Date:
Issue number
Safety issue title
Two tug requirement
Safety Issue Description

The requirement in Sea Swift’s Marine Execution Plan to let Adonis go after clearing the Clinton coal wharves was ambiguous and this led to the crews of Adonis and Wolli misinterpreting the requirement.

Issue Owner
Sea Swift, Cairns
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Permit to work
Safety Issue Description

MSC Siena’s permit to work over the side and the associated procedure required that the ship not be underway when working over the side. However, this requirement could not be complied with when working over the side to rig a combination pilot ladder.

Issue Owner
Allseas Marine, Greece
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Procedure for work over the side
Safety Issue Description

MSC Siena’s safety management system procedure for working over the side required that a risk assessment be carried out, and necessary checks and precautions documented in a work permit. However, the procedure had not been effectively implemented on board the ship.

Issue Owner
Allseas Marine, Greece
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Burner nozzle assembly and documentation
Safety Issue Description

The design of the burner nozzle allowed the nozzle swirl plate and needle valve to be misaligned when being assembled which in turn led to the needle valve stem being damaged during assembly. Furthermore, the maintenance manuals and supporting documentation supplied by Garioni Naval, the thermal oil heater manufacturer, did not provide sufficient guidance to ensure safe and appropriate maintenance of the thermal oil heater burner assembly.

Issue Owner
Garioni Naval SpA
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Port of Brisbane preparedness for incidents
Safety Issue Description

Brisbane port authorities had not put in place sufficient procedures, checklists and/or supporting documents to ensure VTS staff were adequately prepared, trained and practiced to handle a predictable incident such as this.

Issue Owner
Maritime Safety Queensland (MSQ)
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Procedures for ACIII bridge control system
Safety Issue Description

Newlead Bulkers had not implemented any procedures or guidance to inform the crew that extra vigilance was required when operating the main engine in engine room control mode because there was no automatic interlock to prevent ‘wrong way’ operation of the engine and no audible alarm to indicate when it was running the ‘wrong way’.

Issue Owner
Newlead Bulkers
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Flinders Ports passage plan
Safety Issue Description

While the Flinders Ports passage plan for Port Lincoln contained information relating to general navigation in the port, such as depths and navigation/channel marks, it did not contain actual passage specific information, such as courses and speeds to be followed. If the plan had contained course and speed information, the ship’s crew would have been better prepared for the pilotage.

Issue Owner
Flinders Ports
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Risk assessment and contingencies for manoeuvre
Safety Issue Description

Flinders Ports had not undertaken a risk assessment, or developed contingency plans for this specific shiphandling manoeuvre in Port Lincoln. Consequently, the pilot had no guidance regarding what actions to take if the berthing manoeuvre did not progress as he planned.

Issue Owner
Flinders Ports
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Tug masters participation
Safety Issue Description

The participation of the two tug masters in the pilotage process was not actively encouraged in Port Lincoln. Consequently, it was not until after the collision that one of the tug masters advised the pilot that the ship's main engine was still running ahead.

Issue Owner
Flinders Ports
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Automatic defences within the ACIII system bypassed
Safety Issue Description

When the main engine was operated in engine room control mode, there was no automatic interlock to prevent ‘wrong way’ operation of the engine and no audible alarm to indicate when it was running the ‘wrong way’. As a result, the only system protections to warn the crew of ‘wrong way’ running of the engine were the bridge and engine control room console mounted flashing light indicators.

Issue Owner
Newlead Bulkers
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Output Number
Title
MO-2010-004-SAN-016
Organisation
Ship operators, ship masters and maritime training institutions
Date released
Approval Date
Status
Released
Recommendation type
Issue number
Safety issue title
Contingency planning
Safety Issue Description

There has not been a comprehensive risk based approach to contingency planning for deep draught bulk carrier operations in Gladstone.

Issue Owner
Maritime Safety Queensland (MSQ)
Transport Function
Marine: Other
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Commissioning processes
Safety Issue Description

The shipyard commissioning processes did not identify that the ship’s rudder angle indicator transmitter and tiller link-arm were not installed correctly.

Issue Owner
Tsuneishi Group Shipbuilding, China
Transport Function
Marine: Other
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Pilotage safety management system
Safety Issue Description

There has not been a comprehensive safety management system implemented in the Port of Gladstone with the aim of identifying, evaluating and controlling pilotage related risk.

Issue Owner
Maritime Safety Queensland (MSQ)
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Oxygen breathing apparatus training
Safety Issue Description

The ship’s crew were not appropriately trained or drilled in the operation and maintenance of the oxygen breathing apparatus.

Issue Owner
Taiyo Nippon Kisen
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Oxygen breathing apparatus documentation
Safety Issue Description

The ship’s safety management system documentation provided the crew with no guidance in relation to the operation and maintenance of the ship’s oxygen breathing apparatus.

Issue Owner
Taiyo Nippon Kisen
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Cylinder design
Safety Issue Description

The threaded connections on the Kawasaki air breathing apparatus and oxygen breathing apparatus cylinders were the same and there were no other engineering controls to prevent an oxygen cylinder from being connected to the air compressor.

Issue Owner
Water Safety Service
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Safety zone guidance
Safety Issue Description

Patrick Terminals had no formalised policy in place to provide clear guidance to its stevedoring employees about where they could or could not work on a ship when cargo was being loaded or discharged.

Issue Owner
Patrick Terminals
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Risk-event reporting
Safety Issue Description

The culture which existed in the Patrick terminal did not encourage the reporting of non-compliances or unsafe acts. Consequently, two critical parts of an effective safety system, which had a direct impact upon its ability to effectively manage safety in the terminal, the ‘reporting’ culture and the ‘just’ culture, were either not present or were misunderstood in Patrick’s safety system.

Issue Owner
Patrick Terminals
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Hazard assessment process
Safety Issue Description

Patrick Terminals’ hazard identification process had not identified the dangers of working near or under containers being loaded.

Issue Owner
Patrick Terminals
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine