The training provided to the crew did not ensure they were familiar with the function or operation of the wave compensator or its safety interlock
The planned maintenance system on board British Sapphire did not include a specific requirement to maintain or test the wave compensator or its safety interlock on the fast rescue boat davit. As a result, the crew had not identified the issue with the wave compensator safety interlock during periodic maintenance.
There was no evidence to indicate that the operation of British Sapphire's (or its sister ships) fast rescue boat davit’s wave compensator and safety interlock had been sufficiently tested at the time of the ship's delivery to ensure safe operation
Davit International’s fast rescue boat davit manual did not provide sufficient guidance for the crew in the operation of the wave compensator and its safety interlock
The job hazard analysis for the operation of the fast rescue boat was incomplete and did not include an assessment of the hazards associated with the operation of the wave compensator
It was found that the safety interlocks on the wave compensator systems on board British Sapphire, British Emerald and British Ruby had been electrically by-passed thereby preventing the safety interlocks from functioning.. As a result, the wave compensators on board all three ships could be engaged regardless of whether the fast rescue boats were waterborne or suspended from the fall wire
The crew did not use resource management principles to ensure that they had a shared mental model of the task that they were carrying out. As a result there was confusion amongst the various crew members as to their roles and responsibilities at the time of the incident
Dampier Port Authority's pilotage directions are unclear and ambiguous with respect to the requirements for towing vessels or on the use of pilotage exemptions by crew other than the master.
Global Supplier was built and surveyed as a Uniform Shipping Laws (USL) Code vessel and therefore was not fitted with radar or an AIS unit which would be required under the provisions of the current National Standard for Commercial Vessels. Had these devices been fitted, they would have provided information that would have assisted both Global Supplier's skipper and Far Swan's watchkeepers, in avoiding the collision.
Global Supplier was not fitted with the correct navigational lights for a vessel engaged in towing operations.
Preliminary inspections and tests of MSC Basel steering system did not identify any faults. However, more thorough examinations of the entire steering systems may identify any intermittent defects.
In the 30 minutes leading up to the grounding, there were no visual cues to warn either the chief mate or the seaman on lookout duty, as to the underwater dangers directly ahead of the ship.
There was no effective fatigue management system in place to ensure that the bridge watch keeper was fit to stand a navigational watch after the loading in Gladstone.
The ship’s safety management system did not contain procedures or guidance on the proper use of GPS route plans and their relationship to the ship’s passage plans.
At the time of the grounding, the protections afforded by some of the measures currently employed in the more northern sections of the GBR were not in place in the sea area off Gladstone.
The oiler’s actions indicate that he was likely not aware of the ship’s safety management system hot work permit requirements.
The oiler’s actions indicate that he was not aware of the dangers associated with the use of an angle grinder to remove the top of the drum.
Before the incident, Orica Australia had advised the Australian Maritime Safety Authority (AMSA) that their packaging method for the prills was fully compliant with the IMDG Code’s provisions. However, AMSA’s IMDG Code compliance audit regime had not detected that the method was not compliant.
The ammonium nitrate prills were not packaged in the containers in accordance with the requirements of the IMDG Code. The containers were packed in a way which allowed the prills to move within the container in a way that may have contributed to the failure of the containers and/or the lashing system.