediate planks, both key components, were missing and the work platform guard rails were not used. The manufacturer's instructions were also missing but no attempt was made to obtain them, a parts list or the missing parts. Safety advisory notice The Australian ...
Who it affects: Ships' masters and crew
Issue owner:
Operation affected:
Date, status, type
Date: 17 Nov 2010
Original risk: Significant
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2009-005-SI-01Permit system
Number: MO-2009-005-SI-01
Description: MO-2009-005-SI-01:United Treasure’s permit to work aloft system had not been effectively implemented on board the ship. In addition, the standard form for the permit did not ensure that the officer in charge of the work and its authoriser were not the same person and that a risk assessment was formally ...
Who it affects: All ship owners, operators, managers, masters and crews
Issue owner: United Ocean Ship Management, Singapore
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 17 Nov 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2009-005-SI-02Tower assembly
Number: MO-2009-005-SI-02
Description: MO-2009-005-SI-02:The tower was not assembled as designed. The outriggers and intermediate planks, both key components, were missing and the work platform guard rails were not used. The manufacturer’s instructions were also missing but no attempt was made to obtain them, a parts list or the missing parts.
Who it affects: All seafarers
Issue owner: Ship's masters and crews
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 17 Nov 2010
Status: Adequately addressed
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2009-010-SI-01Tank entry checklist system
Number: MO-2009-010-SI-01
Description: MO-2009-010-SI-01:While enclosed space entry checklists were being filled out by the crew members on board Bow De Jin, the checklist system was not being used as a proactive means to ensure that the necessary safety requirements were being met prior to tank entries.
Who it affects: All ship owners, operators, managers, masters and crews
Issue owner: Fleet Management Limited, Hong Kong
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 10 Nov 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Number: MO-2008-013-SR-067
Description: MO-2008-013-SR-067:In this instance, the consensus of the regulatory authorities is that Karratha Spirit was not in a navigable form at the time of the accident and was therefore under NOPSA's jurisdiction according to the OPGGSA. However, the point at which Karratha Spirit became 'navigable' is not clearly defined in the ...
Who it affects: National Offshore Petroleum Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 28 Sep 2010
Status:
Type: Recommendation
Issue, description, who it affects
Number: MO-2008-013-SAN-066
Description: MO-2008-013-SAN-066:NOPSA does not undertake the audits necessary for maritime compliance and AMSA is only able to do so for most of the time, while the facility is on station, with NOPSA's cooperation under an MoU. NOPSA had carried out annual occupational health and safety inspections on board Karratha Spirit and ...
Who it affects: National Offshore Petroleum Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 28 Sep 2010
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2008-013-SI-01Procedures versus practices
Number: MO-2008-013-SI-01
Description: MO-2008-013-SI-01:The ship’s procedures for connecting and disconnecting from the CALM buoy did not provide explicit, succinct and unambiguous guidance and there were differences between the procedures and the actual shipboard practices that increased the level of risk associated with those operations
Who it affects: All owners, operators, managers and masters of offshore production and supply vessels
Issue owner: Teekay Shipping Australia
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 28 Sep 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2008-013-SI-02Shipboard review
Number: MO-2008-013-SI-02
Description: MO-2008-013-SI-02:The procedures for connecting and disconnecting the import hose and disconnecting from the CALM buoy in place on board Karratha Spirit were signed off as being satisfactory and reflecting shipboard practice, but they had not been effectively reviewed on board the ship. Consequently, the ambiguities in the procedures and the ...
Who it affects: All owners, operators, managers and masters of offshore production and supply vessels
Issue owner: Teekay Shipping Australia
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 28 Sep 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2008-013-SI-03 Job Hazard Analysis review
Number: MO-2008-013-SI-03
Description: MO-2008-013-SI-03:The Job Hazard Analysis (JHA) for disconnecting from the CALM buoy did not provide an accurate assessment of the all of the hazards and associated risks in performing the task. In addition, the crew did not use it to assess the risks associated with undertaking an unfamiliar operation and it ...
Who it affects: All owners, operators, managers and masters of offshore production and supply vessels
Issue owner: Teekay Shipping Australia
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 28 Sep 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2008-013-SI-04Regulatory oversight
Number: MO-2008-013-SI-04
Description: MO-2008-013-SI-04:NOPSA does not undertake the audits necessary for maritime compliance and AMSA is only able to do so, while the facility is on station, with NOPSA’s cooperation. NOPSA had carried out annual occupational health and safety inspections on board the ship and AMSA had carried out the necessary third party ...
Who it affects: All regulators, surveyors and inspectors
Issue owner: National Offshore Petroleum Safety Authority NOPSA
Operation affected: Marine: Other
Date, status, type
Date: 28 Sep 2010
Status: Partially addressed
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2008-013-SI-05Jurisdiction
Number: MO-2008-013-SI-05
Description: MO-2008-013-SI-05:In this instance, the consensus of the regulatory authorities is that Karratha Spirit was not in a navigable form at the time of the accident and was therefore under NOPSA’s jurisdiction according to the OPGGSA. However, the point at which Karratha Spirit became ‘navigable’ is not clearly defined in the ...
Who it affects: All regulators, surveyors and inspectors
Issue owner: National Offshore Petroleum Safety Authority NOPSA
Operation affected: Marine: Other
Date, status, type
Date: 28 Sep 2010
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Recommendation
Issue, description, who it affects
Issue: Robinson R44 operators and maintenance organisations
Description: 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 ...
Who it affects: Flag States
Issue owner:
Operation affected:
Date, status, type
Date: 15 Jun 2010
Original risk: Significant
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2009-008-SAN-014
Description: 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 ...
Who it affects: Owners, operators and skippers of small vessels
Issue owner:
Operation affected:
Date, status, type
Date: 15 Jun 2010
Original risk: Minor
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: Ship's safety management system
Description: 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 ...
Who it affects: ASP Ship Management
Issue owner:
Operation affected:
Date, status, type
Date: 14 Apr 2010
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: Ship's health, safety, security and environment meetings and job hazard opportunity log
Description: 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 ...
Who it affects: ASP Ship Management
Issue owner:
Operation affected:
Date, status, type
Date: 14 Apr 2010
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: Design of the cradle for the cargo crane hook
Description: 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 ...
Who it affects: Marlow Navigation
Issue owner:
Operation affected:
Date, status, type
Date: 14 Apr 2010
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MO-2008-003-SAN-047
Description: MO-2008-003-SAN-047: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 ...
Who it affects: Jevkon Oil and Gas
Issue owner:
Operation affected:
Date, status, type
Date: 09 Apr 2010
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MO-2008-003-SAN-048
Description: MO-2008-003-SAN-048: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 ...
Who it affects: Jevkon Oil and Gas
Issue owner:
Operation affected:
Date, status, type
Date: 09 Apr 2010
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: Ship's safety management system
Description: 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 ...
Who it affects: Sierra Leone International Ship Registry
Issue owner:
Operation affected:
Date, status, type
Date: 09 Apr 2010
Status:
Type: Recommendation
Issue, description, who it affects
Number: MO-2008-003-SAN-050
Description: MO-2008-003-SAN-050: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 ...
Who it affects: Ship owners, operators and masters
Issue owner:
Operation affected:
Date, status, type
Date: 09 Apr 2010
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2009-004-SR-008
Description: 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 ...
Who it affects: The Danish Maritime Authority
Issue owner:
Operation affected:
Date, status, type
Date: 16 Dec 2009
Status:
Type: Recommendation
Issue, description, who it affects
Issue: MO-2008-010-SAN-041
Description: 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 ...
Who it affects: Flag States, owners, operators and masters
Issue owner:
Operation affected:
Date, status, type
Date: 22 Oct 2009
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2008-010-SR-039
Description: 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 ...
Who it affects: Volcano Company
Issue owner:
Operation affected:
Date, status, type
Date: 22 Oct 2009
Status:
Type: Recommendation
Issue, description, who it affects
Issue: MO-2008-008-SAN-025
Description: 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 ...
Who it affects: Owners, operators and masters
Issue owner:
Operation affected:
Date, status, type
Date: 13 Oct 2009
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2008-009-SR-020
Description: 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 ...
Who it affects: Parakou Shipping
Issue owner:
Operation affected:
Date, status, type
Date: 29 Sep 2009
Status:
Type: Recommendation
Issue, description, who it affects
Issue: MO-2008-001-SAN-027
Description: 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 ...
Who it affects: Ship operators, ship masters and maritime training institutions
Issue owner:
Operation affected:
Date, status, type
Date: 03 Jun 2009
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MO-2008-001-SAN-029
Description: MO-2008-001-SAN-029:
Who it affects: Fishing vessel owners, operators and skippers
Issue owner:
Operation affected:
Date, status, type
Date: 03 Jun 2009
Status:
Issue, description, who it affects
Issue: MO-2008-001-SR-028
Description: 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 it affects: Maritime Safety Queensland
Issue owner:
Operation affected:
Date, status, type
Date: 03 Jun 2009
Status:
Type: Recommendation
Issue, description, who it affects
Issue: MO-2008-007-SR-023
Description: 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 ...
Who it affects: Atlantic Bulk Carriers Management, Marshell Islands
Issue owner:
Operation affected:
Date, status, type
Date: 21 May 2009
Status:
Type: Recommendation
Issue, description, who it affects
Issue: MO-2008-007-SR-024
Description: 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 RecommendationThe Australian Transport Safety Bureau recommends that Atlantic ...
Who it affects: Atlantic Bulk Carriers Management, Marshell Islands
Issue owner:
Operation affected:
Date, status, type
Date: 21 May 2009
Status:
Type: Recommendation
Issue, description, who it affects
Issue: MO-2008-006-SR-021
Description: 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-017Reederei Alnwick Harmstorf has advised the Australian Transport Safety Bureau that consideration will be given to addressing this safety issue. Safety RecommendationThe ...
Who it affects: Reederei Alnwick Harmstorf
Issue owner:
Operation affected:
Date, status, type
Date: 20 May 2009
Status:
Type: Recommendation
Issue, description, who it affects
Issue: MO-2008-006-SR-022
Description: The ship's safety management system did not contain information to remind the master of the importance in ensuring that roles and responsibilities were allocated to members of the bridge team during the pilot/master information exchange. Action taken by Reederei Alnwick Harmstorf MO-2008-006-NSA-019Reederei Alnwick Harmstorf has advised the Australian Transport Safety Bureau ...
Who it affects: Reederei Alnwick Harmstorf
Issue owner:
Operation affected:
Date, status, type
Date: 20 May 2009
Status:
Type: Recommendation
Issue, description, who it affects
Issue: MS2009001
Description: MSC Lugano’s safety management system gave the master no guidance as to how long to wait before entering the engine room following the release of carbon dioxide into the space. Safety Advisory NoticeThe Australian Transport Safety Bureau advises that owners, managers and masters should consider the safety implications of this safety ...
Who it affects: Owners, managers and masters
Issue owner:
Operation affected:
Date, status, type
Date: 05 Feb 2009
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: MS20090002
Description: MSC Lugano's safety management system gave the master no guidance as to how long to wait before entering the engine room following the release of carbon dioxide into the space. Safety Advisory Notice The Australian Transport Safety Bureau advises that owners, managers and masters should consider the safety implications of this safety ...
Who it affects: Owners, managers and masters
Issue owner:
Operation affected:
Date, status, type
Date: 05 Feb 2009
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: MS2009003
Description: The Esperance based tugs Shoal Cape and Cape Pasley were neither designed nor equipped for the deep sea towage of a ship like MSC Lugano, particularly in the rough sea conditions that were encountered on 1 and 2 April 2008. Safety Advisory NoticeThe Australian Transport Safety Bureau advises that towage vessel ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 05 Feb 2009
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2009-001-SR-001
Description: The pilot had received no training in how to use anchors to assist him with handling a ship in the confined approaches to Grassy. As a result, he was not comfortable with using the ships anchors to assist him with manoeuvring the ship in the close confines of the approaches ...
Who it affects: Tasmanian Ports Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 27 Jan 2009
Status:
Type: Recommendation
Issue, description, who it affects
Number: MS20070020
Description: MS20070020: Safety Issue Silky Ocean's third mate assumed that a collision between his ship and Peter Crombie had not occurred. He did not immediately report the incident to the ships master and he made no attempt to contact the damaged fishing vessel. In doing so, he disregarded his legal and moral obligations to ensure the safety ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 20 Dec 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080027
Description: MS20080027: Safety Issue Rexandra's electronic detectability was reduced because of the vessel's timber construction and the lack of a radar reflector or an AIS unit. Safety Advisory Notice The Australian Transport Safety Bureau advises that ship and fishing vessel owners, operators' masters/skippers and State/Northern Territory marine regulators should consider the safety implications of this safety issue and to take ...
Who it affects: Ship and fishing vessel owners, operators' masters/skippers
Issue owner:
Operation affected:
Date, status, type
Date: 25 Sep 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MR20080026
Description: MR20080026: Safety Issue The execution of bridge resource management on board Searoad Mersey was inadequate because single person errors, such as a loss of situational awareness and the failure to keep an effective lookout, went unchecked. Furthermore, both members of the bridge team operated under erroneous assumptions about their role within the team, believing that the other ...
Who it affects: Searoad Shipping
Issue owner:
Operation affected:
Date, status, type
Date: 23 Jul 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080027
Description: MR20080027: Safety Issue Neither Searoad Mersey nor Ormiston had adequate bridge procedures or an adequate passage plan, with respect to identifying, monitoring and managing traffic. Safety Recommendation The Australian Transport Safety Bureau recommends that Searoad Shipping takes safety action to address this safety issue.
Who it affects: Searoad Shipping
Issue owner:
Operation affected:
Date, status, type
Date: 23 Jul 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080028
Description: MR20080028: Safety Issue Neither Searoad Mersey nor Ormiston had adequate bridge procedures or an adequate passage plan, with respect to identifying, monitoring and managing traffic. Safety Recommendation The Australian Transport Safety Bureau recommends that ASP Ship Management takes safety action to address this safety issue.
Who it affects: ASP Ship management
Issue owner:
Operation affected:
Date, status, type
Date: 23 Jul 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080029
Description: MR20080029: Safety Issue The operating procedures for the vessel traffic service (VTS) covering the South Channel did not define any operations that had an increased level of risk and which may have required greater vigilance. Furthermore, the procedures did not define any operating limits to provide guidance for the VTS operators to determine when they should intervene. Safety ...
Who it affects: Port of Melbourne Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 23 Jul 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MS20080026
Description: MS20080026: Safety Issue The lack of effective radio communication between the two ships meant that Searoad Mersey was not alerted to the presence of the oncoming Ormiston. By not using the radio, Ormiston's master did not take all available measures to reduce the risk of collision. Safety Advisory Notice The Australian Transport Safety Bureau advises that ship owners, operators ...
Who it affects: Ship owners, operators and masters
Issue owner:
Operation affected:
Date, status, type
Date: 23 Jul 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080019
Description: MS20080019: Safety Issue The fumigation contractor did not adequately consider the risks associated with burying the aluminium phosphide fumigant in the cargo. Safety Advisory Notice The Australian Transport Safety Bureau advises that ship owners, operators, masters and fumigation contractors should consider the safety implications of this safety issue and to take action where it is considered appropriate.
Who it affects: Ship owners, operators, masters and fumigation contractors
Issue owner:
Operation affected:
Date, status, type
Date: 26 Jun 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080020
Description: MS20080020: Safety Issue Jin Hui's master was not supplied with sufficient information to enable the ship's crew to effectively supervise the application of the aluminium phosphide fumigant. Safety Advisory Notice The Australian Transport Safety Bureau advises that ship owners, operators, masters and fumigation contractors should consider the safety implications of this safety issue and to take action where it ...
Who it affects: Ship owners, operators, masters and fumigation contractors
Issue owner:
Operation affected:
Date, status, type
Date: 26 Jun 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MR20080020
Description: MR20080020: Safety Issue The maintenance of the generator flexible fuel hoses was inadequate. Inappropriate temporary repairs had been made and hoses longer than specified by the generator manufacturer had been used in the past. As a result, some hoses were in poor condition due to wear and this had not been noted during previous surveys, audits and ...
Who it affects: Baltimar A/S, Denmark
Issue owner:
Operation affected:
Date, status, type
Date: 25 Jun 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080021
Description: MR20080021: Safety Issue The generator manufacturer's instruction book provided no guidance for the maintenance or routine replacement of the flexible fuel hoses. Safety Recommendation The Australian Transport Safety Bureau recommends that Wartsila NSD Australia take action to address this safety issue.
Who it affects: Wartsila NSD Australia
Issue owner:
Operation affected:
Date, status, type
Date: 25 Jun 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080022
Description: MR20080022: Safety Issue Baltimar Boreas's safety management system provided no guidance for the maintenance or replacement of the generator flexible fuel hoses. Safety Recommendation The Australian Transport Safety Bureau recommends that Baltimar A/S take action to address this safety issue.
Who it affects: Baltimar A/S, Denmark
Issue owner:
Operation affected:
Date, status, type
Date: 25 Jun 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080023
Description: MR20080023: Safety Issue The design of Baltimar Boreas's diesel generator fuel system with respect to the length and arrangement of its flexible fuel hoses was not in accordance with International Maritime Organization guidelines. A number of the hoses were not as short as practicable and their use was not limited to only those positions or locations where ...
Who it affects: Lloyds Register
Issue owner:
Operation affected:
Date, status, type
Date: 25 Jun 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080024
Description: MR20080024: Safety Issue The design of Baltimar Boreas's diesel generator fuel system with respect to the length and arrangement of its flexible fuel hoses was not in accordance with International Maritime Organization guidelines. A number of the hoses were not as short as practicable and their use was not limited to only those positions or locations where ...
Who it affects: Wartsila NSD Australia
Issue owner:
Operation affected:
Date, status, type
Date: 25 Jun 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080025
Description: MR20080025: Safety Issue The emission of smoke, sparks and flame from Baltimar Boreas's funnel ventilators just after the engine room fire started effectively cut off access to their locally operated fire dampers which prevented them from being closed. The closing arrangements for the ships funnel ventilators, therefore, did not comply with the intent of the relevant provisions ...
Who it affects: Lloyds Register
Issue owner:
Operation affected:
Date, status, type
Date: 25 Jun 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MS20080021
Description: MS20080021: Safety Issue The maintenance of the generator flexible fuel hoses was inadequate. Inappropriate temporary repairs had been made and hoses longer than specified by the generator manufacturer had been used in the past. As a result, some hoses were in poor condition due to wear and this had not been noted during previous surveys, audits and ...
Who it affects: Ship owners, operators and managers
Issue owner:
Operation affected:
Date, status, type
Date: 25 Jun 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080022
Description: MS20080022: Safety Issue The generator manufacturer's instruction book provided no guidance for the maintenance or routine replacement of the flexible fuel hoses. Safety Advisory Notice The Australian Transport Safety Bureau advises that the manufacturers of marine diesel engines should consider the safety implications of this safety issue and take action when considered appropriate.
Who it affects: Manufacturers of marine diesel engines
Issue owner:
Operation affected:
Date, status, type
Date: 25 Jun 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080023
Description: MS20080023: Safety Issue Baltimar Boreas's safety management system provided no guidance for the maintenance or replacement of the generator flexible fuel hoses. Safety Advisory Notice The Australian Transport Safety Bureau advises that ship owners, operators and managers should consider the safety implications of this safety issue and take action when considered appropriate.
Who it affects: Ship owners, operators and managers
Issue owner:
Operation affected:
Date, status, type
Date: 25 Jun 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080024
Description: MS20080024: Safety Issue While Baltimar Boreas's Halon fixed fire extinguishing system's instruction book provided guidance with regard to the minimum time to allow before considering entry into the protected space after the release of Halon, the master and crew were not aware of the guidance and entered the engine room too soon after the Halon was released. Safety ...
Who it affects: Ship owners, operators and masters
Issue owner:
Operation affected:
Date, status, type
Date: 25 Jun 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080025
Description: MS20080025: Safety Issue At the time of the fire, Baltimar Boreas did not have a dedicated lookout on the bridge during the hours of darkness. The high navigational risks that the ship was exposed to at night while navigating coastal waters were further increased when the second mate left the bridge unattended to investigate the fire ...
Who it affects: Ship owners, operators and masters
Issue owner:
Operation affected:
Date, status, type
Date: 25 Jun 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MR20080003
Description: MR20080003:Sea-Tow did not provide adequate guidance for its tug masters with respect to anchoring a barge and leaving it unattended. Furthermore, the Sea-Tow safety management system did not provide procedures or guidance to disseminate safety information following accidents or incidents involving tugs or barges. Safety Recommendation The Australian Transport Safety Bureau acknowledges ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 06 Jun 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080004
Description: MR20080004:The Carnarvon harbour master was not fully aware of recreational vessel activities in Carnarvon when he provided advice on where to anchor Seatow 61. His advice was based on the good holding ground of the anchorage, its proximity to the boat harbour and the assumption that the barge would remain ...
Who it affects: Marine Safety Business Unit of the Western Australian Department for Planning and Infrastructure
Issue owner:
Operation affected:
Date, status, type
Date: 06 Jun 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080005
Description: MR20080005:The Harbour Master's Operational Manual and the Service Level Agreement between the Marine Safety Business Unit and the Regional Services Branch did not provide sufficient guidance for either the harbour master or the regional transport officer to ensure that all navigational risks for Carnarvon were identified and assessed so that ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 06 Jun 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080006
Description: MR20080006:Despite it being unusual for a barge to anchor off Carnarvon, the Marine Safety Business Unit did not consider it necessary to alert any boat operators to the barge's presence in an area that was regularly transited by them. Safety Recommendation The Australian Transport Safety Bureau recommends that the Marine Safety Business ...
Who it affects: Marine Safety Business Unit of the Western Australian Department for Planning and Infrastructure
Issue owner:
Operation affected:
Date, status, type
Date: 06 Jun 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MS20080006
Description: MS20080006: Safety Issue Norma Jean's probable speed was too high in the almost complete darkness, increasing the risk and consequences of a collision. At a lower speed, the skipper would have had more time to react after seeing the barge and may have avoided colliding with it. A lower speed would also have lessened the impact ...
Who it affects: Owners and operators of recreational vessels
Issue owner:
Operation affected:
Date, status, type
Date: 06 Jun 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080007
Description: MS20080007: Safety Issue Norma Jean's skipper did not keep an effective lookout just before the collision. Whilst he may have been 'looking out', the likely condition of his eyesight, the boat's speed and the lighting inside the boat's cockpit would have reduced his ability to maintain an effective lookout in the darkness. Safety Advisory Notice The Australian Transport ...
Who it affects: Owners and operators of recreational vessels
Issue owner:
Operation affected:
Date, status, type
Date: 06 Jun 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080008
Description: MS20080008: Safety Issue While the lighting on board the barge Seatow 61 complied with the requirements of the International Regulations for the Prevention of Collisions at Sea, 1972, as amended (COLREGS), it was not sufficient to alert Norma Jean's skipper to the barge's presence early enough to prevent the collision. Furthermore, the lighting did not reflect all ...
Who it affects: Owners and operators of vessels that are, or possibly can be, unmanned
Issue owner:
Operation affected:
Date, status, type
Date: 06 Jun 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080009
Description: MS20080009: Safety Issue There was no designated, charted anchorage for the port. Safety Advisory Issue The Australian Transport Safety Bureau advises that harbour masters and port authorities should consider the safety implications of this safety issue and take action where considered appropriate.
Who it affects: Harbour masters and port authorities
Issue owner:
Operation affected:
Date, status, type
Date: 06 Jun 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MR20080007
Description: MR20080007:The Port Hedland Port Authority did not identify the possibility of a ship breaking away from its berth and adequately assess or address the associated risks in the port emergency plan. Safety Recommendation The Australian Transport Safety Bureau recommends that the Port Hedland Port Authority takes action to address this safety issue.
Who it affects: Port Hedland Port Authority
Issue owner:
Operation affected:
Date, status, type
Date: 05 Jun 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080008
Description: MR20080008: Safety issue Creciente's classification society, Lloyd's Register, did not have rules or guidelines in place to ensure that the mooring winch brakes were adequately inspected and maintained, allowing the condition of the brakes to deteriorate and slip at below their designed holding capacity. Safety Recommendation The Australian Transport Safety Bureau recommends that Lloyd's Register takes action to address ...
Who it affects: Lloyd's Register
Issue owner:
Operation affected:
Date, status, type
Date: 05 Jun 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MS20080010
Description: MS20080010: Safety Issue The additional layers of mooring rope stored on the mooring winch drums effectively reduced the holding power of the winch brakes, which caused the brakes to slip at below their designed holding capacity. Safety Advisory Notice The Australian Transport Safety Bureau advises that ship owners, operators and masters should consider the safety implications of this safety ...
Who it affects: Ship owners, operators and masters
Issue owner:
Operation affected:
Date, status, type
Date: 05 Jun 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080011
Description: MS20080011: Safety Issue The winch brake drums had not been effectively maintained, being heavily pitted and generally in poor condition, which further decreased the brakes holding capacity. Safety Advisory Notice The Australian Transport Safety Bureau advises that ship owners, operators and masters should consider the safety implications of this safety issue and take action where considered appropriate.
Who it affects: Ship owners, operators and masters
Issue owner:
Operation affected:
Date, status, type
Date: 05 Jun 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080012
Description: MS20080012: Safety Issue The mooring lines were not monitored effectively in the period leading up to the incident, which allowed the ship to move away from the wharf, because insufficient manpower was utilised for the task. Safety Advisory Notice The Australian Transport Safety Bureau advises that ship owners, operators and masters should consider the safety implications of this safety ...
Who it affects: Ship owners, operators and masters
Issue owner:
Operation affected:
Date, status, type
Date: 05 Jun 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080013
Description: MS20080013: Safety Issue Many of the mooring winch brakes were probably not fully applied which allowed the brakes to slip more easily. Safety Advisory Notice The Australian Transport Safety Bureau advises that ship owners, operators and masters should consider the safety implications of this safety issue and take action where considered appropriate.
Who it affects: Ship owners, operators and masters
Issue owner:
Operation affected:
Date, status, type
Date: 05 Jun 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080014
Description: MS20080014: Safety Issue Creciente did not have any guidelines or procedures for mooring the ship. Consequently, the master did not adequately assess the risks that the ship's mooring arrangement, and the likely winch brake condition, posed to the ship's ability to remain at its berth under the prevailing tidal conditions. Safety Advisory Issue The Australian Transport Safety Bureau ...
Who it affects: Ship owners, operators and masters
Issue owner:
Operation affected:
Date, status, type
Date: 05 Jun 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MR20080001
Description: MR20080001:The ship's safety management system procedures did not provide sufficient guidance to ensure that the crew appropriately assessed the risks associated with removing the stoppers from the hatch covers. As a result, adequate precautions, in the form of a continuous fire watch inside the cargo hold, were not implemented before ...
Who it affects: Briese Schiffahrts
Issue owner:
Operation affected:
Date, status, type
Date: 28 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080002
Description: MR20080002:The fire fighters had received little training in fire fighting on board ships and had only limited experience in responding to such fires. As a result, the hatch covers were prematurely opened on 16 August to enable them to see the fire and assess the situation. Then, when they closed ...
Who it affects: Fire and Emergency Services Authority of Western Australia
Issue owner:
Operation affected:
Date, status, type
Date: 28 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MS20080003
Description: MS20080003: Safety Issue The ship's cargo stowage plan was neither accurate nor complete. Consequently, the ship was in breach of the SOLAS requirements for the carriage of dangerous goods. However, more importantly, the ship's master, its crew and the fire fighters were not armed with documentation that clearly outlined the location, and types, of dangerous goods that ...
Who it affects: Ship owners, operators and masters
Issue owner:
Operation affected:
Date, status, type
Date: 28 May 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080004
Description: MS20080004: Safety Issue The fitter removing the stoppers from the cargo hold hatch covers could not read English and hence could not fully understand the requirements of the ship's safety management system hot work permit. Safety Advisory Notice The Australian Transport Safety Bureau advises that ship owners, operators and masters should consider the safety implications of this safety issue ...
Who it affects: Ship owners, operators and masters
Issue owner:
Operation affected:
Date, status, type
Date: 28 May 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080005
Description: MS20080005: Safety Issue The application of a blanket of hi-expansion foam over the cargo, during the night of 17 August 2007, was effective in preventing the fire from spreading until the local stocks of foam concentrate were exhausted. Safety Advisory Notice The Australian Transport Safety Bureau advises that the Fire and Emergency Services Authority of Western Australia should ...
Who it affects: Fire and Emergency Services Authority of Western Australia
Issue owner:
Operation affected:
Date, status, type
Date: 28 May 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MR20080009
Description: MR20080009: Safety issue The safety management system on board Pasha Bulker did not provide the master with specific guidance about safely putting to sea in adverse weather. Neither the masters standing orders nor the passage plan form prescribed in the safety management system contained any guidance with regard to bridge resource or team management or encouraged its ...
Who it affects: Fukujin Kisen Company
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080010
Description: MR20080010:Newcastle Vessel Traffic Information Centres advisory role was not properly understood by the masters of a number of the ships in the Newcastle anchorage on 7 June 2007. Safety Recommendation The Australian Transport Safety Bureau recommends that Newcastle Port Corporation take action to address this safety issue.
Who it affects: Newcastle Port Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080011
Description: MR20080011: Safety Issue Newcastle Port Corporations incident control system was activated at about 0830 on 8 June 2007, suggesting that the corporation was not sufficiently responsive to the increasing seriousness of the situation that developed off the port from the evening of 7 June. As a result, the Australian Maritime Safety Authority was not notified until about ...
Who it affects: Newcastle Port Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080012
Description: MR20080012: Safety Issue Newcastle Vessel Traffic Information Centre's offers of assistance to Pasha Bulker's master were made at a late stage in extreme weather conditions when it was unlikely that any practical assistance could be provided. Safety Recommendation The Australian Transport Safety Bureau recommends that Newcastle Port Corporation take action to address this safety issue.
Who it affects: Newcastle Port Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080013
Description: MR20080013: Safety Issue Newcastle Vessel Traffic Information Centre requested the masters of four ships to leave the anchorage at a very late stage, when the weather conditions were extreme and just before Pasha Bulker grounded. The masters of several ships, including Pasha Bulker, had expected the centre to provide them with similar guidance earlier, when weather conditions ...
Who it affects: Newcastle Port Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080014
Description: MR20080014: Safety Issue On 8 June 2007, Newcastle Vessel Traffic Information Centres advice was limited to the masters of only those ships that were dragging their anchors. Some masters assumed, incorrectly, that the appropriate time to weigh anchor was when the centre informed them that their anchor was dragging and may have waited for this guidance to ...
Who it affects: Newcastle Port Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080015
Description: MR20080015: Safety Issue On 8 June 2007, Newcastle Vessel Traffic Information Centre did not cancel the scheduled berthing of any ship even after weather conditions had become severe. This may have compounded the confusion of some masters about the appropriate time to leave the anchorage. Safety Recommnedation The Australian Transport Safety Bureau recommends that Newcastle Port Corporation take action ...
Who it affects: Newcastle Port Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080016
Description: MR20080016: Safety Issue On 8 June 2007, Newcastle Vessel Traffic Information Centre asked the masters of three ships, including Pasha Bulker, to leave the restricted area off the ports entrance. Given that all three ships were struggling to clear the coast and that there was no need to keep the area clear because there was no ...
Who it affects: Newcastle Port Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080017
Description: MR20080017: Safety Issue On 8 June 2007, one ship fouled its anchor on a discarded anchor cable which delayed it from safely putting to sea. At least 40 discarded anchors and cables lie on the seabed in the Newcastle anchorage but most are not charted. The position of some of these hazards and the approximate location ...
Who it affects: Newcastle Port Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080018
Description: MR20080018: Safety issue The queue of 57 ships off Newcastle on 7 June 2007 increased the risk of collisions, groundings and other difficulties in the subsequent heavy weather. Capacity allocations systems have proved effective in reducing the queue in the past and, consequently, reduced the risks to ships, the port and the environment. The significant public benefit ...
Who it affects: Newcastle Port Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20080019
Description: MR20080019: Safety Issue The queue of 57 ships off Newcastle on 7 June 2007 increased the risk of collisions, groundings and other difficulties in the subsequent heavy weather. Capacity allocations systems have proved effective in reducing the queue in the past and, consequently, reduced the risks to ships, the port and the environment. The significant public benefit ...
Who it affects: Port Waratah Coal Services
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: MS20080015
Description: MS20080015: Safety Issue The safety management system on board Pasha Bulker did not provide the master with specific guidance about safely putting to sea in adverse weather. Neither the master's standing orders nor the passage plan form prescribed in the safety management system contained any guidance with regard to bridge resource or team management or encouraged its ...
Who it affects: Owners, operators and masters of ships
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080016
Description: MS20080016: Safety Issue Water depths in parts of Newcastle anchorage make it difficult for sufficient length of cable to be deployed to anchor a ship safely. On 7-8 June 2007, the masters of a number of ships in the anchorage had not deployed the Admiralty recommended minimum scope of anchor cable and fewer still had deployed ...
Who it affects: Owners, operators and masters of ships
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080017
Description: MS20080017: Safety Issue On 8 June 2007, a number of ships off Newcastle were inappropriately ballasted for the forecast weather and some took additional ballast after the onset of heavy weather. These ships were exposed not only to the risk of manoeuvring difficulties but also structural damage caused by the water ballast sloshing in partly filled cargo ...
Who it affects: Owners, operators and masters of ships
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080018
Description: MS20080018: Safety Issue A number of masters at Newcastle anchorage on 8 June 2007 had inadequate knowledge of the local weather and the limitations of the Newcastle anchorage. Operational, rather than safety considerations, may have been the priority in their decisions to remain anchored. Consequently, most of the ships remained at anchor in heavy weather and later ...
Who it affects: Owners, operators and masters of ships
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080001
Description: MS20080001: Safety Issue The ships safety management system was not effective in ensuring that the crew carried out a formal risk analysis for the hazardous task of preparing the cargo holds with hydrochloric acid. Safety Advisory Notice The ATSB advises that Dojima Marine should consider the safety implications of this safety issue and to take action where ...
Who it affects: Dojima Marine
Issue owner:
Operation affected:
Date, status, type
Date: 31 Jan 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20080002
Description: MS20080002: Safety Issue The ship's crew were not aware of the safety information provided by material safety data sheets. Safety Advisory Notice The ATSB advises that Dojima Marine should consider the safety implications of this safety issue and to take action where it is considered appropriate.
Who it affects: Dojima Marine
Issue owner:
Operation affected:
Date, status, type
Date: 31 Jan 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20070018
Description: MS20070018: Safety Issue Silky Ocean's master and crew did not appropriately consider the information provided by the navigational charts and publications when they planned the ship's passage from Port Kembla to Ardrossan. This led to the ship sailing through a charted fishing area and being two miles closer to the coastline than was recommended.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 20 Dec 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20070019
Description: MS20070019: Safety Issue During the period of time leading up to the collision, Silky Ocean's third mate was not keeping a proper lookout by sight and he was not appropriately using all means available, in particular the radar, to make a full appraisal of the situation and the risk of collision. Safety Advisory Notice The Australian Transport Safety ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 20 Dec 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20070022
Description: MS20070022: Safety Issue Peter Crombie was possibly difficult to detect, either visually or by radar, because of the vessels timber construction, paint scheme, lack of a radar reflector and 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 ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 20 Dec 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MR20070027
Description: MR20070027: Safety Issue The engine manufacturer did not provide sufficient guidance for monitoring the fatigue life of the gudgeon pin or for inspecting the gudgeon pin for early signs of impending failure. Safety Recommendation The Australian Transport Safety Bureau recommends that SEMT Pielstick, and its licensees, take action to address this safety issue.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 20 Nov 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070030
Description: MR20070030: Safety Issue The Australian Maritime Safety Authority did not appropriately assess the risks associated with the leakage of dangerous goods on board Kota Pahlawan until 19 June 2006, more than one day after the master had reported it and before the ship started its transit of the Great Barrier Reef Inner Route. Safety Recommendation The Australian Transport ...
Who it affects: Australian Maritime Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 20 Nov 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070031
Description: MR20070031: Safety Issue The actions taken by the Port of Brisbane Corporation on 24 June 2006, in relation to the reloading of the xanthates containers onto Kota Pahlawan, were inconsistent with its publicly stated core value of 'safety first' and did not adequately consider the master's legal and safety responsibilities to comply with the requirements of the ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 20 Nov 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070032
Description: MR20070032: Safety Issue The Australian Maritime Safety Authority has advised that xanthates have a recognised capacity to emit the odour of carbon disulphide even when packaged in accordance with the International Maritime Dangerous Goods Code and an odour from xanthates shipments, similar to Kota Pahlawan's, is commonplace according to their Australian importers. This suggests that the information for ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 20 Nov 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MS20070014
Description: MS20070014: Safety Issue The odour of carbon disulphide vapours from xanthates shipments, similar to Kota Pahlawan's, was known to be commonplace by Australian importers of xanthates. This indicates that xanthates are frequently not hermetically sealed strictly in accordance with the International Maritime Dangerous Goods Code. This regular violation of the Code's requirements was not reported. Safety Advisory Notice The ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 20 Nov 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20070015
Description: MS20070015: Safety Issue The odour of carbon disulphide vapours from xanthates containers on board Kota Pahlawan indicated that the xanthates were not hermetically sealed strictly in accordance with the International Maritime Dangerous Goods Code and there was an increased risk of a fire or toxic exposure incident. Safety Advisory Notice The Australian Transport Safety Bureau advises that shippers, receivers, ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 20 Nov 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20070016
Description: MS20070016: Safety Issue The Australian Maritime Safety Authority was not made aware of the dangerous goods leakage on board Kota Pahlawan until 18 June 2006, two days after it was first noted by the ship's crew. Safety Advisory Notice The Australian Transport Safety Bureau advises that owners, operators and masters of ships should consider the safety implications of this ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 20 Nov 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20070017
Description: MS20070017: Safety Issue The packing group assigned to sodium isobutyl xanthate and sodium isopropyl xanthate in the dangerous goods declarations for carriage on board Kota Pahlawan was not consistent with the packing group assigned to them in the material data safety sheets provided by the consignees for these consignments. Safety Advisory Notice The Australian Transport Safety Bureau advises ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 20 Nov 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20070011
Description: MS20070011: Safety Issue The ship's crew were not aware of similar previous flashbacks involving Osaka OECV2 boilers and they were not aware of all of the hazards associated with servicing the boiler burner. Safery Advisory Notice The Australian Transport Safety Bureau advises that ship owners, operators and masters should consider the safety implications of this safety issue and ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 16 Nov 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20070012
Description: MS20070012: Safety Issue The personal protective equipment being used by the crew members while they were servicing the boiler burner did not provide them with adequate protection and, therefore, was not appropriate for the task. Safety Advisory Notice The Australian Transport Safety Bureau advises that ship owners, operators and masters should consider the safety implications of this safety issue ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 16 Nov 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20070013
Description: MS20070013: Safety Issue The injured crew members were not provided with the appropriate first aid treatment for their burn injuries. Safety Advisory Notice The Australian Transport Safety Bureau advises that ship owners, operators and masters should consider the safety implications of this safety issue and take action where it is considered appropriate.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 16 Nov 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MR20070028
Description: MR20070028: Safety Issue The maintenance for a critical piece of equipment, the main lubricating oil pump, was not planned according to the manufacturers recommendation, despite the fact that a previous failure had occurred. Safety Recommendation The Australian Transport Safety Bureau recommends that AJ Ship Management takes action to address this safety issue.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 20 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070029
Description: MR20070029: Safety Issue The shipboard procedures and practices for operating, maintaining and monitoring the K8E lubricating oil filter were inadequate. The standby filter was not checked to ensure that it was ready for use and the in-service K8E filter's condition was not adequately monitored. Safety Recommendation The Australian Transport Safety Bureau recommends that AJ Ship Management takes action to ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 20 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MS20070021
Description: MS20070021: Safety Issue At the time of the collision, there was no lookout being maintained on board Peter Crombie. The skipper had not adequately managed the crews work/rest periods and, consequently, on the morning of 23 April, they were all tired and needed to sleep. Furthermore, the skipper did not consider it necessary to keep a lookout ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 20 Oct 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20070009
Description: MS20070009: Safety Issue The placement of the steam vent pipe, and the direction in which it exhausted, meant that any personnel on the funnel casing top platform were vulnerable when a boiler safety valve operated. Safety Advisory Notice The ATSB advises the owners, operators and masters of ships to consider the implications of this safety issue and ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 27 Sep 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20070010
Description: MS20070010: Safety Issue The surveyor did not check that the ships crew had implemented strategies that would effectively control the risks associated with operating the boiler safety valves. Safety Advisory Notice The ATSB advises surveyors to consider the implications of this safety issue and take action where it is considered appropriate.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 27 Sep 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20070027
Description: MS20070027: Safety Issue The senior deck and engineering officers did not discuss their work programs frequently enough to ensure that each department was always aware of the others activities. Safety Advisory Notice The ATSB recommends that MSC Ship Management takes action to address this safety issue.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 27 Sep 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MR20070022
Description: MR20070022: Safety Issue The ship's procedures for re-entry into the engine room after the operation of the FM-200 fire extinguishing system did not adequately consider the time required to cool the fire scene and did not provide the master with adequate guidance about when to safely re-enter the engine room, therefore, exposing the ship to the potential ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070024
Description: MR20070024: Safety Issue The endurance test, as required by the American Bureau of Shipping (ABS), was not successfully completed before ABS issued a certificate of class for the platform in March 2005. Consequently, unresolved faults remained in the propulsion electrical system that may have compromised the platforms DP-2 classification. Safety Recommendation The Australian Transport Safety Bureau recommends that ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MS20070002
Description: MS20070002: Safety Issue The absence of a discharge valve on the main fuel pump necessitated the fitting of blanks in the fuel system so that the engine could be run using the stand-by pump, while keeping the main pump depressurised. Safety Advisory Notice The Australian Transport Safety Bureau advises that the owners and operators of ships should consider ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jun 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20070003
Description: MS20070003: Safety Issue The fitting of gasket discs in an open ended cap to blank off a fuel pipe was ineffective for the task because the discs probably became looser due to the effect of pressure pulses within the fuel pipe, allowing fuel to spray into the engine room where it was ignited on the hot ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jun 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20070004
Description: MS20070004: Safety Issue Leaving fire doors open between the engine room and the fire control station exposed the ship to the risk that its fire control systems could be rendered inoperable by an engine room fire. Safety Advisory Notice The Australian Transport Safety Bureau advises that the owners, operators and masters of ships should consider the safety implications ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jun 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20070007
Description: MS20070007: Safety Issue While suitable materials were used for the task of bridging out a major electrical component, the task was not adequately performed, resulting in a fire in the cabinet housing the electrical equipment. Safety Advisory Notice The Australian Transport Safety Bureau advises that the owners and operators of platforms consider the safety implications of this safety issue ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jun 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20070008
Description: MS20070008: Safety Issue The safety case submitted to the National Offshore Petroleum Safety Authority (NOPSA) did not take into account the problems within the propulsion electrical system that had occurred before the platform was deployed to the Yolla gas field in Bass Strait, Australia. Safety Advisory Notice The Australian Transport Safety Bureau advises that the owners and operators of ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jun 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MR20070025
Description: MR20070025: Safety Issue The American Bureau of Shipping (ABS) rules do not define Safe Concordias column structure spaces, containing the propulsion electrical system, as Category A machinery spaces. Therefore, the need for a fixed fire fighting extinguishing system and two means of access to the thruster machinery spaces have not been adequately addressed. Safety Recommendation The Australian Transport Safety ...
Who it affects: American Bureau of Shipping (ABS)
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070023
Description: MR20070023: Safety Issue The ship's elevator instruction manuals did not provide the crew with sufficiently detailed and unambiguous safety guidance. Safety Recommendation The Australian Transport Safety Bureau recommends that the Hyundai Elevator Company takes action to address this safety issue.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 22 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MS20070005
Description: MS20070005: Safety Issue The ship's safety management system risk minimising strategies, including the permit to work system and the risk assessment process, were not implemented before the electrical technician started working on the elevator second deck landing door switches. Safety Advisory Notice The Australian Transport Safety Bureau advises ship owners, operators and masters to consider the implications of this ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 22 Jun 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MS20070006
Description: MS20070006: Safety Issue The electrical technician, the second engineer and the third engineer were either not aware of, or did not consider, all of the hazards associated with working in the ship's elevator shaft. Safety Advisory Notice The Australian Transport Safety Bureau advises ship owners, operators and masters to consider the implications of this safety issue and to ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 22 Jun 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MR20070019
Description: MR20070019: Safety Issue The vessel's engine room and accommodation ventilation arrangements did not comply with the relevant requirements with respect to their closing arrangements. Safety Recommendation The Australian Transport Safety Bureau recommends that Marine and Safety Tasmania takes action to address this safety issue.
Who it affects: Marine and Safety Tasmania
Issue owner:
Operation affected:
Date, status, type
Date: 15 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070020
Description: MR20070020: Safety Issue The vessel's battery locker ventilator and fuel tank air pipes were not fitted with adequate closing arrangements. Safety Recommendation The Australian Transport Safety Bureau recommends that the owners of Windeward Bound takes action to address this safety issue.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 15 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070021
Description: MR20070021: Safety Issue The considerations, with respect to the vessel meeting the intact stability requirements, taken by Marine and Safety Tasmania, should have been made available to the Australian Maritime Safety Authority before the vessel was permitted to undertake an interstate voyage. Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian Maritime Safety Authority takes action to ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 15 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MS20070001
Description: MS20070001: Safety Issue The vessel was unable to transmit an AUSREP deviation report after the change of course to Jervis Bay during the afternoon of 4 June due to the fact that the generator was not operational and so the computer used to compile messages for the satellite communication system was not functioning. Safety Advisory Notice The Australian ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 15 Jun 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: MR20070009
Description: MR20070009: Safety Recommendation Port Phillip Sea Pilots should review their training, procedures and practices to ensure that pilots implement all aspects of bridge resource management, to ensure that all bridge team members are aware of their responsibilities, and how the pilot expects the bridge team to interact.
Who it affects: Port Phillip Sea Pilots
Issue owner:
Operation affected:
Date, status, type
Date: 02 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070010
Description: MR20070010: Safety Recommendation Port Phillip Sea Pilots should review their procedures and practices to ensure that pilots board ships at a location that ensures sufficient time is available for the pilot to adequately brief the crew before the ship reaches the port's entrance.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 02 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070011
Description: MR20070011: Safety Recommendation Port Phillip Sea Pilots should review their procedures and practices to ensure that squat and the ship's movement in the prevailing conditions are adequately considered when it's under keel clearance is calculated.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 02 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070012
Description: MR20070012: Safety Recommendation The Shipping Corporation of India should review their training, procedures and practices to ensure that all aspects of bridge resource management are implemented on board their ships; and that all bridge team members are aware of their responsibilities, and how they are expected to interact with a pilot.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 02 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070013
Description: MR20070013: Safety Recommendation The Shipping Corporation of India should review the procedures and practices on board their ships in relation to the use and monitoring of echo sounders.
Who it affects: Shipping Corporation of India
Issue owner:
Operation affected:
Date, status, type
Date: 02 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070014
Description: MR20070014: Safety Recommendation Suppliers of hoses and fittings for high pressure oxygen installations should ensure that the equipment they supply is fit for purpose and manufactured according to appropriate standards.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 02 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070015
Description: MR20070015: Safety Recommendation The Australian Maritime Safety Authority should consider reviewing Marine Orders Part 12, or issuing a Marine Notice, with the aim of highlighting the potential risks of high pressure oxygen systems.
Who it affects: Australian Maritime Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 02 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070016
Description: MR20070016: Safety Recommendation Det Norske Veritas should consider reviewing its rules with the aim of providing more detailed guidance for high pressure oxygen systems.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 02 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070017
Description: MR20070017: Safety Recommendation Ship owners, managers and masters should ensure that equipment procured for fixed high pressure oxygen installations is fit for purpose in accordance with the appropriate standard and that the system is adequately maintained.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 02 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070018
Description: MR20070018: Safety Recommendation Parker Hannifin should review its Newsletter, 'Hose assemblies used with oxygen' and training procedures/practices in line with the international standard ISO 14113.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 02 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070001
Description: MR20070001: Safety Recommendation Pilots and masters should ensure that they are able to read, or otherwise be able to check, the rudder angle when conning a ship. They should also ensure that the conventions governing helm orders are observed, particularly the use of 'midships' when changing rudder direction, and 'closing the loop' when communicating orders to a ...
Who it affects: Pilots and masters
Issue owner:
Operation affected:
Date, status, type
Date: 16 Mar 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070002
Description: MR20070002: Safety Recommendation TasPorts should consider reviewing their procedures with respect to contingency planning with a view to providing pilots with adequate support aimed at preventing groundings and ensuring that a pilot's response to grounding is effective and helps to mitigate the potential adverse consequences.
Who it affects: TasPorts
Issue owner:
Operation affected:
Date, status, type
Date: 16 Mar 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070003
Description: MR20070003: Safety Recommendation TasPorts should review their procedures to ensure that the use of mobile telephones by pilots, if at all permitted, does not interfere with the safe navigation of ships in pilotage areas.
Who it affects: TasPorts
Issue owner:
Operation affected:
Date, status, type
Date: 16 Mar 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070004
Description: MR20070004: Safety Recommendation TasPorts should consider revising the standard passage plan for Bell Bay, and its means of dissemination, to make it possible for ship's masters and mates to use it when preparing ship's passage plans.
Who it affects: TasPorts
Issue owner:
Operation affected:
Date, status, type
Date: 16 Mar 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070005
Description: MR20070005: Safety Recommendation ClassNK should review the conning positions identified on Crimson Mars, and other similar ships, with a view to ensuring that rudder angle indicators are readable from all conning positions.
Who it affects: ClassNK
Issue owner:
Operation affected:
Date, status, type
Date: 16 Mar 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070006
Description: MR20070006: Safety Recommendation The managers of Crimson Mars should review their safety management system with a view to ensuring that any response by ship's crews to an emergency is effective and safe.
Who it affects: Managers of Crimson Mars
Issue owner:
Operation affected:
Date, status, type
Date: 16 Mar 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070007
Description: MR20070007: Safety Recommendation Tidewater Marine should review the procedures and practices on board Massive Tide, and other ships in their fleet, to ensure that the watchkeepers comply with the instructions, relating to navigational practices, issued by the company and the ships master.
Who it affects: Tidewater Marine
Issue owner:
Operation affected:
Date, status, type
Date: 16 Mar 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20070008
Description: MR20070008: Safety Recommendation Tidewater Marine should review the procedures and practices on board Massive Tide, and other ships in their fleet, to ensure that watchkeepers meet the requirements of STCW 95 and are fit for duty.
Who it affects: Tidewater Marine
Issue owner:
Operation affected:
Date, status, type
Date: 16 Mar 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060038
Description: MR20060038: Safety Recommendation Ship owners, managers and masters should ensure that operations, maintenance and emergency procedure manuals are provided on board their ships for all critical equipment so that responsible personnel can familiarise themselves with any hazards associated with the equipment.
Who it affects: Ship owners, managers and masters
Issue owner:
Operation affected:
Date, status, type
Date: 20 Feb 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060039
Description: MR20060039: Safety Recommendation Ship owners, managers and masters of ships with ventilation openings in funnel casings which have similar closing arrangements to those on board Java Sea should assess their adequacy in consultation with the ship's classification society and Flag State administration.
Who it affects: Ship owners, managers and masters
Issue owner:
Operation affected:
Date, status, type
Date: 20 Feb 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060040
Description: MR20060040: Safety Recommendation Owners and operators of FSO and FPSO ships should provide unambiguous procedures and guidelines for the disconnection and manoeuvring of their ships during cyclones.
Who it affects: Owners and operators of FSO and FPSO ships
Issue owner:
Operation affected:
Date, status, type
Date: 20 Feb 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060041
Description: MR20060041: Safety Recommendation Owners and operators of FSO and FPSO ships should ensure that mooring hawsers and associated equipment are inspected and replaced according to their service conditions and loading.
Who it affects: Owners and operators of FSO and FPSO ships
Issue owner:
Operation affected:
Date, status, type
Date: 20 Feb 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060033
Description: MR20060033: Safety Recommendation Ship owners, operators and masters should ensure that safety harnesses and lanyards used by personnel when working aloft are appropriate for the purpose considering all aspects of the tasks to be performed.
Who it affects: Ship owners, managers and masters
Issue owner:
Operation affected:
Date, status, type
Date: 22 Dec 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060034
Description: MR20060034: Safety Recommendation Ship owners, operators and masters should ensure that the procedures, permits and risk assessments for personnel working aloft identify all of the hazards and stipulate measures to mitigate all of the risks.
Who it affects: Ship owners, operators and masters
Issue owner:
Operation affected:
Date, status, type
Date: 22 Dec 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060036
Description: MR20060036: Safety Recommendation Prime Marine Management and Probo Bears masters should review mooring practices and procedures with a view to improving preparedness and communication.
Who it affects: Prime Marine Management and Probo Bears masters
Issue owner:
Operation affected:
Date, status, type
Date: 14 Dec 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060037
Description: MR20060037: Safety Recommendation Ship managers and masters should ensure that personnel supervising mooring operations are stationed such that they can clearly sight all operations that they are responsible for.
Who it affects: Ship managers and masters
Issue owner:
Operation affected:
Date, status, type
Date: 14 Dec 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060035
Description: MR20060035: Safety Recommendation Flinders Ports should review their training regime and pilotage procedures to ensure that all pilots are adequately trained in the principles and practices of bridge resource management (BRM) as soon as possible after starting pilotage training with particular emphasis on the pilots role and the master/pilot information exchange.
Who it affects: Flinders Ports
Issue owner:
Operation affected:
Date, status, type
Date: 10 Nov 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060029
Description: MR20060029: Safety Recommendation Adsteam Harbour should review their current maintenance and reportingsystems with a view to implementing procedures that consider the causes offailures and the likelihood and risks associated with similar failures in the future.
Who it affects: Adsteam Harbour
Issue owner:
Operation affected:
Date, status, type
Date: 06 Sep 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060030
Description: MR20060030: Safety Recommendation Adsteam Harbour should carry out an assessment of the risks associated with the engineer being in the engine room during various stages of towage operations, with a view to developing procedures and practices to ensure the running machinery is more actively monitored.
Who it affects: Adsteam Harbour
Issue owner:
Operation affected:
Date, status, type
Date: 06 Sep 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060031
Description: MR20060031: Safety Recommendation Adsteam Harbour should review the alarm and monitoring systems fitted on board Tom Tough, and similar tugs in their fleet, with a view to ensuring that the alerting of tug masters to critical alarms is adequate.
Who it affects: Adsteam Harbour
Issue owner:
Operation affected:
Date, status, type
Date: 06 Sep 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060032
Description: MR20060032: Safety Recommendation All owners and operators of tugs should consider carrying out a risk analysis of their towage operations with a view to implementing a system of ongoing professional development and training in emergency procedures for their tug masters.
Who it affects: Owners and operators of tugs
Issue owner:
Operation affected:
Date, status, type
Date: 06 Sep 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060027
Description: MR20060027: Safety Recommendation Shipowners, managers and ship's engineers should ensure that the maintenance regime applied to slow speed diesel engine scavenge spaces is thorough and takes into account the engine's history, condition and conditions of service.
Who it affects: Shipowners, managers and ship's engineers
Issue owner:
Operation affected:
Date, status, type
Date: 21 Jun 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060028
Description: MR20060028: Safety Recommendation It is recommended that ABB Turbo Systems release a further service bulletin pursuant to service bulletin 5/98 detailing instances of turbocharger overspeeds with appropriate warnings and guidance for the safe operation of the affected turbochargers.
Who it affects: ABB Turbo Systems
Issue owner:
Operation affected:
Date, status, type
Date: 21 Jun 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060022
Description: MR20060022: Safety Recommendation ASP Ship Management should review the safety management systems on board River Embley and her sister ships to ensure they contain adequate control measures for critical tasks such as a steam valve repair. The review should include all job safety analysis data to ensure that the analysis is complete, reviewed and approved.
Who it affects: ASP Ship Management
Issue owner:
Operation affected:
Date, status, type
Date: 14 Jun 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060023
Description: MR20060023: Safety Recommendation Ship owners, managers and auditing authorities should review routine safety management system auditing plans to ensure that procedures and control measures that are critical to personnel safety, such as work permits, tag-out systems and safety analysis, are implemented on board all ships.
Who it affects: Ship owners, managers and auditing authorities
Issue owner:
Operation affected:
Date, status, type
Date: 14 Jun 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060024
Description: MR20060024: Safety Recommendation Training institutions, regulatory authorities and ship managers should consider the implementation of a form of team resource management training for engineers. This training should be aimed at encouraging the implementation of principles and practices consistent with the STCW95 requirements for BRM training of deck officers.
Who it affects: Training institutions, regulatory authorities and ship managers
Issue owner:
Operation affected:
Date, status, type
Date: 14 Jun 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060025
Description: MR20060025: Safety Recommendation Subee Explorer Pty Ltd should review their vessel designs, methods of construction, testing, certification, equipping and quality assurance system with a view to ensuring that vessels meet the required statutory and/or contracted standards.
Who it affects: Subee Explorer Pty Ltd
Issue owner:
Operation affected:
Date, status, type
Date: 19 May 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: MR20060026
Description: MR20060026: Safety Recommendation Search and rescue authorities should consult with satellite and other mobile telephone service providers to determine under what circumstances useful information from satellite telephones and switch records could aid search and rescue operations under certain conditions.
Who it affects: Search and rescue authorities
Issue owner:
Operation affected:
Date, status, type
Date: 19 May 2006
Status:
Type: Recommendation
Total records: 321
 
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