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Safety issues and actions

Issue, description, who it affects	Date, status, type
Issue, description, who it affects Issue: RO-2020-019-SI-01Absence of authority-overrun protection Number: RO-2020-019-SI-01 Description: RO-2020-019-SI-01:The absence of authority-overrun protection (such as TPWS) at signal SST535 increased the potential consequences of a SPAD. Issue owner: V/Line Corporation Operation affected: Rail: Passenger - regional	Date, status, type Date: 07 Dec 2021 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: MO-2018-011-SI-05 Regulatory oversight Number: MO-2018-011-SI-05 Description: MO-2018-011-SI-05 :Regulatory safety oversight of Iron Chieftain, which comprised flag State audits, surveys and inspections had not identified safety deficiencies with respect to the ship’s fire safety, risk management, emergency preparedness and emergency response. Issue owner: Australian Maritime Safety Authority Operation affected: Marine: Other	Date, status, type Date: 11 May 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: MO-2018-011-SI-04Fire and Rescue New South Wales marine firefighting capability Number: MO-2018-011-SI-04 Description: MO-2018-011-SI-04:The capability of Fire and Rescue New South Wales to effectively respond to a shipboard fire in Port Kembla, was limited by: a lack of specialised marine firefighting expertise outdated marine training for firefighters relative inexperience in shipboard firefighting associated with the rarity of major shipboard fires an absence of marine-specific firefighting resources and ... Issue owner: Fire and Rescue New South Wales Operation affected: Marine: Other	Date, status, type Date: 11 May 2021 Status: Open – Safety action pending Type: Proactive action   Safety recommendation
Issue, description, who it affects Issue: MO-2018-011-SI-03 Shipboard emergency contingency plans Number: MO-2018-011-SI-03 Description: MO-2018-011-SI-03 :Iron Chieftain's Emergency Contingency Plan did not include a response plan to fire in the high fire risk self-unloading system spaces. Consequently, there was no clear plan or practiced sequence of actions that could aid emergency preparedness. Issue owner: Canada Steamship Lines Australia Operation affected: Marine: Shipboard operations	Date, status, type Date: 11 May 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: MO-2018-011-SI-02 Inadequate standards and regulation Number: MO-2018-011-SI-02 Description: MO-2018-011-SI-02 :The cargo handling spaces of specialised self-unloading bulk carriers continue to present a very high fire risk due to the inadequacy of standards or regulations for self-unloading systems, including for conveyor belts, and dedicated fire detection/fixed fire-extinguishing systems. This has been a factor in at least three major fires over ... Issue owner: Australian Maritime Safety Authority, Lloyd’s Register, and International Association of Classification Societies Operation affected: Marine: Other	Date, status, type Date: 11 May 2021 Status: Open – Safety action pending Type: Safety recommendation   Proactive action   Proactive action
Issue, description, who it affects Issue: MO-2018-011-SI-01 Management of risk Number: MO-2018-011-SI-01 Description: MO-2018-011-SI-01 :Iron Chieftain's operators had formally identified the fire risk in the ship’s cargo self-unloading system spaces, particularly the C-Loop, as being unacceptably high 5 years before the fire due to the absence of fire detection or fixed fire extinguishing system. However, at the time of the fire, the prevention and ... Issue owner: Canada Steamship Lines Australia Operation affected: Marine: Shore-based operations	Date, status, type Date: 11 May 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: MO-2018-004-SI-001Critical spares Number: MO-2018-004-SI-001 Description: MO-2018-004-SI-001:No procedure or system was in place to ensure critical spares were identified and their inventory controlled to ensure availability when required. As a consequence, the fan belts for the emergency generator had been on order for several months. Issue owner: Kowa Marine Service Operation affected: Marine: Shipboard operations	Date, status, type Date: 11 Sep 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: MO-2018-008-SI-01 Shore planning Number: MO-2018-008-SI-01 Description: MO-2018-008-SI-01 :The ship’s manager’s (Yang Ming) cargo-planning process ashore did not ensure that the proposed container stowage plan complied with the stowage and lashing forces requirements of the ship's Cargo Securing Manual. Consequently, compliance with these requirements relied entirely on shipboard checks, made at a late stage, with limited options available ... Who it affects: Ships operated by Yang Ming Issue owner: Yang Ming Marine Transport Corporation Operation affected: Marine: Shipboard operations	Date, status, type Date: 13 Feb 2020 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2017-010-SI-02Usage of tugs Number: MO-2017-010-SI-02 Description: MO-2017-010-SI-02:Tugs were to be available to escort the mini cape-size ships until they had entered the South Channel, where they were stood down. However, the tug masters had not been trained in the specifics of escort towage nor in emergency response. Who it affects: All owners, operators and crewmembers involved in pilotage Issue owner: Ports North Operation affected: Marine: Shipboard operations	Date, status, type Date: 14 Nov 2019 Status: Closed – Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2017-010-SI-01Mini cape-size risk assessment Number: MO-2017-010-SI-01 Description: MO-2017-010-SI-01:In pre-trial simulations, the risks associated with engine failure during departure were only considered up to when a ship had entered the South Channel. Consequently, the tugs were not in attendance to assist if propulsion was lost. Who it affects: All owners, operators and crewmembers involved in pilotage Issue owner: Maritime Safety Queensland Operation affected: Marine: Shipboard operations	Date, status, type Date: 14 Nov 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2018-001-SI-01 Knowledge and use of fall arrest safety equipment Number: MO-2018-001-SI-01 Description: MO-2018-001-SI-01 :The fall arrest equipment used was incorrectly attached to the workers on the suspended platform. Consequently, had either of them fallen from the platform the equipment would not have worked correctly, resulting in serious or fatal injuries. Who it affects: All workers on ship Issue owner: Berge Bulk Maritime Operation affected: Marine: Shipboard operations	Date, status, type Date: 30 Oct 2019 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: MO-2017-009-SI-04Hydrographic use of point features Number: MO-2017-009-SI-04 Description: MO-2017-009-SI-04:The hydrographic use of point feature objects to represent physical features of relatively significant spatial extent on an Electronic Navigational Chart can increase the risk of the hazard posed by such features being misinterpreted by mariners and potentially reduce the effectiveness of the ECDIS safety checking functions. Who it affects: Vessels using Australian Electronic Navigational Charts Issue owner: Australian Hydrographic Office Operation affected: Marine: Shore-based operations	Date, status, type Date: 27 Jun 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2017-009-SI-03ECDIS software Number: MO-2017-009-SI-03 Description: MO-2017-009-SI-03:ECDIS on board most Australian Border Force cutters, including ABFC Roebuck Bay, operated with a non-type-approved naval software version that was not updated to the latest applicable standards of the International Hydrographic Organization. The ECDIS therefore did not comply with the minimum requirements of an ECDIS being used to meet ... Who it affects: Operators of Australian Border Force cutters Issue owner: Australian Border Force Operation affected: Marine: Shipboard operations	Date, status, type Date: 27 Jun 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2017-009-SI-02Vessel survey and certification Number: MO-2017-009-SI-02 Description: MO-2017-009-SI-02:Most Australian Border Force cutters, including ABFC Roebuck Bay, were installed with ECDIS operating on non-type-approved naval software. Subsequently, DNV GL, acting on behalf of the Australian Maritime Safety Authority, incorrectly certified these vessels as using type-approved ECDIS to meet the chart carriage requirements of the regulations. This removed an ... Who it affects: Australian flagged vessels Issue owner: Australian Maritime Safety Authority Operation affected: Marine: Shore-based operations	Date, status, type Date: 27 Jun 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2017-009-SI-01ECDIS familiarisation Number: MO-2017-009-SI-01 Description: MO-2017-009-SI-01:Although the online VisionMaster FT ECDIS type-specific familiarisation training included the relevant content, the training as undertaken by Australian Border Force deck officers was not effective in preparing ABFC Roebuck Bay's officers for the operational use of the ECDIS. Who it affects: Australian Border Force deck officers Issue owner: Australian Border Force Operation affected: Marine: Shipboard operations	Date, status, type Date: 27 Jun 2019 Status: Safety action pending Type: Proactive Action
Issue, description, who it affects Issue: MO-2017-001-SI-01Inadequate on-board documentation Number: MO-2017-001-SI-01 Description: MO-2017-001-SI-01:Guidelines for the provision, care and use of shipboard equipment were not supported by suitable documentation. The only documentation was for mobile scaffolding equipment of different design and not for that in use on the ship. Who it affects: All owners and operators and crewmembers involved in working aloft Issue owner: Asia Maritime Pacific Operation affected: Marine: Shipboard operations	Date, status, type Date: 21 Feb 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2015-007-SI-04Audit response Number: MO-2015-007-SI-04 Description: MO-2015-007-SI-04:The regional harbour master and the pilotage service did not have processes in place to follow up audit findings, to ensure that they were appropriately monitored, actioned and closed out in a timely manner. Who it affects: All ships entering and departing Townsville under pilotage Issue owner: Maritime Safety Queensland Operation affected: Marine: Shipboard operations	Date, status, type Date: 19 Feb 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2015-007-SI-03Tug reduction process Number: MO-2015-007-SI-03 Description: MO-2015-007-SI-03:The Port Procedures manual for Townsville allowed shipping agents to request a tug reduction without the knowledge of the ship’s master. Who it affects: All ships entering and departing Townsville under pilotage Issue owner: Maritime Safety Queensland and Port of Townsville Limited Pilotage Services Operation affected: Marine: Shipboard operations	Date, status, type Date: 19 Feb 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2015-007-SI-02Contingency planning Number: MO-2015-007-SI-02 Description: MO-2015-007-SI-02:The Port of Townsville Limited Pilotage Services’ Pilotage Service Safety Management System did not have documented guidance on berthing manoeuvres nor any associated contingencies. Who it affects: All ships entering and departing Townsville under pilotage Issue owner: Port of Townsville Limited Pilotage Services Operation affected: Marine: Shipboard operations	Date, status, type Date: 19 Feb 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2015-007-SI-01Risk management Number: MO-2015-007-SI-01 Description: MO-2015-007-SI-01:The Port of Townsville Limited Pilotage Service risk management processes were not sufficiently mature nor resilient enough to effectively identify and mitigate risks during pilotage. Who it affects: All ships entering and departing Townsville under pilotage Issue owner: Port of Townsville Limited Pilotage Services Operation affected: Marine: Shipboard operations	Date, status, type Date: 19 Feb 2019 Status: Adequately addressed Type: Proactive Action