The aircraft manufacturer's documentation did not provide information or guidance to pilots for flight in turbulent conditions, increasing the risk of an inadequate pilot response to an encounter with severe turbulence.
SANs description
The Australian Transport Safety Bureau draws the attention of all operators to the contributory and other factors identified by this investigation. Operators are encouraged to review their procedures to ensure an appropriate awareness amongst operating personnel of the implications for aircraft performance of the combination of aircraft weights and speed, and of the ambient conditions.
Investigation: AO-2007-044: Go-around event Melbourne Airport, Victoria, 21 July 2007, VH-VQT, Airbus Industrie A320-232
Safely action number
AO-2007-044-SAN-110
Risk category
Significant
Safety issue description
The aircraft operator did not conduct a risk analysis when changing the go-around procedure, nor did its safety management system require one to be conducted.
SANs description
The aircraft operator had changed the standard operating procedure for the go-around. The change resulted in the flight crew being unaware of the flight mode status of the aircraft during the first part of the first missed approach. This incident highlights the potential for unintended consequences when changes to standard operating procedures are introduced without first conducting an appropriate risk analysis. Therefore, the Australian Transport Safety Bureau advises that all aircraft operators should consider the safety implications of this safety issue and take action where considered appropriate.
Action organisation
All operators
Safety action release date
1/03/2010
Safety action status
Closed
Safety action complete date: 1/03/2010
Investigation complete date
5/03/2010
Marine
Investigation: MO-2008-003: Independent investigation into the drifting and subsequent grounding of the Sierra Leone registered products tanker Breakthrough at the Cocos (Keeling) Islands on 12 February 2008.
Safely action number
MO-2008-003-SAN-050
Risk category
Significant
Safety issue description
The operation of the ship’s systems and the decisions made by the ship’s senior officers suggests that they did not have appropriate knowledge and experience to safely undertake Breakthrough’s delivery voyage and that they did not effectively use the time spent in China, standing by the ship, to acquire the necessary knowledge.
SANs description
The Australian Transport Safety Bureau advises ship owners, operators and masters should consider the safety implications of this safety issue and take action where considered appropriate.
The International Safety Management (ISM) Code requires ship owners to ensure that each ship’s master is given all necessary support to fulfil their duties. However, Jevkon Oil and Gas did not provide the necessary support either before the commencement of the delivery voyage or after the ship’s crew began having difficulties using the intermediate fuel oil in the main engine and started drifting in the Indian Ocean.
SANs description
The ATSB advises that Jevkon Oil and Gas should consider the implications of this Safety Issue and take action where considered appropriate.
The ship's safety management system was inadequate. Had Jevkon Oil and Gas implemented an effective safety management system on board Breakthrough, the risk of an incident such as the one that occurred on the delivery voyage would have been reduced.
SANs description
The ATSB advises that Jevkon Oil and Gas should consider the implications of this Safety Issue and take action where considered appropriate.
Action organisation
Jevkon Oil and Gas
Safety action release date
09/04/2010
Safety action status
Closed
Safety action complete date: 09/04/2010
Investigation complete date
09/04/2010
Investigation: MO-2008-008: Independent investigation into the grounding of the Isle of Man registered bulk carrier Iron King at Port Hedland, Western Australia, on 31 July 2008
Safely action number
MO-2008-003-SAN-025
Risk category
Significant
Safety issue description
Iron King’s safety management system did not include procedures that adequately ensured that the ship’s master and crew were aware of, and drilled in, the emergency steering system change over procedure to be followed in the event of steering control loss.
SANs description
The Australian Transport Safety Bureau advises that owners, operators and masters should consider the safety implications of this safety issue and take action where considered appropriate.
Action organisation
Ship owners, managers and masters
Safety action release date
13/10/2009
Safety action status
Closed
Safety action complete date: 13/10/2009
Investigation complete date
13/10/2009
Investigation: MO-2008-010: Auxiliary boiler explosion on board Saldanha off Newcastle, 18 November 2008
Safely action number
MO-2008-010-SAN-041
Risk category
Significant
Safety issue description
Saldanha’s master and crew were not aware of the appropriate first aid treatment required for burn injuries. As a result, the third engineer was not immediately provided with appropriate first aid.
SANs description
The ATSB advises that flag States, owners, operators and masters should consider the safety implications of this safety issue and take action where considered appropriate.
Investigation: MO-2008-011: Independent investigation into the fatal injury on board the Maltese registered container ship Spirit of Esperance in Townsville, Queensland on 24 November 2008
Safely action number
MO-2008-010-SAN-019
Risk category
Significant
Safety issue description
The design of the cradle for the crane’s hook did not allow for unassisted stowage of the hook when the ship had a stern trim in excess of 2.1 m.
SANs description
The Australian Transport Safety Bureau advises that Marlow Navigation should consider the safety implications of this safety issue and take action where considered appropriate.
Action organisation
Marlow Navigation
Safety action release date
14/04/2010
Safety action status
Closed
Safety action complete date: 14/04/2010
Investigation complete date
14/04/2010
Investigation number
MO-2008-011
Safely action number
MO-2008-010-SAN-045
Risk category
Significant
Safety issue description
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.
SANs description
The Australian Transport Safety Bureau advises that ASP Ship Management should consider the safety implications of this safety issue and take action where considered appropriate.
Action organisation
ASP Ship Management
Safety action release date
14/04/2010
Safety action status
Closed
Safety action complete date: 14/04/2010
Investigation complete date
14/04/2010
Safely action number
MO-2008-010-SAN-042
Risk category
Minor
Safety issue description
The ship's safety management system working aloft procedure was not effectively implemented on board the ship and was not routinely followed when crew members climbed the emergency ladder to assist with the stowage of the cargo crane hook.
SANs description
The Australian Transport Safety Bureau advises that ASP Ship Management should consider the safety implications of this safety issue and take action where considered appropriate.
Action organisation
ASP Ship Management
Safety action release date
14/04/2010
Safety action status
Closed
Safety action complete date: 14/04/2010
Investigation complete date
14/04/2010
Investigation: MO-2009-008: Collision between Silver Yang and Ella’s Pink Lady off Point Lookout, Queensland, 9 September 2009
Safely action number
MO-2009-008-SAN-012
Risk category
Significant
Safety issue description
While most flag States have laws in place that implement the UNCLOS requirement for a ship’s master to render assistance to the crew of another vessel following a collision, these laws are not being effectively implemented on board all ships.
SANs description
The Australian Transport Safety Bureau advises that all flag States should consider the safety implications of this safety issue and take action where considered appropriate.
