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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