Atsb transport safety report
Download 1.46 Mb.
|
- Navigate this page:
- Proactive industry safety actions in marine
- ATSB Safety Recommendations in marine
- Summary (Marine)
Safety actionsThe majority of safety actions taken as a response to a marine occurrence were proactive in nature (Figure 21). Figure 21: Safety actions in response to marine investigations 
Proactive industry safety actions in marineThere were 34 proactive industry safety actions in total, which were spread across various safety action categories, such as procedures, organisational supervision and training, documentation, and education (Figure 22). The proactive industry safety actions related to procedures carried out by the industry can be categorised into three broad areas. The first proactive action is related to revising the operator’s own safety management processes– mainly with regards to steering drills, mobile phone usage and anchor positioning. The second was modifying or reviewing procedures and guidance on ballast operations, anchoring in berth to berth, anchor cable release, and anchorage boundaries from gas pipeline. The third type of procedural safety action was related to risk assessments regarding ballast operations, responses to emergency scenarios, and anchorage boundaries from gas pipeline. Some examples of proactive organisational supervision include regular attendances on-board vessels and audits to monitor crew performance and compliance with company guidelines, as well as reviewing and discussing relevant safety bulletins and boiler instruction manuals during safety meetings. Some examples of the documentation-related proactive industry safety actions as an outcome of identified significant safety issues include reviewing manuals to confirm guidance given, revising planning procedures and practices, developing a ballast operations checklist, posting instruction tables, and requiring training officers to provide the company with written reports covering auditing and training activities. The great majority of education safety actions in response to safety issues of significant risks were associated with issuing company circulars and fleet safety bulletins, placing placards with clear directions regarding anchor cable release procedures, and conducting English classes ashore and on board ships for crew.
Rupture of a submarine gas pipeline by APL Sydney in Port Phillip, Victoria (MO-2008-012) The training provided as a result of the safety issues of significant risk were related to training crew in emergency procedures, such as undertaking emergency procedure simulations. Other examples include the ships’ masters acting as ‘training officers’ to train crews in accordance with company guidelines, chief mates ensuring all deck department crews are trained in anchor cable release procedures, and the review of current training and qualifications of pilots with respect to anchor positions. Figure 22: Proactive industry safety actions in marine 
ATSB Safety Recommendations in marineAll of the ATSB safety recommendations were a result of the safety issues of significant risk identified in marine investigations (Figure 23). A full list of safety recommendations made can be seen in Table 9. An occurrence16 involving an engine room flooding attributed to the work permit system not being effectively implemented on board the ship resulted in three ATSB safety recommendations. Consequently, the operator conducted education in the form of issuing company circulars to inform crew of the accident, increased organisational supervision in terms of regular audits, and ensured work permit procedures for maintenance and repair work are carried out. In an incident17 where a ship's engineer was burned when the auxiliary boiler furnace 'flashed back' during a routine boiler oil firing unit burner exchange, the company had previously warned of the dangers associated with servicing the VJ type burner. But it did not inform operators that the burner could be replaced with a VJP burner (a similar burner fitted with a diesel pilot burner), or recommend that existing oil firing units could be modified. The ATSB recommended that safety action be taken to address these issues. The safety actions taken were related to the design or modification of the existing oil firing units, education about the possibility of replacing the burner with another type, and changing servicing procedures in light of the dangers associated with the VJ type burner. Regulatory surveillance was increased after it was found that the work routine for crew and the compliance with the ILO 18018 and STCW19 requirements for rest probably resulted in a cumulative level of fatigue for crew in an occurrence11. In response to another occurrence20 where the ship’s certification was issued by a management company to itself on behalf of a State, the ATSB also recommended that the Registry should address this regulatory surveillance safety issue. Figure 23: ATSB Safety Recommendations in marine 
Summary (Marine)Individual actions were found to be the most common safety factor identified in marine investigations, closely followed by local conditions and risk controls. The same pattern was found for contributing safety factors. A large amount of safety issues (including those assessed to pose a significant risk to safety) were related to procedures. The issues with procedures were varied and included a lack of anchoring procedures and ineffective SMSs and work permit systems. Local conditions were the second most identified safety issue with significant risk (including those with significant risk). These were typically related to the knowledge, skills and experience of the crew. The vast majority of safety issues were associated with deck operations and other functional areas. Deck operations and navigation (pilotage) were linked to the most safety issues with significant risk. Most of the safety actions taken by organisations and agencies in response to safety issues were proactive in nature. These actions taken spread across various safety action categories such as procedures, organisational supervision, documentation, education, and training. There were four ATSB safety recommendations made and all of these were in response to safety issues of significant risk. The safety recommendations were mainly related to regulatory surveillance, procedures, and education. Directory: media media -> Applications to Drill media -> Unicef voices of Youth Chat Theme: Children and aids nigeria and Zimbabwe 13 October 2006 Background media -> Tsunami Terror Alert: Voices of Youth media -> Biblical Eschatology Presentation by: D. Paul Beck May 4, 2016 Ground Rules media -> Guide to completing the collection using the Omnibus system media -> The milk carton kids media -> Events Date and Location media -> The Gilded Age: The First Generation of Historians by H. Wayne Morgan University of Oklahoma, April 18, 1997 media -> Analysis of Law in the United Kingdom pertaining to Cross-Border Disaster Relief Prepared by: For the 30 June 2010 Foreword media -> Cuba fieldcourse 2010 Download 1.46 Mb. Share with your friends:
|
