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.
To be advised.
The ATSB welcome’s the proactive safety action 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.
Maritime Safety Queensland (MSQ) has, among others, taken the following actions:
The organisations engaged include:
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.
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.
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.
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.
On 22 September 2025, MSQ responded to the outstanding safety recommendation. The response letter summarised MSQ's response to the published final report for the investigation and restated MSQ's December 2024 commitment to completing a review of its emergency response protocols. The letter acknowledged ATSB's June 2025 follow-up to this safety recommendation and confirmed the focus to be on ensuring MSQ has appropriate documentation to support hazard and risk management.
The response went on to summarise updates made to MSQ's hazard and risk management processes including the incorporation of lessons learnt during recent disaster management exercises and following disaster response reviews after having implemented updated processes in preparing for extreme weather events and seasons.
Formation and implementation of a Maritime Emergency Working Group (MEWG) for the port of Brisbane and the other Queensland maritime regions was explained and highlighted. The establishment of a State Response Team to provide specialist assistance to regional harbour masters was also highlighted.
The ATSB continues to acknowledge and commend MSQ on its response and commitment to continuous improvement and to building processes and structures to assist in risk and emergency management throughout areas of MSQ responsibility in Queensland.
However, the ATSB notes that the response did not include physical documentation and records to support and verify the actions described therein.
The ATSB remains in correspondence with MSQ to seek such additional information and will continue to monitor this safety issue and recommendation.
