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Safety issues and actions

Issue, description, who it affects	Date, status, type
Issue, description, who it affects Issue: MO-2017-003-SI-01Processes for the monitoring of the exciter unit insulation resistance Number: MO-2017-003-SI-01 Description: MO-2017-003-SI-01:The processes for monitoring the condition of the brushless exciter units’ electrical insulation were ineffective in detecting deterioration prior to unit failure. Who it affects: Those responsible for maintaining Azipods Issue owner: Norwegian Cruise Line Holdings Ltd (NCLH) and ABB Industry Oy (ABB) Operation affected: Marine: Shipboard operations	Date, status, type Date: 24 May 2018 Status: Safety action pending Type: Recommendation   Recommendation
Issue, description, who it affects Issue: MO-2016-005-SI-01Steering gear planned maintenance instructions Number: MO-2016-005-SI-01 Description: MO-2016-005-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: Adequately 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