Spirit of Tasmania I’s safety management system procedure for Job Safety Analyses (JSA) was not effectively implemented. As a result, the JSA required for replacing the main engine turbocharger bearing housing cover plate was not in place. In addition, JSAs covering other work on top of the engine did not address the risks involved in accessing the work site.
Proactive safety actions taken by TT-Line: 1) Provision of a portable access platform provides safe access to the engine top, eliminating the risks of walking along the uneven and potentially slippery main engine rocker covers. 2) Amended Job Safety Analyses (JSA) for work on the engines, providing involved personnel with greater awareness of the risks involved and the risk controls. These measures adequately address the safety issue.
TT-Line Company has amended all job hazard analyses (JSA) for work on top of the engine to include controls for the access hazard and has incorporated them in its shipboard safety management system. Additionally, the updated JSA include a restriction on routine maintenance of critical equipment during short duration port calls reducing time pressure constraints in case of unforeseen problems.
Following the incident, TT-Line commissioned the construction of a portable aluminium access platform for the main engines which can be put in place to provide safe access to the top of the engine without the need to climb over the main engine rocker covers.
