Safety Issue

The Australian Maritime Safety Authority (AMSA) advised the ATSB that it generally agreed that there were communication and coordination failures both within and across the agencies responding to the incident. Consequently, it has taken the following safety action:

• Conducted a review of its emergency response coordination arrangements and initiated a program to give effect to the changes recommended by the review for the future operating model to improve the capacity to manage complex incidents, particularly in the AMSA Response Centre.
• Since mid-2024, conducted fortnightly tabletop ‘triage and escalation’ exercises to simulate events involving search and rescue, Maritime Assistance Services (MAS) and pollution, with frontline AMSA staff participating to practice decision-making and incident management to build knowledge, expertise and capacity with exercise evaluations to identify lessons. The inclusion of external agencies and organisations in the exercises was being considered.
• Increased resourcing of its Response Division to improve preparedness and planning arrangements for major incidents with 9 roles created since 2021.
• Increased staff training with 136 completions of accredited incident management training programs since July 2021, including 101 staff completing Australasian Inter‑service Incident Management System (AIIMS) training, across a range of different courses.
• Evaluations of MAS incidents following the Portland Bay incident, including:
  • establishing a ‘lessons board’ and ‘actions allocation working group’, which respectively oversee its lessons management process and ensure identified lessons are addressed,
  • prompt and regular assessment of significant MAS incidents by an external service provider or AMSA lessons management staff (with 9 formal lessons reports containing 135 lessons and findings finalised to date),
  • collection and analysis of incident responder observations for minor incidents, where full evaluation processes are not conducted,
  • reviewing its lessons management doctrine for the lessons management program.

The Australian Transport Safety Bureau recommends that the Australian Maritime Safety Authority (AMSA) completes the safety action proposed to address this safety issue in conjunction with action to address the other safety issues addressed to AMSA in this report.