Date Issue Released
Issue number
Issue Owner
Kuwait Livestock Transport & Trading Company
Safety issue title
Planned maintenance system
Safety Issue Description

The Kuwait Livestock Transport & Trading Company's planned maintenance system did not provide enough detail to track maintenance schedules, and did not have a specific maintenance item to record the maintenance activities on the main engine pneumatic system. 

Response by Kuwait Livestock Transport & Trading Company

Issue Status
Monitor
Date issue released
Mode of Transport
Marine
Transport Function
Marine: Shipboard operations
Issue number
Issue Owner
Fremantle Pilots
Safety issue title
Port radio communication
Safety Issue Description

The Fremantle Pilots’ operational practice of using VHF channel 8 for communication with Fremantle VTS during Inner Harbour transits was not consistent with the port procedures and prevented effective communication. 

Response by Fremantle Pilots

Issue Status
Monitor
Date issue released
Mode of Transport
Marine
Transport Function
Marine: Shipboard operations
Issue number
Issue Owner
Australian Maritime Safety Authority
Safety issue title
National Plan management
Safety Issue Description

The Australian Maritime Safety Authority had not adequately managed the National Plan and annual exercises required to prepare for such incidents had not been conducted for 4 years before the incident. This probably resulted in the ineffective implementation of its Maritime Assistance Services procedures, the inefficient process for issuing directions and inadequate coordination of the incident with state authorities.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Port Authority of New South Wales
Safety issue title
Port Authority emergency procedures
Safety Issue Description

Port Authority of New South Wales procedures to comply with its Port Safety Operating Licence and the NSW Coastal Waters Marine Pollution Plan were not effectively implemented. This resulted in delays to the required notifications and incident response, which contributed to prolonging the emergency.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Australian Maritime Safety Authority
Safety issue title
Maritime Assistance Services procedures
Safety Issue Description

The Australian Maritime Safety Authority’s Maritime Assistance Services procedures to support the National Plan for Maritime Environmental Emergencies (National Plan) were not effectively implemented. Consequently, there was a 12-hour delay in tasking the state’s nominated emergency towage vessel, Svitzer Glenrock, which significantly prolonged the emergency.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
United Salvage
Safety issue title
Salvage operation
Safety Issue Description

United Salvage was severely limited in its ability to provide the required salvage services as it did not own, operate or directly control any towage vessels for which it relied on towage providers. This limitation was not made clearly known to Portland Bay’s master, owners or managers or involved authorities to allow them to properly assess whether the most suitable towage vessels, including the emergency towage vessel, had also been promptly deployed for salvage and emergency response.

Response by United Salvage

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Pacific Basin Shipping
Safety issue title
Ship’s emergency procedures
Safety Issue Description

Portland Bay’s manager, Pacific Basin Shipping, did not provide the master advice about notifying authorities as per the ship’s safety management system emergency procedures, instead focusing on the engineering matters. This probably led to the master delaying the notification and the request for tug assistance.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Australian Maritime Safety Authority
Safety issue title
Process for issuing directions
Safety Issue Description

The Australian Maritime Safety Authority’s process to issue directions was inefficient and resulted in excessive time to issue directions allowing Portland Bay to enter Port Botany as a place of refuge. While this delay did not further prolong the emergency, such delays increase risk in time‑critical situations.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Port Authority of New South Wales
Safety issue title
Emergency response coordination (Port Authority of NSW)
Safety Issue Description

The Port Authority of New South Wales did not have a proper and correct understanding of its responsibilities for emergency response under its operating licence and relevant state plans. This contributed to the inadequate coordination of emergency towage, salvage and refuge, which were critical for the single, integrated and comprehensive response required and significantly prolonged the emergency.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Transport for NSW (NSW Maritime)
Safety issue title
Emergency response coordination (NSW Maritime)
Safety Issue Description

Transport for NSW (NSW Maritime), as the statutory agency responsible for ensuring that New South Wales was prepared to respond to an incident in accordance with the state’s plan that it maintained, had not effectively met this obligation. This resulted in the long delay in New South Wales assuming control of the incident and contributed to the inadequate coordination of the emergency response required for a single, integrated and comprehensive response and significantly prolonged the emergency.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Australian Maritime Safety Authority
Safety issue title
Emergency response coordination (AMSA)
Safety Issue Description

The Australian Maritime Safety Authority, with direct control of key national emergency response arrangements, did not have the required understanding of its central role in any response, regardless of location. Consequently, its support to, and coordination with, the control agency in relation to emergency towage, salvage and refuge was inadequate, inconsistent with National Plan principles of a single, integrated and comprehensive response and significantly prolonged the emergency.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Port Phillip Sea Pilots
Safety issue title
Training documentation
Safety Issue Description

Documentation supporting the training and competency assessment of launch coxswains was limited in detail and training records were incomplete.

Issue Status
Closed – Partially addressed
Date issue released
Mode of Transport
Marine
Transport Function
Marine: Other
Issue number
Issue Owner
Port Phillip Sea Pilots
Safety issue title
Safety management system guidance documentation
Safety Issue Description

The safety management system for Corsair did not include detailed guidance and reference material for the safe navigation of Port Phillip Heads, the effective use of launch navigational equipment and the role of the launch deckhand in supporting safe navigation. 

Issue Status
Closed – Partially addressed
Date issue released
Mode of Transport
Marine
Transport Function
Marine: Other
Issue number
Issue Owner
CMA CGM
Safety issue title
CMA CGM fleetwide steering system guidance
Safety Issue Description

The ship's managers' (CMA CGM) safety management system procedures and guidance for steering gear operation across its fleet were ambiguous and did not clarify the different terminology to those commonly used by the industry. This increased the risk of incorrect configuration of the steering gear, which occurred on board CMA CGM Puccini

Response by CMA CGM

Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Maritime Safety Queensland and Poseidon Sea Pilots
Safety issue title
MSQ and PSP assessment of risk
Safety Issue Description

Maritime Safety Queensland and Poseidon Sea Pilots did not have a process to jointly and effectively identify and risk assess the hazards to shipping and pilotage that were outside normal environmental conditions. 

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Marine
Transport Function
Marine: Other
Issue number
Issue Owner
Pilbara Ports Authority
Safety issue title
Escort towage strategy
Safety Issue Description

The Pilbara Ports Authority's port user guidelines and procedures did not reflect the best practice escort towage guidance detailed in the port's draft escort towage strategy and business continuity plan. The detail of these improved towage practices, designed to reduce the risk of channel blockages, were also not integrated into the Port Hedland Pilots' safety management system and were consequently, inconsistently applied by pilots.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Liberia Maritime Authority
Safety issue title
Rules and regulations for rudder angle indicator systems
Safety Issue Description

Although Hagen Oldendorff’s steering and rudder angle indicator systems complied with the applicable rules and regulations, neither the SOLAS regulations, nor the rules of the ship’s responsible classification society, Lloyd’s Register, mandated protection of the ship's rudder angle indication systems against a single point of failure in power supply, nor did they require installation of audible or visual alerts to notify the bridge team of a power failure affecting the indicators.

Response by the Liberia Maritime Authority

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Australian Maritime Safety Authority
Safety issue title
Rules and regulations for rudder angle indicator systems
Safety Issue Description

Although Hagen Oldendorff’s steering and rudder angle indicator systems complied with the applicable rules and regulations, neither the SOLAS regulations, nor the rules of the ship’s responsible classification society, Lloyd’s Register, mandated protection of the ship's rudder angle indication systems against a single point of failure in power supply, nor did they require installation of audible or visual alerts to notify the bridge team of a power failure affecting the indicators.

Response by Australian Maritime Safety Authority

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Lloyd’s Register
Safety issue title
Rules and regulations for rudder angle indicator systems
Safety Issue Description

Although Hagen Oldendorff’s steering and rudder angle indicator systems complied with the applicable rules and regulations, neither the SOLAS regulations, nor the rules of the ship’s responsible classification society, Lloyd’s Register, mandated protection of the ship's rudder angle indication systems against a single point of failure in power supply, nor did they require installation of audible or visual alerts to notify the bridge team of a power failure affecting the indicators.

Response by Lloyd’s Register

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Port Hedland Pilots
Safety issue title
Escort towage strategy
Safety Issue Description

The Pilbara Ports Authority's port user guidelines and procedures did not reflect the best practice escort towage guidance detailed in the port's draft escort towage strategy and business continuity plan. The details of these improved towage practices, designed to reduce the risk of channel blockages, were also not integrated into the Port Hedland Pilots' safety management system and were, consequently, inconsistently applied by pilots.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations