The planned maintenance system on board British Sapphire did not detail a procedure for a recommissioning test following maintenance on the fast rescue boat davit. As a result, any recommissioning test that was done after on board maintenance had not identified the issue with the wave compensator safety interlock prior to the incident.
British Sapphire’s fast rescue boat davit procedures did not provide sufficient guidance for the crew in the operation of the wave compensator
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
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
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 not fitted with the correct navigational lights for a vessel engaged in towing operations.
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.
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.
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.
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 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.
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.
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.
At the time of the incident, there was no requirement for any third party to inspect or survey the fixed and loose lashing equipment on a ship. Had this been done, the maintenance and replacement regime of such equipment on board Pacific Adventurer might have been more effective.
The poor condition of much of the ship’s container lashing equipment indicates that the inspection and maintenance regime applied to this critical equipment had been inadequate.
River Embley’s planned maintenance system did not require routine testing of the compressor high temperature alarm/shutdown.
