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 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.
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
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
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
Training institutions delivering approved STCW courses are not keeping up to date with the introduction of wave compensation units to ensure their courses provide students with the required knowledge to safely operate these units
British Sapphire’s fast rescue boat davit procedures did not provide sufficient guidance for the crew in the operation of the wave compensator
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
Material characteristics of some the LPT blades installed in engine 858322 were consistent with a raw material manufacturing cast that had previously been identified as being susceptible to creep rupture
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.
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.
The operator did not have a procedure in place to ensure independent cross-checking of the helicopter's fuel quantity.
The wheel bearings on train 2224, consist BT22, were only being monitored in-service by periodic inspections, roll-bys, and hot box detections. These measures were ineffective in detecting the failure of the bearing on train 2224 before it led to the derailment.
All limestone bulk hopper wagons have been operated up to 15 km/h higher than speeds specified in the Train Operating Conditions Manual, when loaded above 92 t and operated on class 1 or 1C track.
Ambiguity existed between the Manual of Air Traffic Services and the Aeronautical Information Publication in relation to the assignment of non-standard cruising levels and the definition of an ‘operational requirement’.
The controller had not received training in compromised separation recovery techniques.
Moorabbin GAAP airspace design did not assure lateral or vertical strategic separation between traffic flows. This increased the risk of a mid-air collision.
