Date:
Issue number
Safety issue title
Pilotage SMS and check pilot regime
Safety Issue Description

The pilotage system used by Atlantic Blue’s pilot did not define off-track limits or make effective use of recognised bridge resource management tools in accordance with the Queensland Coastal Pilotage Safety Management Code and regular assessments of his procedures and practices under the code’s check pilot regime conducted over a number of years had not resolved these inconsistencies.

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
Ship's passage planning procedures
Safety Issue Description

Atlantic Blue’s safety management system procedures did not require specific off-track limits to be included in the passage plan or otherwise ensure that limits for effective track monitoring were always defined.

Issue Owner
Fleet Management Limited, Hong Kong
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Drill schedule
Safety Issue Description

Petra Frontier’s safety management system contained procedures outlining how fire and abandon ship drills should be carried out in accordance with SOLAS and Marshall Islands requirements. However, it also contained a drill schedule that provided some contradictory information.

Issue Owner
Petra Marine Australia
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Statutory buy in
Safety Issue Description

While Petra Frontier had undergone an initial flag State inspection on 4 May 2009 and routine class surveys, the most recent being a class survey completed on 12 August 2009, neither authority was aware that the ship was unseaworthy in relation to critical safety equipment when it departed Singapore.

Issue Owner
Marshall Islands International Registries
Transport Function
Marine: Other
Date issue released
Mode of Transport
Marine
Output Number
Title
MO-2009-009-SAN-021
Organisation
American Bureau of Shipping
Date released
Approval Date
Status
Closed
Recommendation type
Issue number
Safety issue title
Permit system
Safety Issue Description

United Treasure’s permit to work aloft system had not been effectively implemented on board the ship. In addition, the standard form for the permit did not ensure that the officer in charge of the work and its authoriser were not the same person and that a risk assessment was formally undertaken by at least two responsible officers.

Issue Owner
United Ocean Ship Management, Singapore
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Tower assembly
Safety Issue Description

The tower was not assembled as designed. The outriggers and intermediate planks, both key components, were missing and the work platform guard rails were not used. The manufacturer’s instructions were also missing but no attempt was made to obtain them, a parts list or the missing parts.

Issue Owner
Ship's masters and crews
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Output Number
Title
MO-2009-005-SAN-024
Organisation
Ships' masters and crew
Date released
Approval Date
Status
Closed
Recommendation type
Issue number
Safety issue title
Tank entry checklist system
Safety Issue Description

While enclosed space entry checklists were being filled out by the crew members on board Bow De Jin, the checklist system was not being used as a proactive means to ensure that the necessary safety requirements were being met prior to tank entries.

Issue Owner
Fleet Management Limited, Hong Kong
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Shipboard review
Safety Issue Description

The procedures for connecting and disconnecting the import hose and disconnecting from the CALM buoy in place on board Karratha Spirit were signed off as being satisfactory and reflecting shipboard practice, but they had not been effectively reviewed on board the ship. Consequently, the ambiguities in the procedures and the discrepancies between the procedures and the ship’s practices were not identified during any shipboard review or audit and were not made known to the ship’s managers through any review process.

Issue Owner
Teekay Shipping Australia
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Procedures versus practices
Safety Issue Description

The ship’s procedures for connecting and disconnecting from the CALM buoy did not provide explicit, succinct and unambiguous guidance and there were differences between the procedures and the actual shipboard practices that increased the level of risk associated with those operations

Issue Owner
Teekay Shipping Australia
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Regulatory oversight
Safety Issue Description

NOPSA does not undertake the audits necessary for maritime compliance and AMSA is only able to do so, while the facility is on station, with NOPSA’s cooperation. NOPSA had carried out annual occupational health and safety inspections on board the ship and AMSA had carried out the necessary third party audits of the system to meet its certification requirements. However, none of these audits or inspections had identified the discrepancy between the mooring hawser procedures and actual shipboard practices or that the ship’s internal review processes had not identified the discrepancy.

Issue Owner
National Offshore Petroleum Safety Authority NOPSA
Transport Function
Marine: Other
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Job Hazard Analysis review
Safety Issue Description

The Job Hazard Analysis (JHA) for disconnecting from the CALM buoy did not provide an accurate assessment of the all of the hazards and associated risks in performing the task. In addition, the crew did not use it to assess the risks associated with undertaking an unfamiliar operation and it was reviewed without any involvement from the crew. Consequently, the JHA was not an effective means for assessing and controlling the risks associated with the operation of disconnecting from the CALM buoy.

Issue Owner
Teekay Shipping Australia
Transport Function
Marine: Shipboard operations
Date issue released
Mode of Transport
Marine
Issue number
Safety issue title
Jurisdiction
Safety Issue Description

In this instance, the consensus of the regulatory authorities is that Karratha Spirit was not in a navigable form at the time of the accident and was therefore under NOPSA’s jurisdiction according to the OPGGSA. However, the point at which Karratha Spirit became ‘navigable’ is not clearly defined in the OPGGSA and is open to interpretation.

Issue Owner
National Offshore Petroleum Safety Authority NOPSA
Transport Function
Marine: Other
Date issue released
Mode of Transport
Marine
Output Number
Title
MO-2009-008-SAN-014
Organisation
Owners, operators and skippers of small vessels
Date released
Approval Date
Status
Closed
Recommendation type
Output Number
Title
MO-2009-004-SR-008
Organisation
The Danish Maritime Authority
Date released
Approval Date
Status
Closed - Partial Action
Recommendation type
Output Number
Title
MO-2008-010-SR-039
Organisation
Volcano Company
Date released
Approval Date
Status
Closed - Action Taken
Recommendation type
Output Number
Title
MO-2008-010-SAN-041
Organisation
Flag States, owners, operators and masters
Date released
Approval Date
Status
Closed
Recommendation type
Output Number
Title
MO-2008-008-SAN-025
Organisation
Owners, operators and masters
Date released
Approval Date
Status
Closed
Recommendation type
Output Number
Title
MO-2008-009-SR-020
Organisation
Parakou Shipping
Date released
Approval Date
Status
Closed - Action Taken
Recommendation type