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.
The shipyard commissioning processes did not identify that the ship’s rudder angle indicator transmitter and tiller link-arm were not installed correctly.
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.
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 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.
Patrick Terminals had no formalised policy in place to provide clear guidance to its stevedoring employees about where they could or could not work on a ship when cargo was being loaded or discharged.
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.
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.
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’ 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.
Patrick Terminals’ hazard identification process had not identified the dangers of working near or under containers being loaded.
Ta Ann Tasmania did not follow the recommendations contained in section 2.3 of Appendix A of the International Maritime Organization’s Code of Safe Practice for Ships Carrying Timber Deck Cargo when they packaged the timber veneer for shipment by sea.
Mimasaka’s cargo securing manual did not contain any information relating to the stowage and securing of timber veneer.
The Operation Manual for Loading and Lashing of Tasmanian/Malaysian Dry Veneer, developed by NYK-Hinode Line for use by ships carrying timber veneer, did not contain any information relating to the stowage and securing of the timber veneer cargo on deck.
The Australian Maritime Safety Authority had not inspected the packs of veneer to establish whether Ta Ann Tasmania was packaging the veneer in line with the recommendations contained in section 2.3 of Appendix A of the International Maritime Organization’s Code of Safe Practice for Ships Carrying Timber Deck Cargo.
The instructions that were emailed to Mimasaka’s master by NYK-Hinode Line did not provide the crew with proper guidance about how to stow and secure the packs of timber veneer on deck.
Prior to 2 February 2011, the crew had encountered problems with the lifting wire jamming in the head of the davit when the bucket was hoisted too high. However, nothing had been done to prevent it from happening again in the future.
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
