An ongoing technical fault in the REEFVTS monitoring and surveillance system caused an abnormally high number of erroneous alerts and alarms. Consequently, REEFVTS operators were experiencing sustained periods of elevated workload, including that of the operator at the time of the Trinity Bay’s grounding.
The illumination of the joystick steering panel’s ‘joystick on’ light indicated which panel was selected (or last selected) for use and bore no relation to the steering mode selected. This increased risk as it was misleading and contrary to the understanding of the ship’s officers who believed that the illumination of the light was only possible when the joystick steering mode was selected.
Neither the master nor the second mate had undertaken required bridge resource management training. This probably contributed to the ineffective implementation of bridge resource management on board, which resulted in the single person errors that contributed to this accident not being detected.
On board routine inspection and maintenance of fixed cargo securing devices on APL England was ineffective. Over an extended period of time, the significant proportion of the devices that were unfit for purpose were not identified and made good.
A significant proportion of the fixed cargo securing devices on the deck of APL England were in poor condition. The heavy wastage of the devices significantly reduced their load carrying capacity and compromised the effective securing of cargo.
The insecure loading of high cube containers into bay 62 was contrary to the ship's cargo securing manual and not identifiable by the cargo computer software in use at the time. Consequently, forces generated during the heavy rolling resulted in dislodging of all containers above the cell guides and the loss of 16 overboard.
BBC Rhonetal’s managers had not effectively implemented the shipboard safety management system procedures in place to prevent the fire. This was the tenth such fire on a company ship in the past 14 years, and the fourth investigated by the ATSB, identifying similar contributing factors.
Regulatory safety oversight of Iron Chieftain, which comprised flag State audits, surveys and inspections had not identified safety deficiencies with respect to the ship’s fire safety, risk management, emergency preparedness and emergency response.
The capability of Fire and Rescue New South Wales to effectively respond to a shipboard fire in Port Kembla, was limited by:
Iron Chieftain's Emergency Contingency Plan did not include a response plan to fire in the high fire risk self-unloading system spaces. Consequently, there was no clear plan or practiced sequence of actions that could aid emergency preparedness.
The cargo handling spaces of specialised self-unloading bulk carriers continue to present a very high fire risk due to the inadequacy of standards or regulations for self-unloading systems, including for conveyor belts, and dedicated fire detection/fixed fire-extinguishing systems. This has been a factor in at least three major fires over a 25-year period, including Iron Chieftain’s constructive total loss.
Iron Chieftain's operators had formally identified the fire risk in the ship’s cargo self-unloading system spaces, particularly the C-Loop, as being unacceptably high 5 years before the fire due to the absence of fire detection or fixed fire extinguishing system. However, at the time of the fire, the prevention and recovery risk mitigation measures had not reduced the risk to an acceptable level.
No procedure or system was in place to ensure critical spares were identified and their inventory controlled to ensure availability when required. As a consequence, the fan belts for the emergency generator had been on order for several months.
The ship’s manager’s (Yang Ming) cargo-planning process ashore did not ensure that the proposed container stowage plan complied with the stowage and lashing forces requirements of the ship's Cargo Securing Manual. Consequently, compliance with these requirements relied entirely on shipboard checks, made at a late stage, with limited options available for amendments without unduly impacting commercial operations.
Tugs were to be available to escort the mini cape-size ships until they had entered the South Channel, where they were stood down. However, the tug masters had not been trained in the specifics of escort towage nor in emergency response.
In pre-trial simulations, the risks associated with engine failure during departure were only considered up to when a ship had entered the South Channel. Consequently, the tugs were not in attendance to assist if propulsion was lost.
The fall arrest equipment used was incorrectly attached to the workers on the suspended platform. Consequently, had either of them fallen from the platform the equipment would not have worked correctly, resulting in serious or fatal injuries.
The hydrographic use of point feature objects to represent physical features of relatively significant spatial extent on an Electronic Navigational Chart can increase the risk of the hazard posed by such features being misinterpreted by mariners and potentially reduce the effectiveness of the ECDIS safety checking functions.
ECDIS on board most Australian Border Force cutters, including ABFC Roebuck Bay, operated with a non-type-approved naval software version that was not updated to the latest applicable standards of the International Hydrographic Organization. The ECDIS therefore did not comply with the minimum requirements of an ECDIS being used to meet the chart carriage requirements of the regulations. As a result, the enhanced safety features of the new presentation library, which would have potentially alerted the officers to the danger posed by the reef, were not available.
Most Australian Border Force cutters, including ABFC Roebuck Bay, were installed with ECDIS operating on non-type-approved naval software. Subsequently, DNV GL, acting on behalf of the Australian Maritime Safety Authority, incorrectly certified these vessels as using type-approved ECDIS to meet the chart carriage requirements of the regulations. This removed an opportunity to put in place controls to ensure ongoing safety compliance.