The urgent and priority category defects detected by the AK Car on 4 February 2011 that were located within a 20 m track section were inadequately assessed and controlled in accordance with the ARTC Track and Civil Code of Practice.
Section 4 of Civil Aviation Advisory Publication (CAAP) 5.23-2(0), Multi engine Aeroplane Operations and Training of July 2007 did not contain sufficient guidance material to support the flight standard in Appendix A subsection 1.2 of the CAAP relating to Engine Failure in the Cruise.
Wear of the interlocking shrouds of the intermediate-pressure turbine blades had the potential to reduce the dampening effects of the feature, and may have led to the development of conditions suitable for fatigue cracking of the IP turbine blades.
The operator’s lack of awareness of the data providers’ assumption that the operator was complying with DO-200A Standards for Processing Aeronautical Data, which was not mandated in Australia, meant that the quality of the data was not assured.
The inconsistent application of the operator’s safety management system to the identification and rectification of database anomalies, and intermittent notification of these anomalies to crews increased the risk of inadvertent flight crew non compliance with published instrument approach procedures.
The safety framework prescribed by successive issues of Marine Orders Part 54 (MO 54) has not assigned the responsibility for the overall management of the safety risks associated with coastal pilotage operations to pilotage providers or any other organisation.
Risk identification and mitigation in coastal pilotage operations is inadequate as a result of the under-reporting of risk events and incidents by pilots.
The coastal pilot fatigue management plan is inadequate.
The potential for the Great Barrier Reef and Torres Strait Vessel Traffic Service (REEFVTS) to support coastal pilotage and enhance safety is under-utilised.
The coastal pilot training program and ongoing professional development is inadequate.
As a measure to assess the adequacy of the individual systems of coastal pilotage and pilot competency, the check pilot system is ineffective.
The operator had limited controls in place to manage the fatigue risk associated with early starts.
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.
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 warning systems in place to alert GWA staff as to the severity of a flood event at the Edith River Rail Bridge were ineffective.
GWA policies, procedures and training had little if any guidance for employees quantifying the duration, consequential dangers and responses to severe weather events.
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.
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.
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.
