“For want of a nail the shoe was lost.”
#61

AMSA comical 'lessons learnt' on Sydney Harbour Emerald Ferry incident. -  Rolleyes 

Still trying to track down a copy of the associated incident report and I'm not sure why AMSA are all of a sudden investigating Sydney Harbour DCV incidents, inside of what is normally OTSI turf?? However for the amusement of interested readers, the following is a AMSA LinkedIn post acknowledging their publication of a safety lesson report:

Quote:Australian Maritime Safety Authority
23,477 followers
4d •

This month’s safety lesson report highlights the importance of ensuring all crew, including new employees, are provided appropriate training on a vessel’s safety management system, and understand the practical application and their responsibilities.

Every month we share an overview of a domestic commercial vessel incident investigation and the safety lesson you can learn to ensure safe operations on board your vessel.

Read the monthly safety lesson: https://ow.ly/yYbS50Q1iTi

#SafeSeas

[Image: 1698706830625?e=1699693200&v=beta&t=k38e..._QQaS3AL4U]


Here is the 'safety lessons' report... Rolleyes

Quote:Safety Lessons from Marine Incident Investigation (AMSA Report) No.22 - October 2023

Passenger vessel flooded after access door was left open.

Overview

A passenger ferry was returning from its scheduled service when an unanticipated wave raised its stern and caused its bow to dive under the water. Water rushed over the bow and a significant amount came through the forward portside access door and into the passenger compartment. The master immediately reduced speed, which expelled most of the water overboard. 

The forward portside access door had been left open by a crew member who was attempting to alleviate sea sickness among some passengers. The action of leaving the door open during the voyage was contrary to the vessel’s survey requirements. Signage requiring the door to be kept closed when underway was reportedly not seen by crew members. This resulted in water entering the vessel creating a potentially unsafe situation. 

What happened

At about 14:45, a Class 1 vessel was ferrying passengers back to its city quay on a scheduled service. This service was busier than usual as it was covering for an unavailable service. The conditions were reported as about 1.25 to 2.5m wave height with the vessel speed about 20 knots. 

A significant amount of water entered the vessel over the bow and through the open forward portside access door. The master stated that conditions at one point were such that the stern of the vessel lifted out of the water higher than expected, pushing the bow lower in the water.

The water ingress lasted 10 seconds in total. There were no injuries to passengers or crew and subsequent inspection identified no damage to the vessel. A crew member had left the access door open to alleviate passenger sea sickness, which allowed water to enter the vessel.

Signage was in place above the forward portside door, cautioning crew that the door was to remain closed ‘when underway’. The crew member reported having not seen the signage. The action of leaving the forward portside access door open during the voyage was contrary to the vessel’s survey requirements and the master was not aware that the crew member had left it open.

Investigation findings

The investigation identified the following contributory factors:
  • A review of crew member induction records identified that crew members were made aware of the location of the vessel’s safety management system (SMS), however they were unlikely to know all the requirements in the SMS unless provided with guidance from master/s.
  • The master’s handling of the sea state was deemed to be within acceptable parameters. However, the master had been recently certified competent and was new to the vessel, which may have impacted vessel handling. 

The company was advised to consider putting in place risk control measures to ensure doors remain closed, including the installation of sensors with visual/audible alarms in the wheelhouse monitored by the master/crew, and signage on the door at a suitable visual height.

Safety message

Owners must ensure that all crew, including new employees, are provided appropriate training on the vessel’s SMS and understand the practical application and their responsibilities in relation to this. This requirement is addressed in s6D, Schedule 1 of Marine Order 504 - onboard induction, familiarisation, and training. 

Owners must ensure that crew also understand the vessel’s certificates of survey and any conditions in which the vessel is operating under. 

Safety information on this topic

Marine Order 504 – certificates of operation and operation requirements – national law

Certificates of Survey (CoS)

In other NSW OTSI/TfNSW news I note that the Chief Investigator has jumped ship for a gig as the Chief Executive of the Office of the National Rail Safety Regulator:

Quote:Dr Natalie Pelham GAICD
Chief Investigator and CEO at Office of Transport Safety Investigations
4d •

I am delighted to be joining the ONRSR and to have the opportunity to influence rail safety at the national level. The former CEO and Regulator Ms Sue McCarrey made a considerable contribution to rail safety particularly in establishing a well respected regulator. I look forward to working with the ONRSR team to build on that legacy and to drive further safety and efficiency reforms for the industry.

Quote:National Rail Safety Regulator appoints new Chief Executive

The search for Australia’s next National Rail Safety Regulator is over, with Dr. Natalie Pelham appointed Chief Executive of the Office of the National Rail Safety Regulator (ONRSR).

Dr. Pelham will take on the role from Sue McCarrey who left ONRSR in December last year. Dr. Pelham will be leaving her current role in New South Wales’ Office of Transport Safety Investigations, where she has been Chief Investigator since January 2021.

Dr. Pelham will be the third National Rail Safety Regulator appointed in Australia following the formation of ONRSR in 2013, when the seven state and territory regulatory bodies were brought together under the national banner.

In that time the Australian rail industry has benefitted from a range of national reforms including a consolidated accreditation process and a risk-based national work program of audits and inspections.

ONRSR has also overseen significant improvements to the quality and availability of rail safety data now being harnessed to drive improved decision making by industry and governments alike.

Dr. Pelham will start with ONRSR in early November.

Quotes attributable to Federal Infrastructure, Transport, Regional Development and Local Government Minister Catherine King:

“Rail connects communities and is a major carrier of goods in Australia, being responsible for around 49 per cent of our total domestic freight – making it an important part of our economy and way of life.

“ONRSR plays an important role enforcing and promoting safe railway operations, to ensure that all those working on and using railways get home safely after each shift or trip.

“The Albanese Government is committed to ensuring a safe and productive rail industry in Australia. I welcome Dr. Pelham to this vital role and look forward to continuing to work with ONRSR as they continue to promote and improve national rail safety.”

Quotes attributable to South Australian Minister for Infrastructure and Transport Tom Koutsantonis:

“Dr. Pelham has more than 25 years in the public service leading significant safety regulation, policy, strategy and reform at both state and national levels.

“Dr. Pelham will be a very strong leader for ONRSR and most importantly a wonderful advocate and activist for rail safety.

“Her experience across the regulatory spectrum gives her the ideal skillset and under her leadership ONRSR will continue to deliver for the people of Australia.

“I look forward to working with her and progressing an exciting national rail safety agenda.

“A great deal has been achieved over the first decade of national rail regulation and there is great potential for us to drive further safety and efficiency reforms for the rail industry.”


I also note that the NSW Minister for Transport Jo Haylen has got herself into a spot of political bother within her Ministerial office... Sad

Quote:Transport Minister Jo Haylen fighting for political survival after chief of staff resigns over scandal

ByAlexandra Smith and Max Maddison
Updated November 3, 2023 — 4.53pm first published at 12.53pm

NSW Transport Minister Jo Haylen’s chief of staff has sensationally quit after it emerged the junior public servant parachuted into the office was doing political work while on secondment, including collating a list of Coalition backflips and organising a barbeque to celebrate Labor’s election win.

Scott Gartrell, a long-term Labor staffer, resigned on Friday afternoon as a tranche of documents were tabled to parliament which showed that Transport for NSW employee, Kieren Ash, engaged in political work while in Haylen’s office.

[Image: 49638c39d1d6faed3e23a6b6730b767d37a49bbb]

Gartrell arranged for Ash to be seconded to Haylen’s office just weeks after the junior bureaucrat had run Labor’s unsuccessful election campaign in the inner west seat of Balmain during the March state election.

The resignation will put intense pressure on Haylen, who has faced heavy criticism for the appointment of Transport Secretary Josh Murray, who has long links to Labor, as well as the role of public servants in her office with party ties.

A government source with knowledge of the details of Gartrell’s resignation said Haylen did not ask him to leave, and it was his own decision.

Documents released through the parliament late on Friday show that Ash was appointed to the position of department liaison officer. That position has strict requirements, including not undertaking any work that could be seen as political.

[Image: 3f985015e86b587e96d28c2b1827c058bf91c381]

Gartrell, in his capacity as Haylen’s chief of staff, declared that Ash would not be required to undertake any political work and would be excluded from any political conversations.

“I ... will not require the DLO to perform party political activities, and will exclude the DLO from any meetings where political matters are discussed,” Gartrell signed on April 27.

However, other documents obtained by the Herald disclose that Ash was corresponding with lobbyist firm GRACosway on the launch of a Beam e-scooter trial in conjunction with Transport for NSW and Armidale Council – work outside the scope of DLOs. “I imagine the minister would be more than happy to feature on a media release,” he wrote on July 5.

In other emails, Ash referred to government MPs as “our Labor colleagues” and agreed to help organise a barbeque in Haylen’s Summer Hill electorate to celebrate 100 days of the Minns government.

On May 10, Ash circulated a “backflips timeline” with a list of Coalition MPs who were responsible during their time in government, including former transport minister Andrew Constance and former planning minister Rob Stokes.

Ash also emailed staff asking for “any notices of motions for our colleagues for the next fortnight of parliament” and made a range of suggestions, such as the return of the Freshwater ferries, and “maintenance/cleaning insourcing”.

Ash also drafted lines on how Haylen should respond in parliament to questions about transport from Coalition MPs, including new members, suggesting the minister say “it’s their mess we inherited [from the former government] and we were elected to fix”.

Ash’s appointment drew the attention of then-acting transport secretary Howard Collins, internal documents previously released to parliament revealed.

An email between transport officials on July 4 showed that Collins raised concerns about Ash sticking to the boundaries of the role when Gartrell asked to extend his time in the minister’s office from three to 12 months.

“Howard raised with Scott his concerns to ensure Keiran [sic] adheres to the parameters of the scope of a DLO role,” the email states.

In a statement made before Gartrell’s resignation, Haylen said: “After being made aware of the existence of a number of documents, my office has subsequently written to the Secretary of Transport for NSW to request that the department look into whether some actions conducted by a DLO in the minister’s office were in line with their employer obligations.

“It is clear that the practice of requesting Departmental Liaison Officers from TfNSW, whilst not against the rules, has created questions around the role of DLOs and their relationship with the ministerial office,” Haylen’s statement said.

Haylen has asked her department head to investigate Ash. However, the minister was forced to write to Murray on Friday in his “employer capacity for all necessary action” after the release of the emails indicated that he may have broken the rules of his employment.

The opposition seized on the latest revelations engulfing Haylen and said the investigation into Ash should be conducted by the Public Service Commissioner Kathrina Lo, not Murray.

Opposition transport spokeswoman Natalie Ward said, “the investigation is nothing more than an attempt to throw a junior staffer under the bus to protect a minister.”

“Does any reasonable person think Josh Murray, the minister’s handpicked secretary is really going to find the minister committed any wrongdoing?,” Ward said.

“A controversially Labor appointed secretary is investigating the minister who got him the job regarding an operative her office requested doing political activities – it doesn’t pass the pub test.”


MTF...P2 Tongue
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“For want of a nail the shoe was lost.” - by Peetwo - 11-26-2022, 05:50 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 11-26-2022, 09:47 PM
RE: “For want of a nail the shoe was lost.” - by Kharon - 11-28-2022, 05:23 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 11-28-2022, 05:59 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 11-30-2022, 07:41 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 11-30-2022, 05:29 PM
RE: “For want of a nail the shoe was lost.” - by Kharon - 12-01-2022, 05:35 AM
RE: “For want of a nail the shoe was lost.” - by Wombat - 12-01-2022, 05:54 AM
RE: “For want of a nail the shoe was lost.” - by Kharon - 12-02-2022, 07:54 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 12-02-2022, 07:54 PM
RE: “For want of a nail the shoe was lost.” - by Kharon - 12-03-2022, 07:26 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 12-05-2022, 09:22 AM
RE: “For want of a nail the shoe was lost.” - by Kharon - 12-06-2022, 06:38 AM
RE: “For want of a nail the shoe was lost.” - by P7_TOM - 12-06-2022, 05:32 PM
RE: “For want of a nail the shoe was lost.” - by Kharon - 12-08-2022, 06:14 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 12-10-2022, 10:52 AM
RE: “For want of a nail the shoe was lost.” - by Kharon - 12-12-2022, 07:33 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 12-13-2022, 11:08 PM
RE: “For want of a nail the shoe was lost.” - by Kharon - 12-15-2022, 07:42 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 12-16-2022, 06:46 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 12-19-2022, 08:53 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 01-12-2023, 08:50 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 01-20-2023, 07:01 PM
RE: “For want of a nail the shoe was lost.” - by Kharon - 01-24-2023, 05:48 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 02-03-2023, 08:05 PM
RE: “For want of a nail the shoe was lost.” - by Kharon - 02-04-2023, 06:17 AM
RE: “For want of a nail the shoe was lost.” - by Kharon - 02-08-2023, 07:32 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 02-08-2023, 07:39 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 02-09-2023, 06:43 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 02-10-2023, 05:08 PM
RE: “For want of a nail the shoe was lost.” - by P7_TOM - 02-10-2023, 06:54 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 02-11-2023, 07:46 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 02-13-2023, 12:28 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 02-18-2023, 10:46 AM
RE: “For want of a nail the shoe was lost.” - by Kharon - 02-20-2023, 07:24 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 02-21-2023, 09:52 AM
RE: “For want of a nail the shoe was lost.” - by P7_TOM - 02-21-2023, 04:08 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 02-22-2023, 07:51 PM
RE: “For want of a nail the shoe was lost.” - by Kharon - 02-23-2023, 06:23 AM
RE: “For want of a nail the shoe was lost.” - by P7_TOM - 02-23-2023, 05:12 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 02-25-2023, 09:39 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 03-04-2023, 11:27 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 03-14-2023, 09:02 AM
RE: “For want of a nail the shoe was lost.” - by Kharon - 03-15-2023, 05:02 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 03-19-2023, 10:44 PM
RE: “For want of a nail the shoe was lost.” - by P7_TOM - 03-21-2023, 05:16 PM
RE: “For want of a nail the shoe was lost.” - by P7_TOM - 03-27-2023, 04:49 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 03-28-2023, 09:40 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 03-31-2023, 07:38 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 04-10-2023, 04:51 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 04-11-2023, 09:02 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 04-12-2023, 09:18 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 04-20-2023, 09:00 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 06-06-2023, 09:30 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 06-12-2023, 09:51 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 07-14-2023, 06:38 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 06-13-2023, 09:57 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 06-21-2023, 09:51 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 06-23-2023, 06:57 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 08-10-2023, 08:44 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 11-04-2023, 06:57 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 02-22-2024, 08:20 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 03-01-2024, 08:06 AM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 03-01-2024, 06:04 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 03-11-2024, 03:29 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 03-20-2024, 07:37 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 03-23-2024, 04:35 PM
RE: “For want of a nail the shoe was lost.” - by Peetwo - 03-29-2024, 08:54 AM



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