The ship’s managers did not have effective systems to ensure that the defective control system for the controllable pitch propeller was reported to the relevant organisations as required.
Consequently, Brisbane’s vessel traffic services, pilotage provider and the pilot remained unaware of the defect and could not consider it in their risk assessments before the pilotage started.
Bosphorus’ safety management system did not detail any guidance or instructions relating to watch handover or changing the helmsman during high risk areas of a pilotage.
Brisbane Marine Pilots’ ‘Port of Brisbane Passage Plan’ did not detail any guidance or instructions relating to watch handover or changing the helmsman during high risk areas of a pilotage.
Bosphorus’ safety management system provided no guidance in relation to the allocation of function based roles and responsibilities to members of the bridge team during pilotage.
The on board familiarisation process did not ensure that new crew members were informed of the precautions required when working on deck while the gantry cranes were in operation.
There was a lack of mapping information available to assist the ‘triple zero’ operator in providing the emergency responders with directions to a defined location within the port area.
The gantry crane in motion warning light nearest to the assistant electrician’s location was not operating and the warning sirens were not audible from his location. As a result, he was not provided with either a visual or audible warning of the crane’s movement.
The Cayman Islands requirements in relation to a yacht’s compliance with the Large Commercial Yacht Code and other relevant legislation are determined by the yacht’s mode of operation. As a result, a commercially operated yacht in excess of 24 m in length must comply with the requirements of the Code while a similar sized privately operated yacht that poses the same risks to safety of life at sea and the environment does not.
Calliope’s safety management system (SMS) did not provide the crew with adequate guidance regarding passage planning, training and familiarisation. Individual crew familiarisation records and risk assessment forms were not retained on board the yacht and there was no system of auditing or checking to ensure the adequacy of the SMS or the effectiveness of its implementation.
Calliope was not required to carry a pilot during Sydney Harbour voyages because the yacht was considered to be a recreational vessel, even though the risks it posed to the port were the same as those posed by similarly sized commercially operated vessels.
Atlantic Princess’s safety management system provided no guidance relating to actions that should be taken when persons less experienced than a pilot used a pilot ladder to board or disembark the ship.
The examples of non-compliance with the requirements of Whyalla Launch Services’ safety management system indicate that the system was not fully and effectively implemented on board Switcher.
There were no facilities on board the Floating Offshore Transfer Barge Spencer Gulf that could be used to provide a safe means of access for personnel transfers between the barge and the ship. Furthermore, the barge operator’s procedures prohibited such personnel transfers.
Whyalla Launch Services’ safety management system did not provide effective guidance in relation to assessing a passenger’s ability to climb a pilot ladder or positioning of pilot launches while passengers were climbing and descending ladders. The system also referenced superseded SOLAS regulations and IMO resolutions relating to pilot ladders.
The ship’s pilot transfer procedures had not been revised to incorporate the most recent SOLAS requirements that manropes be secured at the rope end to a ring plate fixed to the deck.
The pilotage company’s procedures did not explicitly require the pilot to check the pilot ladder and manrope arrangements before disembarking the ship.
The pilotage company’s procedures did not require pilots to inform launch crews whether manropes would or would not be deployed in advance of the transfer.
The pilotage company’s procedures for positive communication of readiness between the pilot and the launch crew were adequate. However, it was common for employees to vary these communication protocols, leaving perceptions of readiness open to error and misinterpretation.
The ship’s pilot transfer procedures did not specify a requirement for additional crew members to assist the supervising officer. As a result, the supervising officer was actively involved in deploying the pilot ladder and manropes, and transferring the pilot’s belongings to the launch, and could not focus his efforts on properly checking the arrangements and supervising the transfer.
The condensate drainage pots fitted to Nireas’ main air receivers were not fit for purpose as they were not capable of withstanding the internal pressures that were likely to accumulate in service.
