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Maritime Safety Queensland emergency preparedness
Date issue released
Issue number
MO-2022-003-SI-01
Issue Status
Open – Safety action pending
Transport Function
Shore operations
Issue Owner
Maritime Safety Queensland
Mode of Transport
Marine
Safety Issue Description

Maritime Safety Queensland (MSQ) did not have structured or formalised risk or emergency management processes or procedures. Consequently, MSQ was unable to adequately assess and respond to the risks posed by the river conditions and current exceeding operating limits and ensure the safety of berthed ships, port infrastructure or the environment, and avoid CSC Friendship’s breakaway. 

Proactive action
Action number
MO-2022-003-PSA-02
Organisation
Maritime Safety Queensland
Action Status
Closed
Action description

Maritime Safety Queensland (MSQ) has, among others, taken the following actions:

  • Completed
    • an internal investigation into the breakaway 
    • a departmental internal audit of response to the weather event
    • current and mooring studies for the port
    • ship simulation exercises to determine operation capabilities and limits for varying environmental conditions in the port. These simulations aided in developing flood evacuation procedures and flood manoeuvring guidelines in collaboration with port pilots and towage providers. 
  • adopted the Australian Warning System (AWS) 
  • developed and implemented a ‘Brisbane Flood Evacuation Guideline’ which included:
    • a list of ‘key planning considerations which when assessed against the forecast will develop key decision points’ to enable port evacuation prior to the onset of extreme weather
    • an evacuation sequence
    • manoeuvring guidance developed from ship simulation exercises conducted in collaboration with port pilotage and towage organisations
    • specific high current departure manoeuvring guidance for individual berths, including Ampol products.
  • developed an aide memoire, in line with the AWS, for actions to be taken in the event of an extreme weather event. The colour-coded alert actions vary from warning level yellow (advice – 24 to 48 hours prior to the event) through orange (watch and act – 12 to 24 hours prior) to red (emergency warning – less than 12 hours prior).
  • Updated and amended MSQ and vessel traffic services (VTS) procedures:
    • Port procedures manual to include:
      • emergency management of extreme weather events, including advice regarding mooring considerations, communications and possible changes to operational limitations during the event
      • wind limit guidance.
    • VTS extreme weather event procedure to
      • Align with the Australian Warning System
      • highlight that ‘the main impact to port operations is high current velocities and at times debris, whereas BoM warnings are based on inundation. The information below…the DHM (duty harbour master) may amend based on the specific circumstances occurring.’
    • Port pilot training requirements to include simulator training in high current flow conditions
    • Extreme weather event contingency plan to include relevant AWS information.
  • Implemented a new incident management system 
  • Made port environmental data and real-time information, including current and wind meter, available through a port weather webpage.
  • Upgraded port/river instrumentation and equipment, including
    • Installed 3 additional current meters in the river, one upstream of the Ampol products berth, 12 miles from the river entrance. A further 2 current meters are to be installed with bridge infrastructure completion in the city (13 miles from the river entrance) and further upstream, about 27 miles from the entrance.
    • Tested the use of an acoustic deployable current profiler for current measurement in variable locations.
  • Engaged with port and related stakeholders to establish and/or clarify 
    • emergency management and response arrangements
    • communications arrangements and protocols
    • collaborative information and knowledge sharing arrangements 
    • preventative and response measures for flood events: mooring management, ship manoeuvring, scheduling, flood modelling, current meters and simulation. 

The organisations engaged include:

ATSB Response

The ATSB welcomes the proactive safety action above taken by MSQ to respond to emergencies due to extreme weather events, including a flood in the Brisbane River, which partially addresses the safety issue. However, the ATSB remains concerned that MSQ does not have adequate structured and formalised risk management processes or procedures to manage any type of emergency for which it could be responsible.

Recommendation
Action number
MO-2022-003-SR-32
Organisation
Maritime Safety Queensland
Action Status
Monitor
Action description

The Australian Transport Safety Bureau recommends that Maritime Safety Queensland takes further safety action to address the safety issue through adequately structured and formalised risk management processes and procedures to manage emergencies.

Organisation Response

Date Received
Organisation
Maritime Safety Queensland
Response Text

The ATSB notes that MSQ did not agree with the safety recommendation and identified safety issue of not having structured, formalised, risk or emergency management processes or procedures.

MSQ stated that the agency had ‘undertaken a large amount of organisational improvements following internal and external audits in the months after the rain events of Feb 2022, and from other maritime emergencies that have occurred in the State over the last 2 ½ years.’ MSQ further committed to conducting an ‘internal review of MSQ’s statewide risk management processes and procedures, as they relate to the management of maritime emergencies’ with completion expected in June 2025.

ATSB Response

The ATSB welcomes MSQ's response and commitment to continuous improvement and looks forward to the results of and outcomes from the internal review of MSQ risk management arrangements in 2025.

The ATSB notes that, throughout the investigation, MSQ referenced emergency and risk management processes but that physical documentation or records of such processes was not provided. The evidence was not, therefore, sufficient to show that the existing processes provided a verifiable, reliable structure and guidance for, or record of, how a high risk or emergency event was to be managed.

The ATSB encourages MSQ and all responsible organisations to continue to review, update and improve risk and emergency management processes and procedures. In doing this, organisations should continue to reflect changes in knowledge and capability and demonstrate due diligence in organisational preparedness for and response to such events.

The ATSB will continue to monitor this safety issue and recommendation and look to further information in 2025.

ATSB Response date