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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 028/11
Issued To Australian Operator on 26 Oct 11
The safety management system on board the Oceanic Discoverer did not adequately address the issue of watertight door maintenance, which could be an indicator that other aspects of the safety system need improving
It is recommended to the Director of the Australian Maritime Safety Authority that he oversees a special audit of the Safety Management System on board the Oceanic Discoverer with at least a focus on the planned maintenance system and how it addresses the identification and maintenance of safety critical machinery and components. (028/11)
Implementation Status: Open
Reply:

Safety Recommendation 026/11
Issued To IACS on 26 Oct 11
The operating handle of the watertight door protruded into the doorway when it was in its opening position which was why the door could not be opened when the engineer was trapped.
The Commission recommends that the manufacturer assess the design and/or installation of the doors such that this safety issue is resolved. The solution should be promulgated through the International Association of Classification Societies (IACS) and any other way it can.
Implementation Status: Open
Reply:

Safety Recommendation 019/11
Issued To Maritime NZ on 02 Aug 11
Critical components in a fixed CO2 gas fire fighting system such as control valves can cause serious harm or immobilise a vessel if they fail. It is a concern that such components are only required to be internally examined every 5 years and are not required to be tested at the design operating pressure at all.
It is recommended that the Director of Maritime New Zealand forward this report to the International Maritime Organization and the International Association of Classification Societies so that they can draw on the lessons learned from this incident and consider amending the current guidelines to require a more robust examination and testing regime for such critical components. (019/11)
Implementation Status: Open
Reply:

Safety Recommendation 012/11
Issued To Royal NZ Coastguard on 25 May 11
It is a safety issue that the system for tasking a Coastguard rescue vessel does not always ensure that the people responsible for tasking or operating the vessel are in possession of sufficient information to make a prudent decision on whether the task should be undertaken. Further, a person independent of the crew should always involved in the decision process.
It is recommended that the Chief Executive of The Royal New Zealand Coastguard Inc. develops a nationwide standard that supports measured decisions based on the maximum available information when tasking coastguard vessels.
Implementation Status: Open
Reply: Accepted
Coastguard to develop and implement a nationwide standard that supports measured decisions based on the maximum available information when tasking coastguard assets. As the environment we operate in is dynamic we see the investment in the decision making skills of those in charge as, if not more, valuable than a system or process and will continue to pursue this as our primary outcome.
Training component is being addressed within the CRM for CRV Masters and the Duty Officer or nominated Ground Person as part of the current Training Development Project to be completed for implementation from July 2011.

Safety Recommendation 013/11
Issued To Royal NZ Coastguard on 25 May 11
It is a safety issue that there are shortcomings in the standard of navigation training applied by Coastguard crews particularly for navigation at night and in poor weather conditions.
It is recommended that the Chief Executive of The Royal New Zealand Coastguard Inc. ensures that all Coastguard crews achieve a high standard of navigation skills for all Coastguard crews commensurate with the worst case scenario of conducting rescues at night and in bad weather.
Implementation Status: Open
Reply: Accepted
Coastguard volunteer (CoC) training will include high standard of navigation skills commensurate with worst case scenario of conducting weather at night and in bad weather.
This is being addressed as part of the mandatory competency level for Operational Crew as well as an advanced navigation skill set for Senior Crew, through a new course being designed as part of the current Training Development Project to be completed for implementation from July 2011.

Safety Recommendation 014/11
Issued To Royal NZ Coastguard on 25 May 11
It is a safety issue that the Coastguard did not have a process requiring its crews to undertake pre-departure planning when tasked to an incident thus increasing the risk of an accident occurring en-route to the incident area.
It is recommended that the Chief Executive of The Royal New Zealand Coastguard Inc ensures all Coastguard crews conduct an appropriate pre-departure plan , that includes a risk assessment, and that the plan is reassessed at appropriate times as the rescue scenario unfolds.
Implementation Status: Open
Reply: Accepted
All Units have requirements as part of the Safe Ship Management System (MNZ) for standard operating procedures for pre-departure planning. Coastguard will develop and implement a National standard for pre-departure planning that includes a risk assessment process and reinforces the SAPP requirements laid out in the Coastguard Boat Book,
The application of pre-departure planning will be regularly reviewed as part of the Unit Capability Reports completed by Regional Operations Managers. It will also and incorporated into the CRM for CRV Masters as part of the current Training Development Project to be completed for implementation from July 2011.

Safety Recommendation 015/11
Issued To Royal NZ Coastguard on 25 May 11
It is a safety issue that the Coastguard did not extend the training in the concept of crew resource management to all members of the crew so that the crews could work cohesively as a team to maintain situational awareness, monitor the plan, anticipate dangerous situations, acquire timely information and avoid pre-occupation with minor problems.
It is recommended that the Chief Executive of The Royal New Zealand Coastguard Inc incorporates in its training regime for all crew from the very early stages the concept and use of crew resource management as a means of achieving its goal of optimum safety and efficiency in the operation of its vessels.
Implementation Status: Open
Reply: Accepted
Coastguard will develop and implement training from the recruit stage to develop a culture that increases individual?s appreciation of the personal and team responsibility. This will improve the cohesiveness of the team to maintain situational awareness, monitor the plan, anticipate dangerous situations, acquire timely information and avoid pre-occupation with minor problems.
This will be addressed as part of CRM for all crew members as part of the current Training Development Project to be completed for implementation from July 2011. This will also be applied retrospectively to existing crew.

Safety Recommendation 016/11
Issued To MNZ on 25 May 11
It is a safety issue that there appears to be a disparity between the operating limits and designation of the Coastguard vessels and the types of extra curricular work the vessels are engaged in and the qualification requirements of the skippers of Coastguard vessels.
It is recommended that the Director of Maritime New Zealand considers some means of aligning the qualifications of Coastguard certificated skippers with the qualifications structure of Maritime New Zealand to ensure that the Coastguard certification better serves the needs of its skippers with respect to operating limits, designation of vessels and anticipated work to be undertaken.
Implementation Status: Open
Reply: Accepted
Current Coastguard training requirements exceed those required for a number of the MNZ Commercial qualifications so alignment is overdue and would be strongly supported by Coastguard.

Safety Recommendation 017/11
Issued To Royal NZ Coastguard on 25 May 11
Better search and rescue efficiencies and a safer coastguard operation could be achieved if the design and type of vessels assigned to individual coastguard units are compatible with the conditions they are more likely to operate in and easily integrate with other search and rescue resources available locally and nationally.
It is recommended that the Chief Executive of The Royal New Zealand Coastguard Inc review the coastguard fleet with a view to achieving standardization of design, suitability for likely operating conditions and the best fit with other search and rescue resources both locally and nationally.
Implementation Status: Open
Reply: Accepted
Coastguard is responsible for the Coastguard Rescue Vessel fleet and is currently identifying funding to undertake the 'Vessel Standardisation Project' as identified in the 2020 Vision document:
Rescue Vessel fleet built to agreed plans and process
Classes of vessels agreed and replacement aligned with 'fit for purpose' identified through 'evaluation'.
Standard fit out to agreed National standard
Coastguard is also progressing a Coastal Evaluation Tool for use with current and future resourcing.

Safety Recommendation 025/11
Issued To Maritime NZ on 26 Oct 10
The issue of serious harm resulting from the operation of watertight doors remains a safety issue that has not been resolved by the maritime industry worldwide, and some advice to mariners in its various forms, including that given by the International Maritime Organisation, could unintentionally exacerbate the issue.
The Commission therefore recommends that the Director of Maritime New Zealand forwards this report to the IMO, draws its attention to the issues discussed around rules, regulations and advice given to mariners for the operation of watertight doors, and invites the IMO to revisit the issue through other mechanisms that will address the human element, through watertight door design for example. (025/11)
Implementation Status: Open
Reply:

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