Atsb transport safety report
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- Safety issues
- Safety issues of significant risk in marine
- Other risk controls
- Local conditions
- Organisational influences
MARINESafety factorsThe figure below shows that most of the safety factors identified in marine investigations were individual actions, local conditions or risk controls in the 2009-2010 financial year. Furthermore, most of these safety factors were found to have contributed to the occurrence. For instance, individual actions captured 40 percent and local conditions made up about a third of contributing safety factors. No technical failure mechanisms were identified as safety factors in marine investigations in the 2009-2010 financial year. Figure 14: Safety factors identified in marine investigations 
Just under half of all individual actions indentified in marine investigations were related to navigation actions, and assessing and planning issues made up about half of these navigation actions (Figure 15). Broadly speaking, the assessing and planning issues were related to the crew making decisions or changing plans based on insufficient information, not taking appropriate action to avoid collision, and anchoring too close to a pipeline. Figure 15: Individual action safety factors identified in marine investigations
Figure 16: Local condition safety factors identified in marine investigations T Figure 17: Risk control safety factors identified in marine investigations I Figure 18: Organisational influence safety factors identified in marine investigations O All safety issues associated with maintenance, navigation (pilotage) and engine room operations carried the significant risk level. Furthermore, navigation (pilotage) and deck operations were equally associated with safety issues of significant risk (Figure 19). Figure 19: Safety issues by functional area in marine
Risk controls: ProceduresThe majority of procedural safety issues carried significant risk (Figure 20). Of the 22 procedure-related safety issues, 12 involved deck operations (four of which were of significant risk) and six involved navigation (pilotage) (all of which were of significant risk). The procedural safety issues associate with deck operations involved stowage of a cargo crane’s hook, emergency steering system change over, ballast operations, and anchor cable bitter end release arrangements. The navigation (pilotage) significant risk safety issues all related to the same investigation12 and involved: lack of anchoring procedures off Melbourne lack of information about a submarine gas pipeline in Port Phillip inappropriate safe limits for anchorage boundaries from the gas pipeline not using English language on the bridge and so limiting the pilot’s access to all information limitations with the Port of Melbourne Corporation’s shipping control safe operating procedures lack of procedures or guidelines to compensate for the mobile telephone use policy Other significant risk procedure-related safety issues involved ineffective implementation of work permit systems; a SMS did not ensure that the master was certain about his overriding authority and responsibility; lack of port procedures to deal with an incident involving shipping and a submarine gas pipeline; and the assessing and classification of sighting reports in search and rescue procedures. Figure 20: Safety issues identified in marine investigations 
Other risk controlsTraining and assessment safety issues included insufficient training in the emergency steering system change over procedure to be followed in the event of steering control loss; rendering assistance to the crew of another vessel following a collision; and emergency scenario training for pilots. In one investigation13, it was found that the people management and SMS processes in the form of work roster and hours of duty probably contributed to fatigue. The one technical failure management safety issue10 was related to the design of the ship’s windlass and its hydraulic motor casing. The one safety issue involving equipment14 related to a yacht not being fitted with a passive radar reflector and its active radar transponder being turned off at the time of the collision with a bulk carrier. 
Loss of the Department of Immigration and Multicultural and Indigenous Affairs vessel Malu Sara in Torres Strait, Queensland (MO-2009-007) Local conditionsThe local condition safety issues were typically related to the knowledge, skills and experience of the crew. Examples include the lack of knowledge, skills and or experience in relation to the stowage of cargo crane hooks, using the IMO’s SMCP, stowage of the movable lashing bins, and the reliable detection of Class B Automatic Identification System (AIS) by watch keepers on board all ships. Organisational influencesOrganisational safety issues with significant risk either involved SMS processes or regulatory influences (Figure 20). In one investigation15, the ship’s health, safety, security and environment meetings and job hazard opportunity log were not effectively used to raise and discuss safety issues associated with cargo crane operations. Two SMS safety issues involved the lack of processes to avoid fatigue. Regulatory issues identified involved: a lack of independent safety auditing the inability for international work standards to avoid cumulative fatigue the lack of implementation of the international law to render assistance to crew of another vessel following a collision by all countries.
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he physical environment (such as unsecured lashing bins, dirty fuel oil service tanks, and low main engine fuel inlet temperature) contributed to about a third of local condition safety factors in marine investigations (Figure 16). 
ssues with procedures made up 69 per cent of the risk control safety factors Figure 17). Examples included: the lack of procedures or guidance relating to the anchoring equipment and ballast systems, the lack of procedures in place to deal with a lost or overdue small vessel, and insufficient guidance in stowing a ship’s cargo crane hook.
ver half of the organisational influences identified as safety factors were related to safety management system (SMS) processes (Figure 18). Some investigations found that SMS processes were either not used effectively or were inadequate. In one case, equipment was not tested and crew were not familiarised with it before departure. In another, fatigue management was ineffective.
