Over the past 26 years, investigations into 41 collisions between trading ships and small vessels on the Australian coast have identified that not maintaining a proper lookout and taking early avoiding action, in accordance with the collision regulations, has been a consistent and continuing contributor to such collisions.
Kota Wajar’s safety management system procedures with regard to posting a dedicated lookout were not effectively implemented.
Brisbane Marine Pilots’ standard passage plan and master-pilot exchange did not ensure that a ship’s bridge team is provided adequate information with respect to local traffic and areas where attention must be paid to other vessels, including small craft.
The Recognized Organization’s process for the approval of the simulation wires for ‘maintenance and testing’ had not taken into account the shock loading that would be experienced during testing.
An equivalent, alternative arrangement to the safety pin had not been provided to prevent inadvertent tripping of the freefall lifeboat’s on-load release during routine operations, such as inspections and maintenance.
The manufacturer’s calculations did not take into account the shock load imposed on the simulation wires or the lifeboat and launching frame mounting points.
While the design of the on-load release system allowed the reset position of the hook to be visually confirmed, it did not allow for visual confirmation that the release segment and mechanism had been correctly reset. Consequently, the hook device could appear to be properly reset when it was not.
The manufacturer’s instruction manual for Seven Seas Voyager’s waste incinerator contained no specific instructions for ash grate maintenance or replacement. Such instructions would have provided useful information for the ship’s crew to plan and safely complete periodic ash grate maintenance.
Seven Seas Voyager’s planned maintenance system (PMS) contained no information about waste incinerator ash grate replacement, a task that would have been periodically undertaken by different engineering staff since 2003. Therefore, in this respect, the shipboard procedures that documented requirements for the PMS had not been effectively implemented.
HC Rubina’s electronic planned maintenance system did not contain any instructions to ensure that the shaft alternator flexible coupling was maintained in accordance with the manufacturer’s requirements.
The ship’s managers did not have effective systems to ensure that the defective control system for the controllable pitch propeller was reported to the relevant organisations as required.
Consequently, Brisbane’s vessel traffic services, pilotage provider and the pilot remained unaware of the defect and could not consider it in their risk assessments before the pilotage started.
The ship’s agent’s information questionnaire did not ask for all of the information required to complete the QSHIPS booking form and ensure that defects were reported.
Bosphorus’ safety management system provided no guidance in relation to the allocation of function based roles and responsibilities to members of the bridge team during pilotage.
Brisbane Marine Pilots’ ‘Port of Brisbane Passage Plan’ did not detail any guidance or instructions relating to watch handover or changing the helmsman during high risk areas of a pilotage.
Bosphorus’ safety management system did not detail any guidance or instructions relating to watch handover or changing the helmsman during high risk areas of a pilotage.
There was a lack of mapping information available to assist the ‘triple zero’ operator in providing the emergency responders with directions to a defined location within the port area.
The gantry crane in motion warning light nearest to the assistant electrician’s location was not operating and the warning sirens were not audible from his location. As a result, he was not provided with either a visual or audible warning of the crane’s movement.
The on board familiarisation process did not ensure that new crew members were informed of the precautions required when working on deck while the gantry cranes were in operation.
Calliope was not required to carry a pilot during Sydney Harbour voyages because the yacht was considered to be a recreational vessel, even though the risks it posed to the port were the same as those posed by similarly sized commercially operated vessels.
Calliope’s safety management system (SMS) did not provide the crew with adequate guidance regarding passage planning, training and familiarisation. Individual crew familiarisation records and risk assessment forms were not retained on board the yacht and there was no system of auditing or checking to ensure the adequacy of the SMS or the effectiveness of its implementation.
