Date:
Issue number
Safety issue title
Visual and manual checking of ladder and manropes by pilots
Safety Issue Description

The pilotage company’s procedures did not explicitly require the pilot to check the pilot ladder and manrope arrangements before disembarking the ship.

Issue Owner
Australian Reef Pilots
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Securing of manropes to the deck
Safety Issue Description

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.

Issue Owner
Dorval Ship Management
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Condensate drainage pot design
Safety Issue Description

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.

Issue Owner
Laskaridis Shipping / Jiangsu Jinling Shipyard / Lloyds Register / Australian Maritime Safety Authority
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Failure to keep a proper lookout
Safety Issue Description

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 there was an absence of early and appropriate action to avoid the collision.

Issue Owner
Fukujin Kisen and all other operators
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Class requirements
Safety Issue Description

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.

Issue Owner
ClassNK (Nippon Kaiji Kyokai)
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
On board planned maintenance system
Safety Issue Description

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.

Issue Owner
ID Wallem Ship Management
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Stevedore working hours and fatigue
Safety Issue Description

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.

Issue Owner
Newcastle Stevedores
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Aluminium ingot loading procedures
Safety Issue Description

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 tiers was not effectively monitored or enforced.

Issue Owner
Newcastle Stevedores
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Stability of aluminium ingot lifts
Safety Issue Description

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 toppling because the lifting and other straps were not designed to restrain the packs as a single homogenous cargo unit and were prone to failure.

Issue Owner
Patrick Ports and Stevedoring (Patrick) and Gearbulk Norway (Gearbulk)
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Risk assessment for the inner moorings
Safety Issue Description

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.

Issue Owner
Patrick
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Guidance for masters of ships berthed at the inner moorings
Safety Issue Description

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.

Issue Owner
Patrick
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Joining shackle locking pin effectiveness
Safety Issue Description

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 Fish Cove with new shackles that had a more robust locking pin arrangement.

Issue Owner
Patrick
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Inspection of the mooring system in Flying Fish Cove
Safety Issue Description

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.

Issue Owner
Patrick
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Bowen Tug and Barge incident reporting
Safety Issue Description

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.

Issue Owner
Bowen Tug and Barge
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Bowen Tug and Barge safety management system adequacy
Safety Issue Description

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.

Issue Owner
Bowen Tug and Barge
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Bowen Tug and Barge stores container handling
Safety Issue Description

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.

Issue Owner
Bowen Tug and Barge
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Bowen Tug and Barge compliance auditing
Safety Issue Description

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.

Issue Owner
Bowen Tug and Barge
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
BP Shipping compliance auditing
Safety Issue Description

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.

Issue Owner
BP Shipping Ltd
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Towing hook locking pin positioning
Safety Issue Description

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.

Issue Owner
Mampaey Offshore Industries, The Netherlands
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
SMS procedures for quick release of hook
Safety Issue Description

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.

Issue Owner
Sea Swift, Cairns
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine