Marine Report 236, Independent investigation into the engine room ...

More documents

Recommendations

Info

TERMINOLOGY USED IN THIS REPORT Occurrence: accident or incident. Safety factor: an event or condition that increases safety risk. In other words, it is something that, if it occurred in the future, would increase the likelihood of an occurrence, and/or the severity of the adverse consequences associated with an occurrence. Safety factors include the occurrence events (e.g. engine failure, signal passed at danger, grounding), individual actions (e.g. errors and violations), local conditions, risk controls and organisational influences. Contributing safety factor: a safety factor that, if it had not occurred or existed at the relevant time, then either: (a) the occurrence would probably not have occurred; or (b) the adverse consequences associated with the occurrence would probably not have occurred or have been as serious; or (c) another contributing safety factor would probably not have occurred or existed. Other safety factor: a safety factor identified during an occurrence investigation which did not meet the definition of contributing safety factor but was still considered to be important to communicate in an investigation report. Other key finding: any finding, other than that associated with safety factors, considered important to include in an investigation report. Such findings may resolve ambiguity or controversy, describe possible scenarios or safety factors when firm safety factor findings were not able to be made, or note events or conditions which ‘saved the day’ or played an important role in reducing the risk associated with an occurrence. Safety issue: a safety factor that (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operational environment at a specific point in time. Safety issues can broadly be classified in terms of their level of risk as follows: • Critical safety issue: associated with an intolerable level of risk. • Significant safety issue: associated with a risk level regarded as acceptable only if it is kept as low as reasonably practicable. • Minor safety issue: associated with a broadly acceptable level of risk. - ix -
- x -
Page 1 and 2: ATSB TRANSPORT SAFETY INVESTIGATION
Page 3 and 4: Published by: Australian Transport
Page 5 and 6: APPENDIX A: EVENTS AND CONDITIONS C
Page 7 and 8: - vi -
Page 9: - viii -
Page 13 and 14: At 1030, the tug Wickham started to
Page 15 and 16: addition to two very high frequency
Page 17 and 18: detectors are fitted at various loc
Page 19 and 20: 1.4 The incident At 2305 on 8 Febru
Page 21 and 22: At 0255, the second engineer used t
Page 23 and 24: Figure 8: Number three generator an
Page 25 and 26: On 13 April, AMSA and LR verified t
Page 27 and 28: However, a mist of vaporised diesel
Page 29 and 30: 2.3.1 Baltimar Boreas’s fuel hose
Page 31 and 32: a copper pipe between two pieces of
Page 33 and 34: In the absence of adequate SMS proc
Page 35 and 36: the likelihood of the fire reigniti
Page 37 and 38: issuing and then closing the damper
Page 39 and 40: confirmation that the fire had been
Page 41 and 42: 3.3 Other safety factors • While
Page 43 and 44: MR20080025 The emission of smoke, s
Page 45 and 46: - 32 -
Page 47 and 48: - 34 -
Page 49 and 50: - 36 -
Page 51 and 52: UC Davis Environmental Health and S
Page 53: - 40 -

Marine Report 236, Independent investigation into the engine room ...

Create successful ePaper yourself

Delete template?

Save as template?