Brisbane port authorities had not put in place sufficient procedures, checklists and/or supporting documents to ensure VTS staff were adequately prepared, trained and practiced to handle a predictable incident such as this.
The design of the burner nozzle allowed the nozzle swirl plate and needle valve to be misaligned when being assembled which in turn led to the needle valve stem being damaged during assembly. Furthermore, the maintenance manuals and supporting documentation supplied by Garioni Naval, the thermal oil heater manufacturer, did not provide sufficient guidance to ensure safe and appropriate maintenance of the thermal oil heater burner assembly.
When the main engine was operated in engine room control mode, there was no automatic interlock to prevent ‘wrong way’ operation of the engine and no audible alarm to indicate when it was running the ‘wrong way’. As a result, the only system protections to warn the crew of ‘wrong way’ running of the engine were the bridge and engine control room console mounted flashing light indicators.
Flinders Ports had not undertaken a risk assessment, or developed contingency plans for this specific shiphandling manoeuvre in Port Lincoln. Consequently, the pilot had no guidance regarding what actions to take if the berthing manoeuvre did not progress as he planned.
Newlead Bulkers had not implemented any procedures or guidance to inform the crew that extra vigilance was required when operating the main engine in engine room control mode because there was no automatic interlock to prevent ‘wrong way’ operation of the engine and no audible alarm to indicate when it was running the ‘wrong way’.
The participation of the two tug masters in the pilotage process was not actively encouraged in Port Lincoln. Consequently, it was not until after the collision that one of the tug masters advised the pilot that the ship's main engine was still running ahead.
While the Flinders Ports passage plan for Port Lincoln contained information relating to general navigation in the port, such as depths and navigation/channel marks, it did not contain actual passage specific information, such as courses and speeds to be followed. If the plan had contained course and speed information, the ship’s crew would have been better prepared for the pilotage.
The shipyard commissioning processes did not identify that the ship’s rudder angle indicator transmitter and tiller link-arm were not installed correctly.
There has not been a comprehensive safety management system implemented in the Port of Gladstone with the aim of identifying, evaluating and controlling pilotage related risk.
There has not been a comprehensive risk based approach to contingency planning for deep draught bulk carrier operations in Gladstone.
The ship’s crew were not appropriately trained or drilled in the operation and maintenance of the oxygen breathing apparatus.
The threaded connections on the Kawasaki air breathing apparatus and oxygen breathing apparatus cylinders were the same and there were no other engineering controls to prevent an oxygen cylinder from being connected to the air compressor.
The ship’s safety management system documentation provided the crew with no guidance in relation to the operation and maintenance of the ship’s oxygen breathing apparatus.
Patrick Terminals’ hazard identification process had not identified the dangers of working near or under containers being loaded.
The recognised safe practices of not working under or near a container being loaded is not well reflected in national and international guidance published to assist container terminal operators develop their own safety policies and guidelines.
The culture which existed in the Patrick terminal did not encourage the reporting of non-compliances or unsafe acts. Consequently, two critical parts of an effective safety system, which had a direct impact upon its ability to effectively manage safety in the terminal, the ‘reporting’ culture and the ‘just’ culture, were either not present or were misunderstood in Patrick’s safety system.
The implementation of Patrick Terminal’s safety management system resulted in an environment where Patrick Terminal management and stevedores were disconnected in relation to the management of some of the day-to-day workplace safety risks. As a result, there was little ownership of the safe work instructions by the stevedores, and some of the more experienced stevedores were probably no longer aware of the risks posed to them when they undertook unsafe ‘workarounds’ in the workplace and these were not identified by Patrick management.
Patrick Terminals’ safe work instructions for lashing/unlashing did not specifically cover the recognised safe practices of not working under containers or between moving containers and fixed objects. Consequently, there was a discontinuity between the level of awareness regarding these dangers and the training new employees received during their induction period.
Patrick Terminals’ risk assessment process for lashing and unlashing operations had not anticipated a fatal accident resulting from being struck by items falling from a portainer or cargo, or from being struck by a moving container. As a result, while the appropriate risk control for this occurrence had been covered during employee training, this was not reinforced in safe work instructions, an important risk control measure.
