Date:
Issue number
Safety issue title
Risk assessment process
Safety Issue Description

Patrick Terminals’ risk assessment process for lashing and unlashing operations had not anticipated a fatal accident resulting from being struck by items falling from a portainer or cargo, or from being struck by a moving container. As a result, while the appropriate risk control for this occurrence had been covered during employee training, this was not reinforced in safe work instructions, an important risk control measure.

Issue Owner
Patrick Terminals
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Terminal safety management
Safety Issue Description

The implementation of Patrick Terminal’s safety management system resulted in an environment where Patrick Terminal management and stevedores were disconnected in relation to the management of some of the day-to-day workplace safety risks. As a result, there was little ownership of the safe work instructions by the stevedores, and some of the more experienced stevedores were probably no longer aware of the risks posed to them when they undertook unsafe ‘workarounds’ in the workplace and these were not identified by Patrick management.

Issue Owner
Patrick Terminals
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Safe work instructions
Safety Issue Description

Patrick Terminals’ safe work instructions for lashing/unlashing did not specifically cover the recognised safe practices of not working under containers or between moving containers and fixed objects. Consequently, there was a discontinuity between the level of awareness regarding these dangers and the training new employees received during their induction period.

Issue Owner
Patrick Terminals
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Safety issues not covered in guides for operators
Safety Issue Description

The recognised safe practices of not working under or near a container being loaded is not well reflected in national and international guidance published to assist container terminal operators develop their own safety policies and guidelines.

Issue Owner
National and international maritime, cargo and labour organisations
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Veneer packaging
Safety Issue Description

Ta Ann Tasmania did not follow the recommendations contained in section 2.3 of Appendix A of the International Maritime Organization’s Code of Safe Practice for Ships Carrying Timber Deck Cargo when they packaged the timber veneer for shipment by sea.

Issue Owner
Ta Ann Tasmania
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Third party inspection of veneer packaging
Safety Issue Description

The Australian Maritime Safety Authority had not inspected the packs of veneer to establish whether Ta Ann Tasmania was packaging the veneer in line with the recommendations contained in section 2.3 of Appendix A of the International Maritime Organization’s Code of Safe Practice for Ships Carrying Timber Deck Cargo.

Issue Owner
Australian Maritime Safety Authority (AMSA)
Transport Function
Marine: Other
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Emailed instructions
Safety Issue Description

The instructions that were emailed to Mimasaka’s master by NYK-Hinode Line did not provide the crew with proper guidance about how to stow and secure the packs of timber veneer on deck.

Issue Owner
NYK-Hinode Line
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
NYK's Operation Manual
Safety Issue Description

The Operation Manual for Loading and Lashing of Tasmanian/Malaysian Dry Veneer, developed by NYK-Hinode Line for use by ships carrying timber veneer, did not contain any information relating to the stowage and securing of the timber veneer cargo on deck.

Issue Owner
NYK-Hinode Line
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Cargo Securing Manual
Safety Issue Description

Mimasaka’s cargo securing manual did not contain any information relating to the stowage and securing of timber veneer.

Issue Owner
NYK-Hinode Line
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Output Number
Title
Trackside monitoring
Organisation
Pacific National
Date released
Approval Date
Status
Closed
Recommendation type
Issue number
Safety issue title
Learning from previous events
Safety Issue Description

Prior to 2 February 2011, the crew had encountered problems with the lifting wire jamming in the head of the davit when the bucket was hoisted too high. However, nothing had been done to prevent it from happening again in the future.

Issue Owner
Hanjin Ship Management
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
On board maintenance of wave compensator
Safety Issue Description

The planned maintenance system on board British Sapphire did not include a specific requirement to maintain or test the wave compensator or its safety interlock on the fast rescue boat davit. As a result, the crew had not identified the issue with the wave compensator safety interlock during periodic maintenance.

Issue Owner
BP Shipping Ltd
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Team resource management
Safety Issue Description

The crew did not use resource management principles to ensure that they had a shared mental model of the task that they were carrying out. As a result there was confusion amongst the various crew members as to their roles and responsibilities at the time of the incident

Issue Owner
BP Shipping Ltd
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
On board return to service
Safety Issue Description

The planned maintenance system on board British Sapphire did not detail a procedure for a recommissioning test following maintenance on the fast rescue boat davit. As a result, any recommissioning test that was done after on board maintenance had not identified the issue with the wave compensator safety interlock prior to the incident.

Issue Owner
BP Shipping Ltd
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Crew training for wave compensator
Safety Issue Description

The training provided to the crew did not ensure they were familiar with the function or operation of the wave compensator or its safety interlock

Issue Owner
BP Shipping Ltd
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Installation and acceptance
Safety Issue Description

There was no evidence to indicate that the operation of British Sapphire's (or its sister ships) fast rescue boat davit’s wave compensator and safety interlock had been sufficiently tested at the time of the ship's delivery to ensure safe operation

Issue Owner
BP Shipping Ltd
Transport Function
Marine: Other
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
STCW training for wave compensator
Safety Issue Description

Training institutions delivering approved STCW courses are not keeping up to date with the introduction of wave compensation units to ensure their courses provide students with the required knowledge to safely operate these units

Issue Owner
Licensing authorities
Transport Function
Marine: Other
Date issue released
Issue Status
No longer relevant
Mode of Transport
Marine
Issue number
Safety issue title
Incorrect wiring of the interlock
Safety Issue Description

It was found that the safety interlocks on the wave compensator systems on board British Sapphire, British Emerald and British Ruby had been electrically by-passed thereby preventing the safety interlocks from functioning.. As a result, the wave compensators on board all three ships could be engaged regardless of whether the fast rescue boats were waterborne or suspended from the fall wire

Issue Owner
d-i Davit International
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Ship's manuals and procedures for wave compensator
Safety Issue Description

British Sapphire’s fast rescue boat davit procedures did not provide sufficient guidance for the crew in the operation of the wave compensator

Issue Owner
BP Shipping Ltd
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Job hazard analysis
Safety Issue Description

The job hazard analysis for the operation of the fast rescue boat was incomplete and did not include an assessment of the hazards associated with the operation of the wave compensator

Issue Owner
BP Shipping Ltd
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine