Date:
Issue number
Safety issue title
International shore connection
Safety Issue Description

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.

Issue Owner
BHP Billiton and Department of Fire and Emergency Services (DFES)
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Halon system
Safety Issue Description

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

Issue Owner
Korea Leading Company of Ship Management (KLCSM)
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Fixed fire suppression system
Safety Issue Description

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.  

Issue Owner
KLCSM
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Ventilation closedown
Safety Issue Description

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.

Issue Owner
Korea Leading Company of Ship Management (KLCSM)
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Fire doors
Safety Issue Description

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.

Issue Owner
Korea Leading Company of Ship Management (KLCSM)
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Smoking risk controls
Safety Issue Description

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.

Issue Owner
Korkyra Shipping, Croatia
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Bridge deck stairwell fire door
Safety Issue Description

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. 

Issue Owner
Korkyra Shipping, Croatia
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Safety culture
Safety Issue Description

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, and not during recreational activities.

Issue Owner
U-Ming Marine Transport, Singapore
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Implementation of SMS procedures
Safety Issue Description

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 if going over the side when not working.

Issue Owner
U-Ming Marine Transport, Singapore
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Planned and other maintenance
Safety Issue Description

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. 

Issue Owner
Shih Wei Navigation
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Bitter end securing arrangement
Safety Issue Description

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 risk.

Issue Owner
Shih Wei Navigation and ClassNK
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Weather related matters
Safety Issue Description

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 throughout the early hours of 8 May did not trigger the VTS procedural responses until 0600 – after the receipt of BoM-issued warnings.

Issue Owner
Fremantle Port Authority (Fremantle Ports)
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Collisions between ships and small vessels
Safety Issue Description

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.

Issue Owner
Master, owners, operators and skippers of all vessels
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Proper lookout
Safety Issue Description

Kota Wajar’s safety management system procedures with regard to posting a dedicated lookout were not effectively implemented.

Issue Owner
Pacific International Lines, Singapore
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Passage planning
Safety Issue Description

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.

Issue Owner
Brisbane Marine Pilots
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Simulation wire calculation
Safety Issue Description

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.

Issue Owner
Jiangsu Jiaoyan Marine Equipment Company
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
On-load release safety pin
Safety Issue Description

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.

Issue Owner
Jiangsu Jiaoyan Marine Equipment Company
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Lack of visual indication for the resetting of the release segment
Safety Issue Description

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.

Issue Owner
Jiangsu Jiaoyan Marine Equipment Company
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Simulation wire approval by a recognized organization
Safety Issue Description

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.

Issue Owner
Bureau Veritas and the International Association of Classification Societies
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Manufacturer’s instructions
Safety Issue Description

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.

Issue Owner
ISIR Impianti Srl
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine