[Peetwo]

Where the hell is OTSI and AMSA?

The question has to be asked where the hell is OTSI? And why are they apparently refusing to investigate serious systemic safety issues/occurrences involving the Transdev Sydney Ferries operations?

Where the hell is AMSA the safety regulator responsible for overseeing and auditing the SMS for all DCV operations?

The serious safety issues that we are aware of so far:

1) multiple overloading incidents of the Emerald GENII on the F1 route (CQ to Manly)(one of these events was rumoured to have been in excess of 100 pax over the max of 400);
2) a catastrophic engine failure, albeit on a non-revenue RTS run, that Chris Cowper states above could have involved multiple fatalities.

In aviation terms if an aircraft suffers a catastrophic engine failure (think QF32) the National regulator would more than likely ground the airline's fleet of that aircraft type and in some cases they would recommend the entire grounding worldwide of that aircraft type, until initial investigations can establish the level of risk for reoccurrence is low.

Here is the OTSI Ferry safety investigation webpage link: https://www.otsi.nsw.gov.au/ferry/investigations

This is the preamble that tops that page:

Ferry Safety Investigations

The NSW Passenger Transport Act 1990 allows OTSI to investigate any safety occurrence involving a ferry, with a seating capacity of more than 8 adults, that is involved in providing a public passenger service.

An investigation may be initiated by the Chief Investigator or the NSW Minister for Transport and Roads as the result of a safety occurrence or following the identification of an adverse safety trend.

The purpose of an OTSI investigation is to identify why an accident or incident occurred and to make recommendations to prevent recurrence. OTSI Investigation reports are tabled by the NSW Minister for Transport and Roads in both houses of the NSW Parliament and are also published on OTSI's website.

The nature of OTSI investigations is different to those carried out by safety regulators and enforcement agencies. OTSI applies a 'no blame' approach where the primary purpose is to identify the contributory factors that lead to a safety occurrence, rather than apportion blame or liability. If it is identified that the safety occurrence was the result of a malicious act, then the matter maybe referred to the relevant  authority or Police.

While on that page I was curious to note that the "Rockfish 3 collision with John Cadman 3" final report has been released: https://www.otsi.nsw.gov.au/ferry/invest...n-cadman-3

In the OTSI introduction it states:

OTSI does not investigate all transport safety incidents and accidents but focuses its resources on those investigations considered most likely to enhance bus, ferry or rail safety. Many accidents result from individual human or technical errors which do not involve safety systems so investigating these in detail may not be justified. In such cases, OTSI will not generally attend the scene, conduct an in-depth investigation or produce an extensive report.

I guess an overloaded Ferry could be regarded as human error and at a stretch a catastrophic engine failure could have been caused by a technical error. However if the present OTSI Chief Investigator and her Senior Management team honestly believe that to be the case with these serious systemic safety issues at Transdev, then have I got a deal for them...  




Coming back to the 'Rockfish 3 collision with John Cadman 3' FR, I note that findings mainly allude to deficiencies inside of both operators' SMS:

Safety actions taken John Cadman 3

2.73 Following the collision, the company and crew conducted a review of their SMS and risk register. This review resulted in several procedural changes and vessel modifications.

These included:
• modifications to the wheelhouse window framing to reduce blind spots
• the addition of double row party lights down both sides of the superstructure to increase the conspicuity of John Cadman 3 to other vessels
• changes to crew induction procedure to include the confirmation of competency, through assessment criteria and a questionnaire
• the development and inclusion of a Transit Zone and reduced visibility look-out procedure. The procedure calls for a lookout to be in the wheelhouse to assist the Master when travelling through the Transit Zone (day or night). It also instructs Masters to utilise extra lookouts as required in time of reduced visibility.

Rockfish 3

2.74 Following the collision, the company reviewed their SMS and in February 2022 incorporated a revised policy for night-time charters. The new policy - Deck Watch – Evening Charter, highlighted that Sydney Harbour was busy. It recommended that both the Master and deckhand (when carrying one) maintained a lookout for hazards and complied with the collision regulations, while operating during dusk and evening conditions. The policy did not detail how this was to occur

These were the findings:

Contributory Factors

3.1 The operators of the involved vessels did not identify all relevant risks and
mitigation strategies when operating in the Sydney Harbour Bridge Transit Zone
at night. Neither operator identified the increased risk of collision or the
associated visual limitations, including their respective vessel viewing
constraints. This resulted in both Masters sighting the other vessel when it was
too late to take action to avoid a collision.
3.2 Neither vessel involved in the collision saw the other vessel so did not adhere to
the relevant COLREGS Rules.
• The give-way vessel in the crossing situation, did not take early and
substantial action to keep well clear.
• The stand-on vessel in the crossing situation, did not respond in time to the
close quarters situation resulting from the give-way vessel’s failure to give
way.
3.3 John Cadman 3’s Master was focused on the overtaking traffic and did not see
the approaching Rockfish 3 on the port bow.
3.4 John Cadman 3’s Master was alone in the wheelhouse, which limited their ability
to maintain a proper look-out in a recognised high traffic location.
3.5 John Cadman 3’s wheelhouse window structure created significant blind spots for
the Master, which likely concealed Rockfish 3.
3.6 Rockfish 3’s Master was navigating the vessel with lowered clears and internal
cabin lights illuminated. Light reflecting off the clears would have significantly
reduced the Master’s ability to maintain a proper look-out.
3.7 Rockfish 3’s deckhand was primarily focused on preparing the vessel for
overnight shut down and was unaware of the approaching hazard.

Other Safety Factors

3.8 The Sydney Harbour Bridge Transit Zone was a recognised location of high
traffic volume with identified navigational hazards and increased risks during
night operations.
3.9 Rockfish 3’s crew were in their 11th hour of continuous operation. While the crew
had completed a short break between charters, the preparation requirements for
the next charter resulted in the crew not having time to leave the vessel and rest
during their duty period.
3.10 Rockfish 3’s SMS did not identify or include mitigation strategies for several
known risks. These included night operations, operating within the Sydney
Harbour Bridge Transit Zone, use of clears and internal cabin lights. The SMS
was generic and was not tailored to the intended operations of the vessel.
3.11 John Cadman 3’s SMS did not identify or include mitigation strategies for some
known risks. These included night operations, operations within the Sydney
Harbour Bridge Transit Zone, timing of engine rounds and wheelhouse line of
sight challenges.
3.12 John Cadman 3’s navigation lights may have blended into the background lighting
of Luna Park. This may have detracted from Rockfish 3’s Master’s ability to
identify John Cadman 3 prior to the collision. The variable lighting conditions in
the vicinity of the Sydney Harbour Bridge likely exacerbated the ability of a lookout to identify hazards and mitigate risks to safe navigation in a timely manner.
3.13 Gaps in the Safety Management Systems (para 2.62 – 2.72) for both involved
vessels were not identified prior to the collision

And the recommendations:

JC III Pty Ltd

4.1 Review their Safety Management System to ensure that:
• the risk register includes relevant risks encountered during charter
operations, specifically identification and mitigation for night operations
and look-out
• relevant competency-based crew induction and ongoing refresher
training are included.

Rockfish Charters

4.2 Review their Safety Management System to ensure that:
• the risk register includes relevant risks for charter operations, specifically
identification and mitigation for extended hours of work, night operations,
cabin lights, clears and look-out
• onboard procedures are relevant to the vessel
• relevant competency-based crew induction and ongoing refresher
training are included.

Domestic Commercial Vessel Operators

4.3 Review their Safety Management System to ensure that the risks involved in
operating in high traffic density areas such as the Sydney Harbour Bridge Transit
Zone are assessed for all operating conditions, day and night. Implement
mitigation strategies to reduce risks for any of the identified hazards.

I also note that AMSA had input as a DIP to this investigation and in 'References' OTSI provide this helpful link: https://www.amsa.gov.au/vessels-operator...-operation

At the bottom of the page there is this link: https://www.amsa.gov.au/vessels-operator...nt-systems

Hmm..so how come there is no reference, review or recommendations in regards to AMSA's oversight responsibilities of both operators, especially when you consider the obvious deficiencies within both operators' SMS?

MTF...P2