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Marine Safety Recommendations

This page displays a list of safety recommendations that relate to the marine mode.  You can use the filter tool to refine the results and to search for keywords within the text of each recommendation.

Urgent recommendations

Urgent recommendations released publicly in advance of a final report are available here until release of a final report at which time they are incorporated into the database.

Urgent recommendations - Marine inquiry MO-2016-202 Cruise ship Azamara Quest, contact with Wheki Rock, Tory Channel, 27 January 2016, published 29 August 2016RecommendationsMedia Release.

 

Recommendations database (completed inquiries)

 

 
Keywords: Recipient: Mode: Status:

Safety Recommendation 015/15
Issued To Standards NZ on 03 Nov 16
15.2.8. The Commission recommends that Standards New Zealand submit the Transport Accident Investigation Commission?s report MO-2013-203 DEV Aratere, Loss of propeller, Cook Strait, 5 November 2013 to the ISO Secretariat for its information and to consider whether the current standards for manufacturing large-diameter marine propellers are appropriate for modern, high-efficiency propellers that operate closer to cavitation margins
Implementation Status: Closed acceptable
Reply: I can confirm that Standards New Zealand will implement the Commission's final recommendation as soon as we have received the Commission's final report. I can also confirm that, as requested, I will send the commission a further letter following implementation of the recommendation.

Safety Recommendation 014/15
Issued To KiwiRail on 02 Nov 16
The Commission recommends that the Chief Executive of KiwiRail ensure that where KiwiRail makes significant modifications to vessels, appropriate oversight is in place. Oversight includes keeping comprehensive records to demonstrate that components are safe and reliable and comply with the appropriate standards
Implementation Status: Open
Reply: We have already implemented your recommendation by ensuring that all significant modifications to vessels are now always undertaken under the oversight of KiwiRail's Project Management Office which has its own strong project management disciplines including good records? management and strong governance.

Safety Recommendation 020/16
Issued To Talleys on 29 Sep 16
On 29 September 2016 the Commission recommended that the operator of the Captain M. J. Souza: review its internal auditing procedures to ensure that auditors make realistic assessments based on actual practices observed on board; and seek verification that documented procedures are being followed by the crew and they are appropriate for the task. Audit findings should be recorded together with any safety actions taken as a result of the audit.
Implementation Status: Open
Reply: Since August 2014 we have implemented a programme to improve the Health and Safety culture on this vessel. This started wit an internal review of our Health and Safety Systems (ashore and on board) governing the Capt M J Souza and following that review, we have taken several steps to improve Health and Safety outcomes which include:

1. Heightened oversight of the documented H & S procedures on the vessel at turnarounds by the vessel manager and operations manager including debriefing key staff on the vessel on H & S compliance and addressing any new hazards that may have been identified during the trip;

2. Implementation of a revised assurance process on the vessel and ashore to provide evidence to shore based management that Talley?s H&S protocols in fact being applied on board the vessel;

3. We have provided additional third party H & S training to the officers and crew of the vessel to ensure that they are aware of Talley's health and safety procedures, the hazards associated with their tasks and that they are operating safely;

4. Addressed and improved communication structures between senior management and senior vessel staff;

5. Setting out company expectations regarding H & S aboard the vessel and the consequences of departure from these expectations;

Further, when the vessel returns to NZ after its current Pacific Season in December 2016, we have identified an independent Health and Safety expert who will take a trip on the vessel to audit its compliance and to report to management on the H&S culture on the vessel, their compliance with the Talley's H&S programme and thereafter, if appropriate to put in place an effective change management programme.

Safety Recommendation 010/16
Issued To KiwiRail on 25 Feb 16
On 25 February 2016 the Commission recommended that the chief executive of KiwiRail ensure that the bridge resource management policy and procedures outlined in its safety management system remain relevant and effective for all crews on all ships in the fleet, all of the time.
Implementation Status: Open
Reply: KiwiRail accepted the recommendation as proposed.

Safety Recommendation 016/15
Issued To MNZ on 28 Oct 15
On 28 October 2015 the Commission recommended that the Chief Executive of Maritime New Zealand review the Dream Weaver operation with a view to ensuring that the Dream Weaver is fit for its intended purpose and that the operator?s safety management system, or the succeeding MOSS system, is operating as it should.
Implementation Status: Open
Reply: Subsequent to this accident, the Dream Weaver operation entered the MOSS system. It was through this process that Maritime New Zealand reviewed the Dream Weaver?s fitness for purpose and the operator?s safety management system to ensure it was operating as it should.

Safety Recommendation 001/15
Issued To MNZ on 26 Feb 15
The wire pennants parted under tensile overload because they had all been significantly weakened by severe corrosion. Corrosion had gone undetected inside a plastic sheathing that the manufacturer of the lifting sling had placed around the wire pennants.

The presence of the plastic sheathing encasing the wire rope meant that neither the crew nor the various surveyors tasked with inspecting the launching system could inspect and maintain the wire rope as required by SOLAS.

Encasing steel wire in plastic sheathing when it is to be used in the marine environment has significant implications for maritime safety, especially when the wire must be regularly inspected and maintained in order to remain fit for purpose.

On 26 February 2015 the Commission recommended that the Director of Maritime New Zealand, through the port and flag state control programme, verify that wires that require regular inspection and maintenance by a ship?s crew and surveyors are readily accessible and easily maintained as required by Chapter VI of the International Life-Saving Appliance Code.
Implementation Status: Open
Reply: This recommendation will be incorporated into our PSC mentoring and oversight program. We anticipate this will be integrated into our standard PSC inspections by the end of 2015.

Safety Recommendation 002/15
Issued To MNZ on 26 Feb 15
The wire pennants parted under tensile overload because they had all been significantly weakened by severe corrosion. Corrosion had gone undetected inside a plastic sheathing that the manufacturer of the lifting sling had placed around the wire pennants.

The presence of the plastic sheathing encasing the wire rope meant that neither the crew nor the various surveyors tasked with inspecting the launching system could inspect and maintain the wire rope as required by SOLAS.

Encasing steel wire in plastic sheathing when it is to be used in the marine environment has significant implications for maritime safety, especially when the wire must be regularly inspected and maintained in order to remain fit for purpose.

On 26 February 2015 the Commission recommended that the Director of Maritime New Zealand submit this report to the International Maritime Organization and raise the implications that plastic-sheathed wire ropes have for maritime safety through the appropriate International Maritime Organization safety committee for its consideration.
Implementation Status: Closed acceptable
Reply: I can confirm that this recommendation is already on the Domestic and International Policy team international register of work and initial consideration has commenced.

As soon as Maritime NZ receives from TAIC an electronic PDF copy of the final report we can upload this to the IMO's GISIS website, thus completing the initial part of this recommendation.

More detailed consideration is required of the second part of the recommendation as this has an impact on resources and budgets, which must be considered against other work items. In addition the timeline for the range of options to close out the second part of the recommendation varies greatly and thus it is not practicable to confirm the date when the recommendation will be fully implemented.

Safety Recommendation 012/14
Issued To Maritime NZ on 20 Nov 14
Member States are required to undergo five-yearly independent evaluations of their seafarer training systems. However, those evaluations remain confidential between the IMO, the auditing States and the States being assessed. According to Regulation I/10, member States are required to verify for themselves the effectiveness of other States' maritime education, training and certification systems before recognising certificates issued by those States. However, this can only be realistically achieved through a full systemic audit of the seafarer training system. If this were to happen it is likely that the global training system would be unnecessarily overburdened. This safety issue could be resolved if reports made after the five-yearly independent evaluations were required to be made available to other member states.

The Commission recommends that the Director of Maritime New Zealand promote, through the appropriate IMO forum, the importance of sharing amongst member states information regarding the quality of member states' maritime education, training and certification systems, including a consideration of making the five-yearly evaluations of member states' available to other member states.
Implementation Status: Closed acceptable
Reply: The Director of Maritime New Zealand understands this recommendation to be aimed at improving transparency under the existing STCW Convention regime as opposed to revisiting the underpinning principles of that regime. To that end the Director accepts the recommendation and will include it in the work programme (Goal 1) underpinning the Strategy for New Zealand's Engagement in the IMO.

Safety Recommendation 010/14
Issued To CIEL on 19 Nov 14
On board the Rena, the master and crew were not following the navigation and watchkeeping standards and procedures set down in the Rena's safety management system for at least the six coastal voyages leading up to the grounding.

With respect to port state control records, other vessels managed by CIEL also had a higher than average rate of deficiencies than the average for the Asia-Pacific region.

The Commission recommends that CIEL evaluate the effectiveness of its safety management system to ensure that the issues identified with that system as applied on board the Rena do not affect other vessels within its fleet.
Implementation Status: Open
Reply: 1. We understand the first two paragraphs of recommendation 010/14 are given by way of introduction or summary of the conclusions in the report. However, you will also appreciate from our previous submissions, we do not agree with these two paragraphs.

2. The first two paragraphs are statements of facts and opinions and are not recommendations. It is not possible to implement anything asserted in the first two paragraphs as has been suggested.

3. CIEL strongly objects to the content and utility of these two paragraphs in the recommendation for the reasons [given].

. . .

11. With regard to the actual recommendation in the third paragraph CIEL had implemented such a review. This included an internal review of the safety management system and the performance of vessel audits, including navigational audits.

Safety Recommendation 013/14
Issued To Maritime NZ on 25 Sep 14
It is probable that if an aid to navigation of some type had been installed on Astrolabe Reef, the Rena grounding would have been prevented. However, there are many such isolated dangers to navigation around the coast of New Zealand. Installing and maintaining physical navigational aids on remote hazards is costly. Virtual aids to navigation are potentially a cost-effective means of marking such isolated dangers. However, these are still being trialled by the International Association of Marine Aids to Navigation and Lighthouse Authorities and no performance criteria have yet been set regarding their accuracy and intended use. The Commission noted during its inquiry that although the technology is relatively new and there is no regulatory framework in place, some port authorities are already beginning to use virtual aids to navigation. There is a potential safety issue around the use of aids to navigation that have not been fully tested.

The Commission recommends that the Director of Maritime New Zealand consider the use of virtual aids to navigation and monitor progress through the International Air Transport Association (IATA) of the development of performance criteria for them, but meanwhile work with regional councils and port companies to control the use of virtual aids to navigation until they have been fully assessed and appropriate performance criteria set by IATA and Maritime New Zealand.
Implementation Status: Open
Reply: The Director of Maritime New Zealand accepts this recommendation (noting that the references to IATA are erroneous and should be a reference to IALA) and notes that in its Statement of Intent 2014-2020 Maritime New Zealand has included a Review of Costal Navigation Safety as a key strategic review of the safety regulatory system. The Director of Maritime New Zealand initiated this review in August 2014 and the review will consider the use of navigation aids (including virtual aids) as part of its inquiry. The Terms of Reference for the review are attached and include timelines for key deliverables.

In addition The Director of Maritime New Zealand established (in 2012) a joint MNZ/Regional Council CEs' group to facilitate cross agency engagement and promotion of navigation safety matters. A significant initiative, led by Maritime New Zealand, in the first year of the establishment of the group has been the conduct of an environmental scan of the New Zealand Port and Harbour Marine Safety Code. The findings of that scan will inform the Coastal Navigation Safety Review and the cross-agency co-ordinated responses to the findings are expected to address the recommendations of the Commission.

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