Date:
Issue number
Safety issue title
Manufacturers Manuals and procedures for wave compensator
Safety Issue Description

Davit International’s fast rescue boat davit manual did not provide sufficient guidance for the crew in the operation of the wave compensator and its safety interlock

Issue Owner
d-i Davit International
Transport Function
Marine: Other
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Global Supplier's navigation lights
Safety Issue Description

Global Supplier was not fitted with the correct navigational lights for a vessel engaged in towing operations.

Issue Owner
Global Marine & Eng Pty Limited
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Global Supplier without radar and AIS unit
Safety Issue Description

Global Supplier was built and surveyed as a Uniform Shipping Laws (USL) Code vessel and therefore was not fitted with radar or an AIS unit which would be required under the provisions of the current National Standard for Commercial Vessels. Had these devices been fitted, they would have provided information that would have assisted both Global Supplier's skipper and Far Swan's watchkeepers, in avoiding the collision.

Issue Owner
State and Territory Marine authorities
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Ambiguous pilotage direction
Safety Issue Description

Dampier Port Authority's pilotage directions are unclear and ambiguous with respect to the requirements for towing vessels or on the use of pilotage exemptions by crew other than the master.

Issue Owner
Dampier Port Authority
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Output Number
Title
MO-2010-006-SAN-015
Organisation
Small commercial vessels
Date released
Approval Date
Status
Closed
Recommendation type
Issue number
Safety issue title
Fault finding of steering system
Safety Issue Description

Preliminary inspections and tests of MSC Basel steering system did not identify any faults. However, more thorough examinations of the entire steering systems may identify any intermittent defects.

Issue Owner
Laeisz Reederei
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Safety management system for passage planning
Safety Issue Description

The ship’s safety management system did not contain procedures or guidance on the proper use of GPS route plans and their relationship to the ship’s passage plans.

Issue Owner
Tosco Keymax International Ship management company
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Sea area off Gladstone not 'protected'
Safety Issue Description

At the time of the grounding, the protections afforded by some of the measures currently employed in the more northern sections of the GBR were not in place in the sea area off Gladstone.

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

There was no effective fatigue management system in place to ensure that the bridge watch keeper was fit to stand a navigational watch after the loading in Gladstone.

Issue Owner
Tosco Keymax International Ship management company
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Lack of visual cues for dangers
Safety Issue Description

In the 30 minutes leading up to the grounding, there were no visual cues to warn either the chief mate or the seaman on lookout duty, as to the underwater dangers directly ahead of the ship.

Issue Owner
Australian Maritime Safety Authority (AMSA)
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Knowledge of ship’s safety management system
Safety Issue Description

The oiler’s actions indicate that he was likely not aware of the ship’s safety management system hot work permit requirements.

Issue Owner
NSC Schiffahrtsgesellschaft, Germany
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Dangers associated with use of grinder
Safety Issue Description

The oiler’s actions indicate that he was not aware of the dangers associated with the use of an angle grinder to remove the top of the drum.

Issue Owner
NSC Schiffahrtsgesellschaft, Germany
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Third party inspection of lashing equipment
Safety Issue Description

At the time of the incident, there was no requirement for any third party to inspect or survey the fixed and loose lashing equipment on a ship. Had this been done, the maintenance and replacement regime of such equipment on board Pacific Adventurer might have been more effective.

Issue Owner
Flag and coastal states
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Condition of lashing gear
Safety Issue Description

The poor condition of much of the ship’s container lashing equipment indicates that the inspection and maintenance regime applied to this critical equipment had been inadequate.

Issue Owner
Swire Navigation/CNCO
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Container packaging completed by shipper.
Safety Issue Description

The ammonium nitrate prills were not packaged in the containers in accordance with the requirements of the IMDG Code. The containers were packed in a way which allowed the prills to move within the container in a way that may have contributed to the failure of the containers and/or the lashing system.

Issue Owner
Orica
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
IMDG Code requirements oversight
Safety Issue Description

Before the incident, Orica Australia had advised the Australian Maritime Safety Authority (AMSA) that their packaging method for the prills was fully compliant with the IMDG Code’s provisions. However, AMSA’s IMDG Code compliance audit regime had not detected that the method was not compliant.

Issue Owner
Australian Maritime Safety Authority (AMSA)
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Manufacturers guidance
Safety Issue Description

The manufacturer’s maintenance manual did not include a requirement for the routine testing of the compressor high temperature alarm/shutdown.

Issue Owner
CHAMPION COMPRESSORS
Transport Function
Marine: Other
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Planned maintenance system alarm/shutdown testing
Safety Issue Description

River Embley’s planned maintenance system did not require routine testing of the compressor high temperature alarm/shutdown.

Issue Owner
ASP Ship Management
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Shore monitoring of shallow water areas
Safety Issue Description

The ‘shallow water alert’ generated by the Great Barrier Reef and Torres Strait Vessel Traffic Service’s (REEFVTS) monitoring system did not provide adequate warning of Atlantic Blue entering shallow water because the boundary of the defined shallow water alert area was too close to dangers off Kirkcaldie Reef.

Issue Owner
Reef VTS
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Shore monitoring of two-way routes
Safety Issue Description

The REEFVTS monitoring system did not provide an ‘exiting corridor alarm’ when Atlantic Blue exited the two-way route that it was transiting because the route had not been defined as a navigational corridor.

Issue Owner
Reef VTS
Transport Function
Marine: Shore-based operations
Date issue released
Mode of Transport
Marine