[Peetwo]

New Ferry contract deferred; & OTSI's new convoluted website?? 

Courtesy MattO, via the SMH:

New Sydney ferry fleet purchase delayed, again, after shipbuilders rejected



By Matt O'Sullivan
February 23, 2023 — 3.57pm

The purchase of seven new Sydney ferries will be delayed again after the NSW government rejected shipbuilders that had bid for the multimillion-dollar contract to construct them locally.

The state’s transport agency has told shipbuilders bidding for the contract for the fleet of new Parramatta River ferries that the tender “resulted in no contract being awarded”, and it would now gauge market interest in a new process.


One of the seven RiverCat ferries, which are about three decades old.CREDIT:NICK MOIR

The decision comes amid a state election campaign in which the two major parties have been spruiking plans to boost local manufacturing.

The replacement of the three-decades-old fleet of RiverCats, at a cost of more than $43 million, has already been repeatedly delayed.

The state government initially shelved the purchase of new ferries for the Parramatta River route in 2019 after failing to receive suitable offers from shipbuilders. After the plans were later revived, the purchase was delayed last year because of a lack of an investment decision by the government, which internal documents show was needed to “avoid disruptions to services”.

Bidders for seven new ferries were eventually sought in late November, giving companies until mid-January to submit tenders. The government encouraged bids from local shipbuilders.

However, electric ferry builder EV Maritime said a period of just six weeks over the Christmas holidays had made it difficult for serious bidders to participate.

EV Maritime chief executive Michael Eaglen said the process was made harder by the scope excluding electric ferries, which ruled his company out.

“If the government redesigns the tender, the scope really should include electric ferries. The government has stated that is where the future lies,” he said.

Labor transport spokeswoman Jo Haylen said passengers would be waiting longer for new ferries on the Parramatta River because the government was not serious about the contract.


String of ferry setbacks: The Clontarf was out of services for more than two weeks after suffering a catastrophic engine failure.CREDIT:JAMES BRICKWOOD

“[Transport Minister] David Elliott said that this contract was evidence that domestic manufacturing was back on the Liberal Party’s agenda. The fact that it has now been delayed shows that the Liberals haven’t changed,” she said.

Elliott said local manufacturing and content was at the forefront of the state’s record $76.7 billion investment in transport infrastructure over the next four years, and nothing had changed.

“The tender process for the River-class ferries is being independently managed by Transport for NSW, with the direction from the NSW government that the ferries are to be redesigned and built here in Australia,” he said.

Transport for NSW said the market response to the tender for the seven new ferries “did not meet our expectations or all of the tender evaluation criteria”. It declined to reveal the number of bids received.

“The procurement strategy has been reviewed and Transport is re-engaging with the market,” it said. “The final delivery and service dates will be finalised once the tender has been awarded.”

The project to replace the RiverCats, which can carry up to 230 passengers each, is part of internal government plans for a “right sizing” of the Sydney ferry fleet to “avoid unnecessary costs”. Transport for NSW has estimated in internal documents that there are “at least nine surplus vessels”.

The latest setback for the RiverCat replacement project comes as one of three new Manly ferries, which have been plagued with defects since they arrived in 2021, returned to service on Thursday after an engine was replaced.

The Clontarf had a catastrophic engine failure more than two weeks ago during regular safety drills. Transport for NSW said it was awaiting the results of an investigation into the root cause of the Clontarf’s engine failure.

Hmm...so TfNSW are investigating the Clontarf catastrophic engine failure, for State Regulator purposes,  however OTSI and AMSA apparently are not?? 

AMSA monthly serious incident reports: https://www.amsa.gov.au/vessels-operator...nt-reports (monitor here for this month's publication to see if the Clontarf serious incident turns up - I'm betting it won't)

I note that as of two days ago, with zero fanfare, that OTSI have introduced their new convoluted, un-user friendly, ATSB matching, website -  : https://www.otsi.nsw.gov.au/

Still finding my way around but what is bleedingly obvious is that is a complete change in operational and transport safety investigative philosophy. So much so that I would suggest that the obvious question  is - What the hell do we need OTSI for?? But maybe that is the point and with the philosophical redundancy of OTSI leaves the agency ripe for the takeover by the ATSB??

I question that bureaucratic policy decision when you then consider this statement from the 'Who we are page':

In response to the recommendations of the Special Commission of Inquiry into the Waterfall Rail Accident, the NSW Parliament passed the Transport Legislation Amendment (Waterfall Rail Inquiry Recommendations) Bill 2005 which removed OTSI from ITSRR and created the Chief Investigator as a statutory position reporting directly to the Minister for Transport. OTSI began operating independently on 1 July 2005. 

The separation of OTSI was designed to reinforce the independence of the Chief Investigator, and to give the travelling public and the transport sector a high degree of confidence in the safety of the NSW transport network through the conduct of fair, impartial and balanced investigations.

So OTSI have a formally legislated essential independent statutory role that was designed to address recommendations that came from the Waterfall Special Commission of Inquiry. Not sure how that works for the Popinjay, Walsh, Pelham TSI Nationalisation (ATSB) power grab but IMO it sure sounds murky??   

 Next from the investigation process page I note the following:

In some cases, OTSI may request additional information or review an operator’s investigation report into an incident. This may lead to a number of actions, such as the release of a Safety Alert or Safety Advisory to raise industry awareness of safety issues and action to be taken where there are lessons to be shared.

Perhaps (the above) helps to explain why the CI published this SAN back in August 2021..

 Safety Advisory - Domestic commercial vessel (DCV) steering systems - 31 August 2021

...and why the CI didn't continue with the investigation as OTSI was relying on the Transdev internal SMS investigation reports instead, this despite the fact there was apparently 8 similar (reported to OTSI) serious steering failure occurrences, followed by numerous more in the following year? - OTSI independent? - Yeah right! 

MTF...P2 

[Peetwo]

AMSA & OTSI disconnection on Transdev safety issue transgressions??

Ref: https://www.smh.com.au/national/nsw/high...5c35r.html

"..Internal figures seen by the Herald show the incident two weeks ago takes the number of steering failures involving the Fairlight to eight since late last year, while the Balmoral has had three and the Clontarf one...

"...The internal figures also show the six-strong fleet of older first-generation Emerald-class ferries, used mostly on inner-harbour routes, have suffered seven steering failures over the past two years..."

And from the OTSI SAN from the previous year: https://www.otsi.nsw.gov.au/sites/defaul...210831.pdf 

"..In 2021, a total of eight incidents relating to problems with DCV vessel steering systems have
been reported to OTSI with varying failure modes..."

And via the Oz Arab Media, May 26th 2022: https://ozarab.media/government-announce...6367187500

JO HAYLEN MP
SHADOW MINISTER FOR TRANSPORT
MEMBER FOR SUMMER HILL

The NSW Government has announced a major review of its defect ridden crisis prone overseas built Emerald Class Manly ferries just a day after NSW Premier Dominic Perrottet claimed there were no problems with the vessels.

Yesterday, on Wednesday, May 25, Mr Perrottet claimed the vessels were, “world class ferries that are much, much better and advanced than the ones they replaced.”

He went on to say that, “while there will always be difficulties, they aren’t substantive, they are minor.”

However, the overseas built Emerald Class ferries have been plagued by defects for months, with new defects being discovered on an increasingly regular basis.

In the last two weeks alone:

• The ‘Balmoral’ suffered a major steering failure.
  
• The ‘Clontarf’ was docked three times in a week after it’s lubricating oil system cracked and caused hot oil to spray around the engine room, triggering the vessel’s fire alarms. The vessel underwent repairs but a similar incident occurred the day after and then cracks were found in the vessel’s fuel tanks.
  
• The ‘Fairlight’ has been repeatedly docked because of multiple cracks found in the vessel’s fuel tanks.
  

Shadow Minister for Transport Jo Haylen said:

“What planet is the Premier on? These overseas built ferries are riddled with defects and new ones have been discovered just in the last fortnight. These ferries aren’t world class, they are junk and passengers are faced with cancellations and delays because they simply aren’t up to the job.

“These aren’t minor difficulties, they are clearly deep systemic issues, and they occurred on the Liberal party’s watch. The Premier clearly doesn’t understand how serious the problems with these ferries are, and he doesn’t get that his Government’s transport procurement policies have completely failed.

“Building transport infrastructure overseas means the taxpayer doesn’t get value for money, and that passengers get a bad product. It’s time we learnt the lessons from the Government’s failures and start building our trains, trams, buses and ferries in Australia again.”

Add to that the recent catastrophic engine failure on the Clontarf and several rumoured overload events, one of which involved a turn around with more than a 100 pax overload. Yet our Federal regulator AMSA and OTSI apparently do not have any concerns in regards to what appears to be a substantial systemic trail of operational safety issues and non-compliances??

In order to understand why it is the regulator and state safety investigator are seemingly disinterested in the above operator safety issue transgressions, I have began doing some research into other international jurisdiction, namely the USA, the UK and how they are harmonised and compliant with the IMO SARPs. 

Starting with investigation, which in the case of the USA is conducted by their Coastguard in conjunction with the NTSB.

Extract from the 'NTSB Office of Marine Safety':

Office of Marine Safety


Program Description

The Office of Marine Safety (OMS) investigates marine casualties to determine the probable cause of each casualty and identify safety recommendations that will prevent similar events in the future. Investigated casualties include those classified by the US Coast Guard as major marine casualties in US territorial waters or involving US flagged vessels worldwide, and casualties involving both US public (government) and nonpublic vessels. In addition, the office investigates select catastrophic marine casualties, as well as those of a recurring nature.

These responsibilities are specified in the Independent Safety Board Act and Title 49 Code of Federal Regulations Part 850. Major marine casualties may include any one of the following:

• the loss of six or more lives.
  
• the loss of a mechanically propelled vessel of 100 or more gross tons.
  
• property damage initially estimated to be $500,000 or more.
  
• a serious threat, as determined by the Commandant of the Coast Guard with the concurrence of the NTSB Chair, to life, property, or the environment by hazardous materials.
  

After investigating each major marine casualty, the OMS identifies safety issues and issues an investigation report, which may include safety recommendations to federal government agencies (such as the Coast Guard), state agencies, vessel owners and operators, vessel classification societies, or maritime industry organizations.

Under the International Maritime Organization’s (IMO) Casualty Investigation Code, the OMS also participates with the Coast Guard as a Substantially interested State in investigations of serious marine casualties involving foreign-flagged vessels in international waters. For example, the NTSB often participates in casualty investigations that involve foreign-flagged cruise ships with US citizens on board.

The OMS also actively participates in US-based and international groups to improve marine investigations and promote maritime safety. This includes—

[/size]

• reviewing US position papers related to marine casualty investigation.
  
• participation at IMO meetings.
  
• tracking developments in marine casualty investigation and prevention.
  
• cooperation with other marine casualty investigation organizations worldwide
  

Very different system, unlike AMSA Coast Guard is the SAR and safety authority but not the regulator.

The UK investigator is the MAIB: https://www.gov.uk/government/organisati...anch/about

Contents

1. Who we are
   
2. Our responsibilities
   
3. Our priorities
   

1. Regulations and guidance
   
2. Corporate information
   

Our job is to help prevent further avoidable accidents from occurring, not to establish blame or liability.
Marine Accident Investigation Branch receives between 1500 and 1800 reports of accidents of all types and severity each year. On average this leads to 30 separate investigations being launched.

Again a different system as the UK doesn't have individual State investigative bodies to have to deal with. The effectiveness of their system is very much apparent when you review some of their investigation accident and serious incident final reports etc. : https://www.gov.uk/government/publicatio...stigations

IMO one of the best indications of the effectiveness of the MAIB was in their safety digest publication...

Ref: https://www.gov.uk/government/publicatio...ests-20-24

In a passing strange coincidence there was this incident and lessons learnt in the latest safety digest (ref pg 7):

 

Some months later while on passage, a sudden and increasingly loud sound emanated from the main engine. The duty engineer recognised that something serious was occurring and took cover as the main engine
catastrophically failed. Major internal engine components were thrown out through the crankcase and a large fire engulfed the engine room (Figure 2). The duty engineer was fortunate to escape through the thick black smoke that enveloped the engine room as he struggled out of the compartment via the secondary escape route, without the use of an emergency escape breathing device (EEBD).

Once the vent flaps had been closed and the duty engineer accounted for, the engine room was flooded with carbon dioxide, which extinguished the fire. However, it was some days before the engine room could be re-entered as it was unclear whether all the carbon dioxide bottles assigned to the main engine room had been discharged...

The Lessons

1. Qualifed → It is not unusual for contractors to undertake major maintenance work on board a ship;
however, it is imperative that they can provide assurance that they have the skills and equipment to meet the original equipment manufacturer’s expectations of how it should be done. Operators and managers
must endeavour to maintain a level of oversight that ensures work is completed to a satisfactory standard.

2. Maintain → Whereas components were overengineered and could withstand poor treatment in the past, this is not always the case for modern, technically advanced machinery. Engine components, particularly on modern engines, are designed to maximise the power output while keeping component mass and size to a minimum. The components are thus highly stressed and their correct maintenance is critical. What may seem an innocuous cut or heat mark from using inappropriate tools can have serious consequences when the component is heavily loaded or operating at high revolutions. This type of damage affects the component metallurgy and introduces stress raisers, which can lead to fatigue failure.

3. Equipment → The duty engineer was lucky to escape from the smoke-filled engine room. While the
ship had the correct number of emergency escape breathing apparatus as required when the ship was
constructed, it did not have to comply with a 2003 International Maritime Organization (IMO) circular that required one EEBD to be positioned on each deck or platform level near the secondary means of escape. Ship managers and operators should consider increasing and improving EEBD distribution to maximise the likelihood of escape from a smoke-filled space.

4. Signage → The carbon dioxide fixed firefighting system was activated and successfully extinguished the fire. However, it was unclear in the bottle room which gas bottles discharged to which space and therefore impossible to confrm that all bottles had been discharged. This led to delays in gaining entry to the space, which in some circumstances could be critical. Such a problem can be avoided with clear labelling and a means of checking that the necessary bottles have been discharged, as outlined in MGN 389 (M+F), Operating Instructions and Signage for Fixed Gas Fire-Extinguishing Systems.

MTF...P2 

[Peetwo]

Cowper (Legend) Chinese Junk update; & where the hell is OTSI/AMSA?

Courtesy Cowper, via Facebook:

Chris Cowper

Just a little update on our NSW Taxpayer owned, but French operated, Manly Ferry Service and the good ship “Clontarf”.

The Chinese built Gen II Emerald “Clontarf” returned to service a little over 2 weeks after her catastrophic Port Engine failure on 6th February.

Her Port Engine had only been operating for 5,600 hours when she blew up.

Did Transdev replace her totally destroyed Japanese built Yanmar Diesel with a new one?

No way.

“Clontarf” was fitted with an Engine from a Gen I Emerald with 10,000 hours on her.

The blame game is in full swing.

It turns out “Clontarf’s” Port engine was more than 600 hours overdue for a service.

A Lubricating Oil (L.O.) sample had been taken and sent away for testing last year.

For a reason, or reasons, known only to Transdev’s Management, the results of this test had not reached Transdev’s excellent Maintenance Fitters at BSY before she failed.

Former Workmates tell me the L.O. test results have now surfaced.

And are pretty sad.

Below is a paragraph I posted on StMF on 9th February this year.

“Transdev’s Chinese built Gen II Emeralds have 3 ventilation fans in each engine room.

After the port engine detonated, as a precaution, the Engineer on board “Clontarf” attempted to manually close the port engine room vent flaps.

These flaps are designed to starve an engine room fire of oxygen.

Each flap is fastened to the vessel by 2 hinges.

On board “Clontarf” one flap operated as designed.

The second flap also operated as designed, although it had 1 broken hinge.

The 3rd flap had 2 broken hinges and fell into the forward engine room fan.

The large aluminium flap dropping into the fan sheared fan’s blades off.

What this meant, was, if there had been an engine room fire, the Engineer would not have been able to seal the engine room.

He wouldn’t have been able to starve the fire of oxygen.

His fire suppression system would not have been effective.

The port engine fuel filter had been pierced by hot metal, blown out from the disintegrating engine, and was pouring fuel into the bilge.

In January, a “Clontarf” Engineer had reported this faulty Fire Flap to Transdev’s Maintenance department.”

I have seen a photo of the damaged and disconnected Port engine room vent flap, or dampener, lying uselessly where it had dropped down on top of the fan.

This is potentially one of the most dangerous things I have seen in my over 40 years working in our Maritime industry.

The word on the street is, some Management are denying it happened.

Apparently “Balmoral’s” On Board Engineer noticed L.O. in one of her M/E’s coolant and reported it on 14th February.

Last I heard, nothing had been done.

Are our Taxpayer funded regulatory authorities AMSA and OTSI still sitting on their hands?

Do the bureaucrats at Transport for NSW even care what is happening on their watch?

---

Comments in reply:

Jennifer GJ

Is safety being closely monitored? I can see the inconvenience of often needing to take the ferries off the route, but engineers and maintenance crew must not be intimidated into downplaying faults and issues. If they are not being listened to, then this should be offered to someone in the media so proper scrutiny is applied.

Richard Dunn

Thanks Chris, this latest shocking news also adds to the deserved embarrassment for those who claimed that my earlier comment about the near catastrophe was an exaggeration, like a Hollywood movie.

Cowper QON: "..Are our Taxpayer funded regulatory authorities AMSA and OTSI still sitting on their hands?.."

Fair question, a quick perusal of the relevant OTSI and AMSA webpages would seem to indicate that at this point in time there is no activity or even recognition in regards to the Clontarf catastrophic engine failure??

Ref: https://www.otsi.nsw.gov.au/investigatio...stigations & https://www.amsa.gov.au/vessels-operator...nt-reports 

Now very much related when you consider the Cowper post (above), there still hasn't been an update to the ongoing investigation into the..."Safety and assurance systems for defect management (critical steering controls) in the Emerald Class Generation II Fleet - September 2022..":

Extract from IFS:

"..Since 1 December 2021 – 26 September 2022, OTSI received nineteen (19) notifiable
occurrence reports regarding the Generation II ferry class. Ten (10) of these related
to steering defects with no known root cause. The remaining notifiable incidents
related to other general passenger, engineering, operational or assurance incidents
arising from regular passenger ferry services onboard the Generation II vessels.

Scope of the investigation

Based on findings from OTSI’s preliminary enquiries, the Chief Investigator
determined that the matter warranted investigation in accordance with Section 46 of
the Passenger Transport Act 1990 (NSW).

The scope of the investigation includes, but is not limited to:

 Defect management systems and associated assurance processes for critical
steering failures at introduction into service and throughout the service life of
the vessels;
 The effectiveness of the SMS in managing risks to service operations while
critical steering defects are identified and repaired; and
 Engineering resource and competence to support defect management and
associated assurance processes across the fleet

The Chief Investigator has required the Investigator in Charge (IIC) to:

 Identify the factors, both primary and contributory related to critical steering
failure defect management at introduction into service and throughout service
life
 Examine the effectiveness of controls in place to manage the related risks
 Advise on any matters arising from the investigation that would enhance the
safety of ferry operations

The IIC will consult with all Directly Involved Parties (DIPs) throughout the
investigation..."

 
Hmm...here's a thought, since the investigation is still continuing, why doesn't the OTSI Chief Investigator simply expand the scope of the investigation to include the Clontarf catastrophic engine failure and the many Transdev SMS deficiencies highlighted in the Cowper post above? 

I also think it would be worth someone putting in a FOI/GIPA request for the AMSA return to service paperwork after grounding the Gen IIs in October last year and the return to service of the Clontarf after it's catastrophic engine failure on the 6th of February...

MTF...P2 

[Kharon]

Iceberg tip @ 10,000 hrs.

CC - “The Chinese built Gen II Emerald “Clontarf” returned to service a little over 2 weeks after her catastrophic Port Engine failure on 6th February”.

'CC' - “Her Port Engine had only been operating for 5,600 hours when she blew up”.

As this was 'potentially' an event which could have, considering the actual details of the failure, been life threatening (in reality). The engine failed. The 'safety system' which should have starved the engine room fire – failed. The fire suppression system was rendered 'ineffective'. Inquiry time – before it's too late? Please.......

Put the rest aside for a moment – consider; a large, powerful engine began to disintegrate. Is there an 'automatic stop' facility – a 'fail safe' or does someone have to manually hit a big red button? Hot metal, fuel under pressure, oil and engine parts being sprayed around a fire and smoke filled  engine room. You don't get many warnings as clear as this one that 'something' is very, very wrong.

I notice there's mention of a 10, 000 hr engine replacing the 'broken' one. In principal there's nothing wrong with this – the 'spare' providing it has been overhauled and tested is a good stop gap. Commercial aircraft use this system and the 'spare' is always ready to go – the engine which comes off the wing is thoroughly inspected, rectified and certified as a 'good to go' spare and ready. This saves an airframe being out of service for 'days' – the quick change artists on the hanger floor take pride in the time taken to return an aircraft to revenue service.

So, an engine failure – serious enough; it happens, even to scrupulously maintained, certified engines. But here's the thing – if the maintenance, scheduled and routine, is not completed and the systems which are designed to prevent the 'one in a million' chance of catastrophic failure are not up to task and serviceable – Murphy's Law clicks in. Which is bad enough but lets consider the really scary stuff.

The Clontarf engines (x2) have, in order to meet schedule times, been operated at maximum rpm throughout their service life. Now, you can do this provided that the maintenance of ALL systems is commensurate with that hard usage. The OIL in the engine is not only the life blood of the engine but a great story teller. It picks up carbon as it thins and importantly 'metal' which it leaves in the filters – until they can longer hold the metal shaving off the moving parts. So; oil breaking down in ability to lubricate 'correctly'- increased friction – increased 'metal' – full filter – maximum RPM - an equation for the perfect catastrophic engine failure/fire. Fire suppression system failure – with an unconstrained fuel fire – harbour side BBQ - anyone?

The wet lettuce leaf of an OTSI grumble and even the mild inquisitiveness of AMSA is clearly not having the desired, publicly paid for effect. They should be like a terrier on a rat – all the holes in that famous Swiss cheese are lining up; and, luck will only get you so far. Time ladies and Gentlemen; time to get serious; time to send in the wolf pack and sort this fiasco to lip service safety out.

Tick tock says the the ferry boat luck clock.

Toot – toot..

[Peetwo]

TICK TOCK goes the Transdev/TfNSW/OTSI/AMSA doomsday clock??

Via FB:

Chris (Legend) Cowper
1 h  ·

“Fairlight” has another CATASTROPHIC STEERING FAILURE.

Chinese built, 400 passenger, 22 knot, Gen II Emerald, “Fairlight” as purchased by French owned Company, Transdev, who has been contracted by the NSW Liberal Government to operate the Sydney Ferry network in a safe and timely fashion, this evening had another catastrophic steering failure.

Although details are a little sketchy at the moment, I understand she was running at her maximum after Sunset service speed of 20 knots when she suddenly and uncontrollably dived hard to port.

Crews have withdrawn “Fairlight” from service.

“Fairlight” has had many steering failures.

Several have been what I call “catastrophic”.

Before tonight her most recent steering failure was only 8 days ago!

In Circular Quay and once again at night.

Her failure on the evening of Saturday 11th March occurred when her Master was turning around in the Quay to head to Manly, with passengers.

Both her rudders went hard over.

The Port one to Starboard and the Starboard one to Port.

Her extremely competent Engineer went down to the Steering Flats to check if the rudders had in fact, both gone hard over or to ascertain if it was a Rudder Angle Indicator fault.

Both rudders were hard over.

The Engineer re-set the Breaker (switch) labelled Steering RAI. (RAI=Rudder Angle Indicator)

His Starboard rudder now worked.

He could not re-set the port rudder.

Unknown to him, on the Chinese built Emeralds, the Port Rudder breaker was labelled “NMEA2K”

Could anyone, in their wildest dreams, even imagine MMEA2K meant Port Rudder”?

Amazingly, both Port and Starboard Rudder Breakers have now been re-labelled.

The Gen II’s have been on the run for over 2 years.

Did Transdev Management apologise to the Crew for putting their Careers and passengers lives at risk?

No.

Did Transdev try to blame the Engineer and pressure him and the Master to jump on another vessel before they could properly attempt to fault find, or even to fill in the appropriate paperwork?

Yes.

Some readers might ask why the Engineer didn’t shut down all of his 24 volt system in an attempt to re-boot things.

In doing that he risked drifting around Circular Quay at night without any Navigation Lights, VHF Radio, AIS, Radar, Whistle or VDRS etc, etc.

All 3 Gen II Emeralds should be withdrawn from service before fatalities occur.

Maybe this time AMSA, OTSI and Transport for NSW will show they have some balls.

Us Taxpaying voters are paying their wages.

They do have the legislative authority.

Transdev’s contract is up for review this year.

Whoever is in Government should get rid of them.

Just In: https://www.smh.com.au/national/nsw/new-...wWtKeoVUBU

MTF...P2 

[P7_TOM]

FWIW – My two Bob...

For consideration – the following aircraft, depending on the distance to travel may carry the following number of SOB.

737 – up to 200 passengers.
747 – up to 400 passengers.
767 – up to 375 passengers.
777 – up to 550 passengers.
787 – op to 330 passengers.

My point is a simple one: if a 747 should end up in a situation which potentially placed those lives at risk or even harm, the roof would be off the building. Should a 777 with 500 SOB suffer an engine failure; or, a 737 lose directional 'control'; or should a 787 lose steering on the ground; the same rules would apply - to the roof.

Why? - Well they are carrying fare paying members of the public, who bought a ticket in good faith. The aircraft operate in and are aware of an 'elevated' risk level environment; which can become hostile at times. Risk mitigation is a base tenet of air operations. Delivering passengers safely to destination is an essential element. Why? Well consider the fall out should a major carrier 'lose one', resulting in the death and injury of hundreds, due to a repetitive, documented, reported multiple times - system failure; one of which they were made fully aware yet failed to rectify.

The Harbour ferries operate in an elevated risk environment; i.e. at 'sea'. They also carry hundreds of people. People who are entitled to the very highest standards of risk reduction; hundreds swimming, hurt, burned or killed in a crippled ferry v hundreds killed or harmed in an aircraft accident – There's no difference in the toll, fall out and backlash; except, the airline could fully demonstrate an ethical safety culture; the State would lose a government – at very least, due to shabby 'safety' management, poor risk mitigation and denial that despite being forewarned – the worst case happened, despite it being  completely preventable. The legal boys and girls would eat 'em alive.....

The long lists and repetitive history of ferry passengers being placed at risk would not be tolerated by the public, the government or the tax payer who fund the so called 'safety watchdogs' if it was an air operation. Agreed - a 'one off' failure of a steering system – bad, but tolerable provided there was no repeat; a one off bad report on welding quality; or engine failure; or safety system oversight – all not a problem – provided they remain 'one off', demonstrated and certified 'sorted'. But that is just not happening, is it. Repetitive systems failure; indicates a serious failure in 'safety management', poor reporting, and an inability to remove the high risk elements; and, a dismal failure in responsibility to the public to ensure crew, machine and passengers are, demonstrably, made as 'safe as humanly possible' – under the conditions.

OTSI need to get a grip, earn their keep by making certain that the 'risk level' is made as low as possible. They have the power, the mandate and the public money to make sure that no-one even gets worried, let alone harmed on a simple across the harbour boat ride. The current situation would be farcical if it weren't so bloody serious.

My two bob, spent as pleased me best...

[P7_TOM]

Camel, Straws and Promises to keep.

Minns is the new PM for NSW; no doubt he would like (very much) to put the 'Ferry' imbroglio to bed; even if just to save time to deal with many other pressing matters. Yet the solution is so simple, it almost seems too easy. Three short steps, well within his stride.

1) Put someone who 'knows' and understands how 'safety' is supposed to work in charge of OTSI. They do have the ability to rein in the big issues.

2) Put someone who can clearly, without 'spin' or bull-shit CONVINCE Transdev that the road to profit is paved with reliable service, 'safe boats' and good maintenance. The PR value of providing reliable service, safely and efficiently is paramount; and, in the long run saves time, money and the outrage expressed by the regular users.

3) See #1 – OTSI must, (really must) be 'effective'. To do this there needs to someone with the will, the knowledge and the ability to put this outfit back on the road to performing design function.

A Premier has many demands on time, and cannot solve all the problems by beer o'clock Tuesday. BUT he can set the wheels in motion by hiring a professional to carry the load. Someone has to, before there is a serious 'event'. Even the 'small' events are adding up and collectively, they are amounting from Molehill to mountain. One accident – even the 'small' ones, all add up to the real potential of becoming a very big deal. Grab some expert help Mr Minns; or stand alone in the face of public outrage...

[Peetwo]

Cowper's take on what the Minn's Govt should do with the Gen IIs?? - 

Via FB:

Chris (legend) Cowper - Save the Manly Ferry

WHAT CAN WE DO WITH 3 SLIGHTLY USED GEN II EMERALDS?

With our new NSW State Government there is now a light burning brightly at the end of the tunnel and 4 Freshwater Class Ferries can be seen sailing into sight.

So.

What do we do with 3 slightly used, Chinese built Gen II Emerald Class vessels?

First, a little history.

About 5 or 6 years ago, when French owned Transdev had convinced Transport for NSW, “Lady Northcott” (800 passengers) and “Lady Herron” (560 passengers) were no longer a viable proposition, it was rumoured, Taronga Zoo Management suggested painting both Ladies in a Taronga Zoo themed colour scheme and for them to be permanently on the Circular Quay to Taronga Zoo run.

Transdev/Transport for NSW got rid of both Ladies.

And in a secretive operation, towed them to Newcastle, under the cover of darkness.

At present the largest vessels in the Inner Harbour Fleet only carry 400 passengers.

The Zoo run is profitable and often extremely busy.

Taxpaying Passengers are frequently left behind.

Now then:

Why not paint, or vinyl  wrap, the 3 Gen II Emeralds (Fairlight, Clontarf & Balmoral) in a colour scheme with Taronga Zoo motives, and put two permanently on the Zoo Run?

I’m told, if the Gen II Emerald’s survey is downgraded to 1E (Smooth Water Operations) their passenger capacity could be increased to 550 or 600 passengers.

Most of Sydney Ferries/Transdev’s vessels are 1E.

Both Athol Wharf (Zoo Wharf) and Circular Quay Wharves are pontoons, so loading and unloading at high and low tides is not a problem.

Firstly, the steering systems would probably need to be ripped out and replaced with a good Aussie designed set up.

The Yanmar 6AY-WET engines could be governed back to a maximum speed of 14 knots. They would no longer run all day at 100%.

Their engines would be extremely fuel efficient and last for years.

The capacity of their sullage and fresh water tanks would have to be increased.

Balmain Shipyard is capable of doing all this work.

Passengers would love the outside seating.

Kids would love the colour scheme.

Maybe run a competition among schools for the design?

The remaining Supercats could be retired.

Manly and Taronga Zoo passengers would be very happy.

Come on Premier Minns you know it makes sense...

MTF...P2 

[Peetwo]

AMSA acknowledge Clontarf catastrophic engine failure?? So where the hell is OTSI??

From the AMSA Monthly serious incident reports: https://www.amsa.gov.au/vessels-operator...nt-reports

NSW Class 1 - Passenger: Vessel experienced catastrophic engine failure while underway.

   

Very brief description but I can't imagine there was too many other incidents where a Class 1 pax vessel (IE DCV) experienced a catastrophic engine failure? Note there is no indication whether AMSA is actually investigating? 

While on the February 2023 serious incident report pages, I note for the Sate of NSW there is also this serious incident report statement:

NSW Class 1 – Passenger: Vessel experienced fire in engine bay resulting in significant damage. All passengers and crew were evacuated without injury.

   
So we have an incident where a DCV suffered a catastrophic engine failure (read engine explosion) and we have an incident of an engine fire on a DCV that included a complete egress of the crew and pax, yet both occurrences apparently do not fall within the purview of the NSW State Transport Safety Investigator, OTSI...err WTF??

I guess the Chief Investigator is way..way too busy harmonising OTSI's business profile for the soon to occur merger with Popinjay's ATSB? 

But OTSI did today actually make a positive contribution to the proactive enhancement of public transport safety (IE their remit) and in the process completed something?? -    

Via Linkedin: 

Office of Transport Safety Investigations (OTSI)

The Office of Transport Safety Investigations (OTSI) has completed an investigation into a report made under the Confidential Safety Information Reporting Scheme (CSIRS) about the competence and performance management of a rail transport operator’s incident response personnel.

The CSIRS gives transport industry employees a confidential way to make a report about a safety issue affecting a bus, rail or ferry service.

OTSI has released CSIRS Outcome Report – C1016 which summarises the assertions made by the CSIRS reporter, and the response provided to OTSI by the rail transport operator.

OTSI is satisfied that the actions taken by the operator to address the assertions made in this CSIRS report are suitable to manage the issues raised and has closed the report.

You can access the full CSIRS Outcome Report on the OTSI website at https://lnkd.in/gmVAWiFy

 
Hmm...(part in bold) well that OTSI appraisal (based on WTF know's what??) of the operator's response, totally justifies the extra millions of taxpayer dollars flushed into the OTSI coffers over the last two financial years?? Ref: https://www.otsi.nsw.gov.au/publications/annual-reports

---

 
Hmm...as a sidebar this is interesting:

Financial reports

For financial year ended 30 June 2022, OTSI was exempt from Public Finance and Audit Act 1983 (PFAA) financial reporting because it met all the requirements for a ‘small agency’ exemption under clause 3 of Schedule 2 of the Public Finance and Audit Regulation 2015.

Accordingly, as OTSI has no PFAA financial reporting obligations, it is not required to include a full financial report in its annual report.

In 2021-22, OTSI received grants and contributions of $4.6 million.

The net result showed a deficit of $48,150, however OTSI continues to receive financial assurance from Transport for NSW to ensure it remains operational. There were no economic or other factors affecting OTSI’s operational objectives in 2021-22.

Hmm...the underlined bit?? - Err isn't that a conflict of interest for an independent statutory authority?? - 

MTF...P2 

[Peetwo]

Chris Minns Govt to bring back Manly Freshwater ferries??

Via the Telly:

Manly Freshwater ferries set to return to fulltime weekdays to boost commuter services

The fate of a plan to bring back the beloved 40-year-old Manly ferries to regular weekday services under the new Labor Government has been decided. See the outcome here.


Jim O'Rourke @JimORourke6
3 min read
April 4, 2023 - 4:14PM



The old and the new just off Manly Wharf. An the old Freshwater-class ferry, Freshwater, passes the Balmoral, of the three new troubled Emerald-class Gen 2 ferries. The new Labor state government is preparing to permanently return the old ferries to regular weekday services. Picture: NCA NewsWire / Damian Shaw

The iconic 40-year-old Manly ferries are set to be permanently returned to full time weekday services by the new Labor state government.

New Transport Minister Jo Haylen has confirmed the Labor Government will return as many of the beloved Freshwater-class vessels as possible back on the Monday to Friday runs to Circular Quay.

And the new government will continue to provide an express ferry option to commuters — but not necessarily use the troubled fleet of generation-2 Emerald-class ferries now operating on the route.


Transport Jo Haylen says she will follow through on an election commitment to return as many Freshwater-class ferries as possible to the Manly run. Picture: NCA NewsWire / Dylan Coker

Ms Haylen has already received a briefing from transport officials about when and how the refurbished older ferries can be fully brought back into service.

The Freshwater-class ferries — Narrabeen, Freshwater, Collaroy and Queenscliff — were taken out of service to be replaced by the smaller, faster and more frequent Emerald-class twin-hulled ferries in late 2021.

The previous Coalition government argued the older ferries were costing too much to run and maintain.
But after a community pushback, two of the old ferries — Freshwater and Collaroy — were brought back for weekends and public holidays only.

Then in September last year the former government announced that two of the Freshwaters — the Collaroy and the Freshwater — were being called back into weekday work after the new Gen 2 Emerald ferries were temporarily pulled from service for safety reasons.


The three new generation 2 Emerald-class ferries have been beset by safety and mechanical probelms. Picture: NSW Government

The Queenscliff was brought back into service in December to replace the Collaroy, due to be decommissioned later this year.

The three Emerald Gen 2 ferries — Fairlight, Clontarf and Balmoral — have been plagued by problems including cracks in the hull of one vessel.

Late last month the Fairlight was travelling at high speed at approximately 7:30pm on a Sunday, with 150 passengers on-board, when its primary steering failed. It was the ninth steering failure that the overseas built ferry has had since it began service.

Both other Emerald Class 2 Manly ferries, have also had multiple steering failures.

In the run up to the election, Ms Haylen said a Labor Government would be committed to returning refurbished Freshwaters to regular weekday services.


The Collaroy leaving Manly Wharf. Picture: Damian Shaw

It also said there would still be a need for an express service on the Manly route and that discussions would be held with Transport officials about whether other vessels in the Sydney Harbour fleet, not necessarily the Gen 2 Emeralds, would be used.

In a letter read out at the Save the Manly Ferry rally in July Ms Haylen wrote that the current Coalition government had a “failed policy” in getting rid of the “beloved, reliable, Australian-made” Freshwater ferries.

“The people of Manly and the northern beaches deserve a reliable Manly ferry service, which isn’t reliant on overseas built ferries, filled with defects, and which are constantly being taken out of service,” she wrote.

“That’s why I’ll keep working with you to return as many Freshwater class ferries as possible back to the Manly run …

“And that’s why I’ll work with you to deliver a better express service because the Emerald 2 ferries are simply not up to the task, particularly in rough seas”.

On Tuesday Ms Haylen said the Minns Labor Government “stands by our election commitments to deliver a reliable Manly ferry service”.

“It is clear the former Liberal government has left behind serious procurement failures and other issues with our ferry network,” she said.


The Balmoral Gen 2 Emerald-class ferry is smaller, quicker and more frequent than the Freshwater-class ferries. Picture: David Swift

“We will now start the work to fix the many issues facing our ferry system.”

Labor’s ferry pledge was welcomed by community campaigners who fought to keep the Freshwaters until a better alternative was found.

Chair of the Save the Manly Ferry Alliance, Candy Bingham, who is also on Northern Beaches Council for the Manly Ward, said “this is good news”

“This is what the community has been saying from day one, the Freshwaters should remain until a more suitable replacement ferry can be put in place.”

Ms Bingham is helping organise a lobbying effort to have electric ferries, with a seating capacity similar to the Freshwater vessels, eventually take over Manly services.

“I want to acknowledge Jo Haylen and the Labor Government for following through on their commitment to maintain the Freshwaters for the time being.”

MTF...P2 

[Peetwo]

Chris Minns Govt to bring back Manly Freshwater ferries??

Via the Telly:

Manly Freshwater ferries set to return to fulltime weekdays to boost commuter services

The fate of a plan to bring back the beloved 40-year-old Manly ferries to regular weekday services under the new Labor Government has been decided. See the outcome here.


Jim O'Rourke @JimORourke6
3 min read
April 4, 2023 - 4:14PM



The old and the new just off Manly Wharf. An the old Freshwater-class ferry, Freshwater, passes the Balmoral, of the three new troubled Emerald-class Gen 2 ferries. The new Labor state government is preparing to permanently return the old ferries to regular weekday services. Picture: NCA NewsWire / Damian Shaw

The iconic 40-year-old Manly ferries are set to be permanently returned to full time weekday services by the new Labor state government.

New Transport Minister Jo Haylen has confirmed the Labor Government will return as many of the beloved Freshwater-class vessels as possible back on the Monday to Friday runs to Circular Quay.

And the new government will continue to provide an express ferry option to commuters — but not necessarily use the troubled fleet of generation-2 Emerald-class ferries now operating on the route.


Transport Jo Haylen says she will follow through on an election commitment to return as many Freshwater-class ferries as possible to the Manly run. Picture: NCA NewsWire / Dylan Coker

Ms Haylen has already received a briefing from transport officials about when and how the refurbished older ferries can be fully brought back into service.

The Freshwater-class ferries — Narrabeen, Freshwater, Collaroy and Queenscliff — were taken out of service to be replaced by the smaller, faster and more frequent Emerald-class twin-hulled ferries in late 2021.

The previous Coalition government argued the older ferries were costing too much to run and maintain.
But after a community pushback, two of the old ferries — Freshwater and Collaroy — were brought back for weekends and public holidays only.

Then in September last year the former government announced that two of the Freshwaters — the Collaroy and the Freshwater — were being called back into weekday work after the new Gen 2 Emerald ferries were temporarily pulled from service for safety reasons.


The three new generation 2 Emerald-class ferries have been beset by safety and mechanical probelms. Picture: NSW Government

The Queenscliff was brought back into service in December to replace the Collaroy, due to be decommissioned later this year.

The three Emerald Gen 2 ferries — Fairlight, Clontarf and Balmoral — have been plagued by problems including cracks in the hull of one vessel.

Late last month the Fairlight was travelling at high speed at approximately 7:30pm on a Sunday, with 150 passengers on-board, when its primary steering failed. It was the ninth steering failure that the overseas built ferry has had since it began service.

Both other Emerald Class 2 Manly ferries, have also had multiple steering failures.

In the run up to the election, Ms Haylen said a Labor Government would be committed to returning refurbished Freshwaters to regular weekday services.


The Collaroy leaving Manly Wharf. Picture: Damian Shaw

It also said there would still be a need for an express service on the Manly route and that discussions would be held with Transport officials about whether other vessels in the Sydney Harbour fleet, not necessarily the Gen 2 Emeralds, would be used.

In a letter read out at the Save the Manly Ferry rally in July Ms Haylen wrote that the current Coalition government had a “failed policy” in getting rid of the “beloved, reliable, Australian-made” Freshwater ferries.

“The people of Manly and the northern beaches deserve a reliable Manly ferry service, which isn’t reliant on overseas built ferries, filled with defects, and which are constantly being taken out of service,” she wrote.

“That’s why I’ll keep working with you to return as many Freshwater class ferries as possible back to the Manly run …

“And that’s why I’ll work with you to deliver a better express service because the Emerald 2 ferries are simply not up to the task, particularly in rough seas”.

On Tuesday Ms Haylen said the Minns Labor Government “stands by our election commitments to deliver a reliable Manly ferry service”.

“It is clear the former Liberal government has left behind serious procurement failures and other issues with our ferry network,” she said.


The Balmoral Gen 2 Emerald-class ferry is smaller, quicker and more frequent than the Freshwater-class ferries. Picture: David Swift

“We will now start the work to fix the many issues facing our ferry system.”

Labor’s ferry pledge was welcomed by community campaigners who fought to keep the Freshwaters until a better alternative was found.

Chair of the Save the Manly Ferry Alliance, Candy Bingham, who is also on Northern Beaches Council for the Manly Ward, said “this is good news”

“This is what the community has been saying from day one, the Freshwaters should remain until a more suitable replacement ferry can be put in place.”

Ms Bingham is helping organise a lobbying effort to have electric ferries, with a seating capacity similar to the Freshwater vessels, eventually take over Manly services.

“I want to acknowledge Jo Haylen and the Labor Government for following through on their commitment to maintain the Freshwaters for the time being.”

Addendum: Courtesy the Telly, via FB:

 

[Peetwo]

Addendum: Courtesy the Telly, via FB:

 

Addendum II: Minister on 2GB

‘They’re shockers’: Labor government to fix Emerald-class ferries problem

NSW Transport Minister, Jo Haylen, said the Labor government wants to bring back Freshwater-class ferries to replace the Emerald-class ferries.

“These ferries are like rubber ducks, bobbing up and down around Sydney harbor,” said Chris O’Keefe.

Since August 2020, the Emerald-class ferries have had 52 recorded faults.

“I’ve asked the Department of Transport to act NOW,” Minister Haylen told Chris.

“The Minns Labor government will use future ferries, made right here, to get a better product and create jobs.”



https://auntypru.com/wp-content/uploads/2023/04/Theyre-shockers_-Labor-government-to-fix-Emerald-class-ferries-problem-1.mp3

---

Revealed: New Sydney ferries’ staggering list of issues

Major problems plaguing Sydney’s ferries more than doubled after the new fleet arrived, while the new cost of Metro West revealed.

---

Jo Haylen
1 d

They’re the most problem-plagued vessels in our ferry fleet.

Regular power failures, engine problems, steering issues, leaks and even risks they’d take flight.

The previous government called the overseas-built new Manly ferries “world class”, and took no action to fix their obvious faults.

We need a safe and reliable ferry service for Sydney.

That’s why I’m committed to bringing back the Freshwater ferries, but it will take time.

So I’ve also asked the Transport Department to urgently investigate what can be done to improve services across our harbour with existing ferries.

The previous Government left our ferry fleet in a dire state of neglect, but we’re determined to get on with fixing it.

MTF...P2 

[Peetwo]

NSW back to the future on railway comms?? - 

Via the NSW Spokesperson for Transport Safety...

Sydney train drivers told to use walkie-talkie radios as back-up

Matt O'Sullivan

April 17, 2023 — 4.50pm

Sydney Trains has issued a directive for drivers of passenger trains on the suburban rail network to have walkie-talkie radios as a back-up in case a critical digital system at the centre of a shutdown last month fails again.

The temporary reintroduction of old wideband radio technology comes amid an independent review of Sydney’s troubled rail network, which suffered three major disruptions last month. The Labor government has also commissioned a wide-ranging review of Sydney’s massive metro rail projects following a string of cost blowouts.


The digital radio system’s failure on March 8 disrupted 250,000 commuters during the evening peak.CREDIT:WOLTER PEETERS

The digital train radio system was meant to have removed the need for suburban train drivers to have portable walkie-talkie radios, which were pulled from widespread use on Sydney’s passenger rail network more than 10 years ago.

However, the digital system’s failure on March 8, which disrupted 250,000 commuters during the evening peak, has resulted in Sydney Trains requiring each train crew to have wideband radios from April 23.

Transport for NSW confirmed that the rail operator had added another contingency for train crews to utilise wideband radio equipment “if required” as part of its response to the digital radio system failure last month.

“Wideband radios continue to be used for communications by long distance and freight operators but have now been included for suburban rail operations as a back-up system for the [digital train radio system] technology if required,” it said.


Transport Minister Jo Haylen and Premier Chris Minns announced a review into the metro rail projects last Thursday.CREDIT:STEVEN SIEWERT

A spokesman for Transport Minister Jo Haylen said the measures were temporary and precautionary, but they underlined there were many gaps in the state’s train system that needed attention.

“That’s why the Minns Labor government has commissioned an independent rail infrastructure and systems review,” he said.

Wideband radios provide “open-channel communications”, which means conversations between a driver and a signal operator can be heard by other users of the walkie-talkies.

Sydney Trains also quietly dropped on March 30 an order that had prevented a raft of maintenance and project work on signalling and operational systems across the rail network for almost three weeks following the digital train radio system’s failure.

The government has signalled major changes to the state’s transport bureaucracy after sacking Transport for NSW secretary Rob Sharp on Friday and commissioning separate reviews into the suburban passenger rail network and the metro rail projects. Sharp was one of three departmental chiefs axed last Friday.

Senior transport bureaucrat Howard Collins, a former Sydney Trains chief executive, has been appointed acting Transport for NSW secretary, sparking speculation about whether he will become the permanent boss or the government will opt for another internal or external candidate. Collins is a former chief operating officer of the London Underground.

He took charge of the city’s rail network in 2013, when the O’Farrell government disbanded RailCorp and replaced it with Sydney Trains and NSW Trains. In 2019, he moved to a senior role at Transport for NSW following a major reshuffle of the bureaucracy.

MTF...P2 

[Peetwo]

Missed it by that much?? 



Via Ch7 news:

Also in the news...

Courtesy MattO, via SMH:

New Sydney ferry hits wharf at Barangaroo

By Matt O'Sullivan
Updated June 2, 2023 — 10.22am first published at 5.00am

A new Sydney ferry has crashed into wharves at Barangaroo, forcing the private operator to pull the vessel from service due to damage to its bow.

The crash occurred at 6.15am on Wednesday when the Cheryl Salisbury, one of 10 new River-class ferries, was manoeuvring away from Barangaroo Wharf to start its first service from Circular Quay a short time later. There were no passengers on the vessel.


The Cheryl Salisbury hit the Barangaroo ferry wharf on Wednesday morning.

It had backed out and was manoeuvring to depart when it hit the wharf and became wedged. It had to be cut free and was taken to the Balmain shipyards, where it is awaiting a damage assessment.

Transdev, the operator of Sydney’s government-owned ferries, said it had started an investigation into the crash and had notified transport safety regulators.

“A crew member was taken to hospital as a precaution but has been cleared since then. The incident led to five service cancellations [on Wednesday] morning,” it said in a statement.

Transdev said it had worked to minimise the disruption to customers.


The Cheryl Salisbury’s bow was damaged in the collision.

The Australian Maritime Safety Authority confirmed that it had commenced an investigation into the Cheryl Salisbury’s collision with the wharf.

“[The authority] takes the safety of passengers and crew on board domestic commercial vessels ... very seriously,” a spokesperson said.

The collision comes days after the Herald revealed two school children were thrown into the Lane Cove River when a ferry dropping them at Riverview College Wharf floated so far away from the pontoon that the gangplank collapsed into the water. The vessel involved in the February 16 incident was operated by Captain Cook Cruises.

Built in Indonesia, the 10-strong River-class ferry fleet was plagued with defects when the vessels arrived in NSW about two years ago. It was discovered the ferries would be unable to pass under two bridges on the Parramatta River if commuters were seated on the top deck.

The vessels also had to undergo substantial rectification work to their cabins so they could operate after sunset.

Rumour has it that there was a cast of thousands crawling all over the place after the Barangaroo incident...

Meanwhile over at OTSI...err'CRICKETS' -  : https://www.otsi.nsw.gov.au/investigatio...stigations

OTSI (like it's Federal counterpart the ATSB) 'WHAT IS IT GOOD FOR??'



MTF...P2  z

[Peetwo]

Missed it by that much?? - Part II 

I note that OTSI have still not indicated whether they will be investigating either the near miss or the Barangaroo allision?? Very much related to the 'close quarters' I note that in 2016 OTSI conducted a systemic investigation into Sydney Harbour ferry close quarter incidents between 2010-2016: 

• Ferry Safety Investigation - Systemic investigation into ferry close quarter incidents - Sydney Harbour - 2010-2016
  

The following were 5 recommendations issued to Transport NSW:

Transport for NSW

5.1 Support the introduction of robust management of the wharf booking system to reduce the congestion around high usage wharf areas and water taxi operations.
5.2 Designate wharf usage according to geographic destination where practicable in order to minimise ferries crossing paths in congested areas.
5.3 Ensure ferry timetables avoid same time departures.
5.4 Amend ferry timetables to reduce congestion around Wharf 6.
5.5 Support establishing an independent common control centre that has dedicated responsibility for the management of traffic in Sydney Cove.

And to RMS:

Roads and Maritime Services

5.10 Increase monitoring of the wharf booking system to ensure that congestion issues are minimised.
5.11 Assess and control the risk associated with the practice of double stack berthing in Sydney Cove.
5.12 Introduce robust management of the wharf booking system to reduce the congestion around high usage wharf areas and water taxi operations.

Plus to the NSW Port authority:

Port Authority of NSW

5.17 Ensure that effective communication by ship operators occurs when thrusters are in use by ships in Sydney Cove.
5.18 Establish an independent common control centre with dedicated responsibility for the management of traffic in Sydney Cove.
5.19 Allocate a working VHF radio channel and require masters to not only monitor but transmit through this channel when in Sydney Cove.
5.20 Irrespective of vessel length, all masters to have local knowledge for operating in Sydney Cove.

Hmm...wonder if any of those safety recommendations have been properly implemented?? 

MTF...P2 

[Peetwo]

Hunter valley bus tragedy - RIP! 

Something about June 11th for serious NSW transport accident disasters?? ref: Thirtieth anniversary of Monarch Accident  

Via YouTube:

 

And yes apparently OTSI are investigating??

RIP! - 

[Peetwo]

OTSI Greta Bus rollover tragedy: Interim factual statement.

Via OTSI website: https://www.otsi.nsw.gov.au/investigatio...stigations

What happened

Late in the evening of 11 June 2023, Linq Buslines coach number 4666MO departed the Wandin Estate winery in Lovedale for Singleton. It was reported to be carrying 35 passengers who were returning to Singleton after attending an event at the winery.

The coach travelled through Greta township before joining Wine Country Drive in a southbound direction. At about 2330, on approach to the Hunter Expressway westbound onramp, the coach entered a roundabout, and overturned onto the left-hand side. The rollover and subsequent collision resulted in 10 fatalities, significant injuries to multiple passengers, and major damage to the coach.

Investigation scope

Based on findings from OTSI’s preliminary enquiries, the Acting Chief Investigator determined that the incident warranted investigation in accordance with Section 46 of the Passenger Transport Act 1990 (NSW).

The scope of the investigation includes, but is not limited to:

• sequence of events leading up to the rollover/collision
  
• road design, condition, signage and visibility
  
• passenger restraint devices and usage
  
• vehicle condition, roadworthiness and design
  
• vehicle crashworthiness and survivability
  
• emergency exit access, awareness and operability
  
• operator accreditation, and safety management systems.
  

The Acting Chief Investigator has required the Investigator in Charge (IIC) to:

• identify the factors, both primary and contributory, which led to the rollover/collision
  
• advise on any matters arising from the investigation that would enhance the safety of bus operations.
  

The IIC will consult with all Directly Involved Parties (DIPs) throughout the investigation.

IFS PDF link: https://www.otsi.nsw.gov.au/investigatio...-june-2023

Also of interest, I note that yesterday the Acting OTSI Chief Investigator announced the opening of an investigation into a Ferry incident that occurred back on the 15th of February??

Via LinkedIn:  

Office of Transport Safety Investigations (OTSI)
1,806 followers
19h • Edited

The Office of Transport Safety Investigations (OTSI) Acting Chief Investigator has initiated a transport safety investigation into an incident of children going overboard from passenger ferry Violet McKenzie on 16 February 2023.

The ferry, operated by Captain Cook Cruises, was operating the Hunters Hill to Circular Quay passenger route. It departed Hunters Hill wharf at 0801 and made its way to the Riverview College Wharf.

The vessel was secured to the Riverview College Wharf and the gangway deployed on the east top platform, with the vessel laying astern on the deck line and the engine running slow astern. While passengers were disembarking, the vessel drifted away from the wharf, causing the gangway to fall in the water. There were two school students on the gangway at the time. A third student jumped into the water to assist the other two.

The passengers were retrieved from the water before the vessel was repositioned alongside the wharf. The remaining passengers (including the three persons overboard) were then safely disembarked.

Following notification of the incident, OTSI conducted preliminary enquires with the operator and obtained further information, including the operator’s investigation report, which identified several contributing factors, learnings and a corrective action plan.

NSW Minister for Transport, Jo Haylen, MP requested that OTSI investigate this matter, pursuant to Section 46 of the Passenger Transport Act 1990, which enables the Minister to require the Chief Investigator to investigate and report on any transport accident or incident that may affect the safe provision of ferry operations.

The Acting Chief Investigator has initiated an investigation which includes, but is not limited to:

• locations where similar ferry docking circumstances and associated risks may be present
• examining the systems the ferry operator had in place to manage risks associated with wharf design and tidal considerations
• ferry operator crew training and procedures, including emergency response
• the response to the incident by relevant parties.

Information on the role of OTSI, its investigation approach and the scope of this investigation is available in the Interim Factual Statement https://lnkd.in/g3QZytzT

"..NSW Minister for Transport, Jo Haylen, MP requested that OTSI investigate this matter, pursuant to Section 46 of the Passenger Transport Act 1990, which enables the Minister to require the Chief Investigator to investigate and report on any transport accident or incident that may affect the safe provision of ferry operations.."

Hmm...that's a bit embarrassing for the CI?? - 

MTF...P2 

[Peetwo]

Chalk & Cheese: NTSB the exemplar 1st World TSI v ATSB led by a Popinjay. -  

Another for the C&C series, 1st from the NTSB YouTube pages we witness NTSB's Chairperson Jennifer Homendy efficiently oversighting/Chairing the Investigative Hearing into the East Palestine train derailment:

That hearing went for nearly 10 hours and yet Homendy still had the energy and professional integrity to hold a post briefing press conference...  

 

  

NTSB Chair Jennifer Homendy will answer the media's questions on the public community meeting in East Palestine, Ohio, on June 21, 2023.

Now compare that to this pre-prepared bollocks final report presser, into a Marine accident investigation conducted into a GBR vessel grounding incident. that occurred over 2 years and 5 months ago:

Voyage planning errors, spurious false alarms contribute to cargo ship grounding



Key points

• Cargo ship was using newly planned route when it grounded on Harrington Shoal off Cape York;
  
• Route had not been properly reviewed or approved, and planning tool contained waypoint data errors;
  
• Duty operator monitoring vessel traffic in area was experiencing sustained elevated workload due to technical fault triggering abnormally high number of erroneous alarms and alerts.
  

The use of a draft voyage planning tool which included waypoint data errors plus an ongoing technical fault with the vessel monitoring and surveillance system for the Great Barrier Reef contributed to a cargo ship’s grounding on a shoal, an ATSB investigation details.

The 81-metre general cargo ship Trinity Bay grounded on Harrington Shoal, a charted feature with a depth of 0.9 metres north-west of Harrington Reef, on the morning of 19 January 2021 while conducting a regular weekly passage from Thursday Island to Cairns. Fortunately, the ship sustained only minor hull damage (some dents and paint stripping), with no injuries or pollution reported, and it was refloated on the rising tide.

The investigation report details that in an effort to address a deficiency identified during a recent internal audit, which required the use of approved routes and waypoints, the ship’s master had used a draft passage planning tool that was being trialled by the operator to plan new routes.

The planned routes from the planning tool were entered into the Trinity Bay’s electronic chart system (ECS), a navigation information system which displayed the vessel’s position and relevant nautical chart data. However, the ECS was not approved for use as the ship’s primary means of navigation and did not possess automatic route safety checking functions.

“Errors in the planning tool meant the new route took Trinity Bay dangerously close to the charted danger of Mid Rock, and then about an hour later directly over the charted danger of Harrington Shoal, where the ship grounded,” ATSB Director Transport Safety Stuart Macleod said.

“The investigation found the new passage plan was not independently verified by another of the ship’s deck watchkeeping officers, as required by the operator’s procedures, and the planned routes were entered into the electronic chart system instead of being annotated on the ship’s paper charts. In accordance with chart carriage regulations, these paper charts were the ship’s primary means of navigation, and were marked with the ship’s established previously-used routes.

“Consequently, the dangers on the newly planned route were not identified, and the monitoring of the ship’s passage was ineffective in identifying these dangers.”

The ship’s operator, Sea Swift, subsequently removed Trinity Bay’s electronic chart system from service and advised the ATSB that it was investigating the fitting of electronic chart display and information systems (ECDIS) on its ships. ECDIS is an approved navigational chart and information system that can be used in place of paper charts.

“This investigation highlights how the development and use of a detailed passage plan in accordance with the accepted principles of passage planning remains essential to safe navigation,” Mr Macleod said.
“Passage planning should be thoroughly appraised, with the route laid out and independently checked on the ship’s primary means of navigation, and then effectively monitored.”

Mr Macleod said the ATSB’s investigation also found that at the time of the grounding an ongoing technical fault in the REEFVTS (Great Barrier Reef and Torres Strait vessel traffic service) monitoring and surveillance system, meant the duty operator at the VTS Centre in Townsville was being presented with an abnormally high number of erroneous alerts and alarms. REEFVTS monitors and communicates with ships to ensure safe and efficient navigation in Torres Strait and the inner route of the Great Barrier Reef.

Among the genuine alarms received during that timeframe were warnings as Trinity Bay sailed close to Mid Rock, and again as it approached Harrington Shoal.

“Alerts associated with Trinity Bay were acknowledged by the duty operator but not followed up, due to the operator experiencing a sustained period of elevated workload, combined with a high level of expectancy that the ship was not at risk, as it frequently transited the area,” Mr Macleod said.

“Between the duty operator commencing their shift in Townsville at 0600, and when they were alerted by the ship’s master of the grounding at 0822, that operator received over 80 alerts from the REEFVTS monitoring and surveillance system, of which at least 42 were false, generated as a result of the system fault.”

Maritime Safety Queensland, which operates REEFVTS, has since implemented a software update for the system, reducing the incidence of false alarms.

Further, the reporting area covered by REEFVTS was split into two, a north and a south area operated respectively from Townsville and Gladstone, with a separate operator responsible for each area.
Read the ATSB’s report: Grounding of Trinity Bay, Harrington Shoal, Queensland on 19 January 2021

Publication Date
22/06/2023

What is it with Popinjay's crew? Why can't they just rely on the final report speaking for itself? I also note that in marine world investigations the ATSB are not obliged to have prelim or interim reports on the anniversary of the incident...  

Of a side interest was AMSA's involvement in this incident. From the AMSA monthly incident web pages for January 2021 there is one very short on detail entry for a vessel grounding in QLD:

QLD/Class 1 – Passenger: Vessel ran aground. Ballast water was pumped out to reduce draught on the flood tide and the vessel re-floated. No damage, pollution or injuries reported.

For more detail you have to refer to the ATSB report:

..The master established that there was no immediate danger to the ship and that there were no visible signs of damage or pollution.[13] The ship’s bow appeared to be clear of the shoal which was composed mostly of sand.

The master asked the chief engineer to commence deballasting[14] and called the ship’s designated person ashore (DPA)[15] to advise them of the grounding. At the request of the DPA, the master sounded the ship’s tanks to confirm the integrity of the hull and sounded the surrounding waters to establish depths around the ship. The DPA also instructed the master to notify REEFVTS of the situation while they notified the Australian Maritime Safety Authority (AMSA).

At 0822, the master called the duty REEFVTS operator using a mobile phone and informed them that Trinity Bay was aground on Harrington Shoal. The REEFVTS operator, who was unaware of the grounding, notified their supervisor and the regional harbour master for Cairns.

At about 0950, the second mate, positioned at the bow, advised the master that the ship appeared to be moving with the rising tide. The master used the bow thruster to confirm that the bow was moving freely and then engaged astern propulsion (about 25% of available RPM), which resulted in the ship moving astern.

The ship continued to make sternway off the shoal while the master used the bow thruster to control the ship’s head and, by 1010, Trinity Bay was clear of Harrington Shoal. At about 1035 the master anchored the ship about 2 miles to the south-south-west of the shoal, just inside the western boundary of the designated shipping area (DSA).[16]

AMSA subsequently instructed the ship manager to ensure the ship remained at anchor until a hull inspection had been completed. Trinity Bay remained at anchor overnight while the crew undertook regular soundings of the ship’s accessible double bottom and wing tanks to confirm there was no water ingress.

Bizarrely there doesn't appear to be any follow up, nor is there any reference to AMSA in the findings or safety issues/actions. This could be because the coastal waters of QLD fall within the bailiwick of the State Marine regulator MSQ but we also know of AMSA's aversion to dealing with DCV issues.

That's what makes another incident, that occurred 4 months later to the same vessel Trinity Bay, that AMSA apparently did to take issue with and investigate...

Sea Swift vessel suspended after major fuel leak

3 May 2021 | Matt Nicholl



The Australian Maritime Safety Authority has suspended MV Trinity Bay, the main barge for Weipa, pending a full investigation into the cause of the diesel spill, which leaked into the living quarters on the vessel.

“AMSA is investigating a serious incident involving the cargo supply ship, Trinity Bay,” a spokesperson for the marine watchdog said on Friday.

“Shortly before 7am Thursday it was reported to AMSA that Trinity Bay suffered an internal fuel oil (diesel) spill.

“AMSA understands that about 1000 litres of fuel was spilled into crew accommodation quarters, with a smaller amount – about 20 litres – being lost overboard in Cairns.

“Thankfully there were no reported injuries to crew who were on board at the time.

“AMSA has serious concerns about the ship’s operations, and the potential risk it poses to the safety of mariners and Queensland’s precious marine environments.

“AMSA has prohibited the ship from being operated while its investigation into the incident is underway and rectification action is undertaken by the operator.”

The major incident was the worst possible start for new Sea Swift chief executive officer Rochelle Macdonald, who began last Monday, slightly earlier than first advertised.

“I can confirm that an incident occurred on Sea Swift vessel MV Trinity Bay while it was docked at Cairns Port,” she said in a statement.

“At 6.30am, Sea Swift staff were transferring fuel from the cargo to the bunker tank on the vessel when a volume of fuel leaked into crew rooms and the galley.

“The vessel is in no danger, there were no injuries, and the fuel leak has not caused major damage to the vessel.”

Dr Macdonald said Sea Swift had put plans in place to ensure food and essential freight would still arrive as normal and on time on Thursday Island and Horn Island (Sunday), and in the NPA and Weipa (Monday), although Cape York Weekly has been told the Weipa barge will not arrive on Monday.

“The incident has however led to a five-day delay for general, non-time critical cargo from Cairns to Weipa due to the necessary clean-up operation on the MV Trinity Bay,” she said.

“These items will now arrive in Weipa on Saturday, May 8, with all services departing Cairns back to normal by next Friday (May 7).

“We are also in the process of securing additional capacity to move the current backlog of vehicles and recreational vessels.

“We anticipate this service will occur within the next two weeks.”

Cape York Weekly understands Sea Swift was forced to ring a number of barge operators trying to obtain a vessel to help with the freight backlog.

MV Trinity Bay is expected to be out of action for at least a fortnight, according to sources.

“I would like to apologise to everyone affected by this delay to our general cargo service,” Dr Macdonald said.

“We have notified customers of these changes to our schedule via email, and our website is being updated accordingly.

“Sea Swift has immediately launched a full investigation, and we are working closely with the AMSA to find the cause of this incident.”

Freight times had already been compromised by Sea Swift’s inability to work on public holidays.

Vessels that would normally depart on Mondays were delayed until Tuesday because Sea Swift won’t pay the public holiday rates.

It means that groceries destined for Weipa arrive on Friday night instead of Thursday, forcing local supermarket workers to scramble to get the produce on shelves.

As there is no Sunday trading, the stock can only be sold on Saturday and the following Tuesday, a result of back-to-back Monday public holidays.

   
 
MTF...P2 

[Peetwo]

Missed it by that much?? - Part III

Previous thread post:

I note that OTSI have still not indicated whether they will be investigating either the near miss or the Barangaroo allision?? Very much related to the 'close quarters' I note that in 2016 OTSI conducted a systemic investigation into Sydney Harbour ferry close quarter incidents between 2010-2016: 

• Ferry Safety Investigation - Systemic investigation into ferry close quarter incidents - Sydney Harbour - 2010-2016
  

The following were 5 recommendations issued to Transport NSW:

Transport for NSW

5.1 Support the introduction of robust management of the wharf booking system to reduce the congestion around high usage wharf areas and water taxi operations.
5.2 Designate wharf usage according to geographic destination where practicable in order to minimise ferries crossing paths in congested areas.
5.3 Ensure ferry timetables avoid same time departures.
5.4 Amend ferry timetables to reduce congestion around Wharf 6.
5.5 Support establishing an independent common control centre that has dedicated responsibility for the management of traffic in Sydney Cove.

And to RMS:

Roads and Maritime Services

5.10 Increase monitoring of the wharf booking system to ensure that congestion issues are minimised.
5.11 Assess and control the risk associated with the practice of double stack berthing in Sydney Cove.
5.12 Introduce robust management of the wharf booking system to reduce the congestion around high usage wharf areas and water taxi operations.

Plus to the NSW Port authority:

Port Authority of NSW

5.17 Ensure that effective communication by ship operators occurs when thrusters are in use by ships in Sydney Cove.
5.18 Establish an independent common control centre with dedicated responsibility for the management of traffic in Sydney Cove.
5.19 Allocate a working VHF radio channel and require masters to not only monitor but transmit through this channel when in Sydney Cove.
5.20 Irrespective of vessel length, all masters to have local knowledge for operating in Sydney Cove.

Hmm...wonder if any of those safety recommendations have been properly implemented?? 

Hallelujah! There is a light at end of the OTSI bureaucratic TSI irrelevance tunnel and perhaps a win for the proper transport safety investigation tin kickers...

Why? Well it would appear, that despite not initiating an investigation into the serious 'close quarters' occurrence (above), OTSI has seen the error of it's ways and allowed their transport investigative team to compose and publish an excellent 'Safety Advisory' that carries the weight of past findings and safety recommendations from their previous 'systemic investigation': "Ferry Safety Investigation - Systemic investigation into ferry close quarter incidents - Sydney Harbour - 2010-2016". 

Safety Advisory SA05/23

Close quarters situations in the Sydney Harbour area Safety message Sydney Harbour is an extremely busy waterway, used by recreational and commercial vessels, from big ships and high-speed ferries to small powerboats, yachts and kayaks. It has busy navigational channels. The normal collision regulations apply to navigation, with additional local rules to assist in the management of marine traffic.

A recent close quarters situation1 in Sydney Harbour involving two passenger ferries2 highlights the importance for all operators to understand and apply the rules, monitor the appropriate radio frequencies, and maintain a proper lookout. This applies particularly in congested areas, such as Sydney Cove and the Sydney Harbour Bridge Transit Zone.

The incident

On the afternoon of Sunday 4 June 2023, there was a close quarters situation involving MV Collaroy, which was conducting a timetabled ferry service, and a charter vessel, MV Sydney 2000. MV Collaroy was tracking from the west to enter Sydney Cove and MV Sydney 2000 was departing Sydney Cove for a route to the east.

As the vessels approached each other, both Masters performed avoidance manoeuvres, with the vessels coming into close proximity. As the two Masters manoeuvred to avoid collision, a third vessel, a small recreational craft, narrowly avoided colliding with MV Sydney 2000. There were no reported injuries or damage to any vessel.

At the time of the close quarters situation, a cruise ship and fuel barge were berthed at the International Passenger Terminal. The presence of these vessels resulted in a significantly reduced channel for vessels operating to Circular Quay ferry wharves.

OTSI review

Following notification of the incident, the Office of Transport Safety Investigations (OTSI) requested and reviewed information about the occurrence from the involved operators and the Port Authority of NSW. This review identified that there was a misalignment between the involved Masters’ plans, and their expectations of the other vessels’ tracking intentions.

The Master of MV

Sydney 2000 reported that they planned to pass MV Collaroy starboard3 to starboard, as they expected Collaroy would be tracking to berth at Wharf 3 Circular Quay.

The Master of MV Collaroy, which was heading to berth at Wharf 3, reported that they planned to pass the other vessel portside to portside4 as they had observed MV Sydney 2000 alter course to starboard to head east.

With differing plans and expectations between the two Masters, the distance and proximity between the vessels reduced. When it became apparent to each Master that the other was not tracking as expected, both Masters manoeuvred to avoid a collision.

Figure 1: Close quarters situation near Sydney Cove, 4 June 2023


Source: WebcamSydney. Image annotated by OTSI.

Following the incident, the Master of MV Collaroy reportedly tried to call the Master of MV Sydney 2000 on ‘VHF 13’, the radio communication channel for that area of Sydney Harbour, but was unable to raise them. Vessel Traffic Services and the Master of MV Sydney 2000 later reported that the radio call from MV Collaroy was unreadable.5 The two Masters subsequently communicated via radio regarding the occurrence.

Key points for operators Schedule 6 ‘Requirements relating to Sydney Cove’ of the Marine Safety Regulation 2016 (NSW), 6 documents key rules and requirements for operating in Sydney Cove. Sydney Cove is defined as the portion of Sydney Harbour that lies south of an imaginary line drawn from the position of the northernmost fixed red beacon on Dawes Point to the position of the fixed red beacon on Bennelong Point. A supporting map for Sydney Cove navigation rules is published by Transport for NSW (Figure 2).7

Transport for NSW has published the ‘Rules for boating on Sydney Harbour’8 which includes information about operating in the Sydney Harbour Bridge Transit Zone, give-way rules and ferry operations.

OTSI identified increased traffic in Sydney Harbour and ineffective communication between vessels as key contributory factors in close quarter incidents through a systemic investigation into incidents between 2010 and 2016.

The investigation was launched in response to a significant increase in the number of reported close quarters incidents, giving rise to concerns of systemic safety issues associated with ferry operations in Sydney Harbour. OTSI noted that congestion in Sydney Cove increased when cruise ships and servicing vessels, such as fuel barges, were present.

OTSI’s objective was to determine the extent of these incidents, identify any commonality, identify the contributory factors, and provide recommendations to prevent or minimise a recurrence.

In addition to communications and congestion, the investigation also identified scheduling and timetabling of ferry services, and ferry design as contributory factors to close quarters incidents.

Through the investigation, OTSI made recommendations to Transport for NSW, the former Roads and Maritime Services (now part of Transport for NSW), Australian Maritime Safety Authority, Port Authority of NSW and ferry operators.

For details on the findings and recommendations, you can read the full investigation report on the OTSI website.

Figure 2: Sydney Cove Navigation Map

Well done OTSI! - Finally some sanity prevails...

MTF...P2 

[Peetwo]

Popinjay to the rescue on 2020 Wallan train derailment?? - 

Remember this when HVH once again rushed to the rescue?? - 

Well after three and a half years, of making sure all of the asses within the DIPs of Commonwealth bureaucracies are totally covered, the PJ led ATSB have released their final report...  

Via the other Aunty (PJ quotes in bold):

Final report into Wallan train derailment finds there was no way to confirm driver understood route changes

By Courtney Withers and staff

Posted Yesterday at 10:31am, updated Yesterday at 3:39pm

• In short: A final report into the Wallan train derailment has found no protocol was in place to ensure the driver understood changes to his route
  
• What's next? The ATSB recommended emerging technologies be adopted to mitigate risks
  

The Australian Transport Safety Bureau (ATSB) says the absence of a protocol to ensure train drivers understood changes to their route contributed to the 2020 derailment of a passenger train north of Melbourne which killed two people.

The ATSB has released its final report into the incident, in which an XPT train travelling from Sydney to Melbourne left the tracks, killing the train's driver, Canberra man John Kennedy, 54, and train pilot, 49-year-old Sam Meintanis of Castlemaine.

The ATSB report said the driver was given information on the routing of the train through the Wallan loop, but no protocol was in place to ensure the driver understood it.

A fire in a signalling hut two weeks earlier meant drivers were being given instructions on paper documents.


The XPT train from Sydney to Melbourne derailed near Wallan on February 19, 2020.(Supplied: James Ashburner)

"In the 12 days prior to the accident, the driver had operated the XPT service through Wallan eight times, and on all occasions the crossing loop was locked out of service," ATSB Chief Commissioner Angus Mitchell said in the final report. - P2 comment: I think they mean in the final report word weasel confection attributed to Popinjay?? (see HERE)

"This has led us to believe they probably expected to remain on the straight track, where the speed limit was 130Km/h through Wallan.

"However, there was no protocol in place to confirm the driver's understanding of the revised instruction, with no requirement for the driver to read back or confirm the instructions to the network control officer."

The train entered the crossing loop at a speed of 114-127km/h when the maximum speed permitted to enter the crossing loop was 15 km/h.

The report made 37 findings, including identifying 15 safety issues which contributed to the derailment.

The Investigator said the administrative systems used deviated from established network rules in Victoria, with weaknesses in delivering critical safety information.

Report recommends adoption of new technology

Chief Commissioner Mitchell said the Wallan loop had been out of action but was brought back into service on the day of the accident.

That information was included in the written advice given to the train driver, but he was not required to confirm verbally that he had understood it.

"In other industries there is a read back or acknowledgement of the change so it's fully understood. That didn't occur in this instance," he said.


The cab and first passenger carriage of the train completely derailed during an incident on February 20, 2020.(AAP: David Crosling)

"When systems change and risks are changed and modified there needs to be an understanding of what the new risks are, how they're going to be mitigated and, particularly, how all of the users understand it and are part of that mitigation."

Chief Commissioner Mitchell said there was an "over reliance on administrative controls" and missed opportunities to embrace "existing and emerging technologies" to mitigate risk associated with human error.

Train driver's cabin safety highlighted

The ATSB's final report found that the design of the XPT train's cab contributed to the "adverse outcome for the driver and accompanying qualified worker", who both died in the crash.

The report found the power car's left-side door detached when it overturned, allowing earth and other material to enter the driver's cabin as it slid on its side.

That resulted in both people in the cabin becoming trapped.

Chief Commissioner Mitchell said cabin safety was an issue that should be addressed.

"When we understand dynamic forces that occur in an accident and ergonomic design of cabins and how they may have contributed to adverse outcomes then we can make recommendations to address that and that's what we've done in this particular case," he said.

The ATSB also recommended audio and video recording equipment be installed in driver cabins to give a better understanding of events.

Rail track operator commits to all recommendations

The Australian Rail Track Corporation (ARTC), which owns and maintains the section of track where the derailment occurred, said it had already begun to address the six recommendations addressed to it.

"Since the incident, ARTC has implemented additional controls into our operations to ensure that we provide a safe rail network," a spokesperson said.

"Over the months ahead, ARTC will continue to work with the ATSB, rail regulators and industry so that all the recommendations are fully implemented."

The national Rail, Tram and Bus Union said the report highlighted the need to review and reform Australia's rail safety regime.

"This was a failure of communication, a failure of process, and a failure of risk management," assistant national secretary Shayne Kummerfeld said.

"We can only hope that this tragic incident spurs genuine change to rail safety processes so that something like this never happens again."

While on the subject of Popinjay again sacrificing his tax-payer funded expertise in transport safety investigation, I note that PJ is donating more of his (our) valuable time and wisdom to appear in not one but two presentations at the (International tin-kickers association) ISASI in Nashville Tennessee, in two weeks time:  
 

Wednesday, August 23, 2023, Main Session (11 Presentations/Speakers)
Wednesday Morning Events, Broadway 2 and 3
(Seated at 8:00 a.m.)

Morning Moderator – Stacey Jackson

8:00 – 8:05 Morning Announcements
8:05 – 8:30 Keynote Speaker – Angus Mitchell, Chief Commissioner and Chief Executive
Officer, Australian Transport Safety Bureau (ATSB)

---

Thursday, August 24, 2023, Main Session (10 Presentations/Speakers)
Thursday Morning Events, Broadway 2 and 3
(Seated at 8:00 a.m.)

9:25 - 9:55 Announcements and Break
9:55 – 10:25 Wet-Runway Overruns: Still a Slippery Problem – J. O'Callaghan, NTSB
10:25 – 10:55 Human Factors Failure Modes and Effects Analysis (HF - FMEA) - Tools for
Pre-Mishap and Post-Mishap Investigation – D. Hollaway and C. Pohlen, National
Air and Space Administration (NASA)
10:55 – 11:25 Accident Investigation - Sydney Seaplanes DHC-2 Collision with Water Accident
– Angus Mitchell, Chief Commissioner and Chief Executive Officer, Australian
Transport Safety Bureau (ATSB)

 

Hmm...Sydney Seaplanes Beaver accident - curious choice for PJ?? Wonder if he will explain how it took 3 years to complete and how it took till the DIP draft final report review for the ATSB to consider doing a toxicological testing of the pilot and pax blood samples to examine for possible CO poisoning?

Update: 3 July 2020

During the draft investigation report review process, the aviation medical specialist engaged by the ATSB recommended that carbon monoxide (CO) toxicology testing be undertaken on blood samples of the aircraft occupants that had been taken and suitably stored by the New South Wales State Coroner. This required testing at a specialised laboratory. With results pending, the ATSB draft report was submitted to Directly Involved Parties (DIPs) in December 2019 for comment.

The results of the testing were provided to the ATSB in March 2020, indicating that the pilot and two of the passengers had elevated levels of CO. The ATSB notes that post-mortem examinations established that the pilot and passengers received fatal injuries sustained as a result of the impact sequence.

MTF...P2