NOPSA does not undertake the audits necessary for maritime compliance and AMSA is only able to do so, while the facility is on station, with NOPSA’s cooperation. NOPSA had carried out annual occupational health and safety inspections on board the ship and AMSA had carried out the necessary third party audits of the system to meet its certification requirements. However, none of these audits or inspections had identified the discrepancy between the mooring hawser procedures and actual shipboard practices or that the ship’s internal review processes had not identified the discrepancy.
The ship’s procedures for connecting and disconnecting from the CALM buoy did not provide explicit, succinct and unambiguous guidance and there were differences between the procedures and the actual shipboard practices that increased the level of risk associated with those operations
The Job Hazard Analysis (JHA) for disconnecting from the CALM buoy did not provide an accurate assessment of the all of the hazards and associated risks in performing the task. In addition, the crew did not use it to assess the risks associated with undertaking an unfamiliar operation and it was reviewed without any involvement from the crew. Consequently, the JHA was not an effective means for assessing and controlling the risks associated with the operation of disconnecting from the CALM buoy.
The procedures for connecting and disconnecting the import hose and disconnecting from the CALM buoy in place on board Karratha Spirit were signed off as being satisfactory and reflecting shipboard practice, but they had not been effectively reviewed on board the ship. Consequently, the ambiguities in the procedures and the discrepancies between the procedures and the ship’s practices were not identified during any shipboard review or audit and were not made known to the ship’s managers through any review process.
In this instance, the consensus of the regulatory authorities is that Karratha Spirit was not in a navigable form at the time of the accident and was therefore under NOPSA’s jurisdiction according to the OPGGSA. However, the point at which Karratha Spirit became ‘navigable’ is not clearly defined in the OPGGSA and is open to interpretation.
The servo valve within the left green aileron servo was incorrectly adjusted during manufacture.
The aircraft operator did not comply with the reporting requirements of the Transport Safety Investigation Act 2003.
Fatigue cracking originated within the aircraft nose landing gear (NLG) right axle as the result of surface damage associated with grinding during manufacture, and was probably assisted in its initiation by hydrogen evolved during plating processes.
The helicopter operator's induction checklist did not include the notation of instructors’ ratings and validity periods.
There were no specific training requirements for Robinson helicopters in Australia, such as those in Federal Aviation Administration Special Federal Aviation Regulation 73-2.
The CFM56-7B engine design was susceptible to VSV bushing and shroud wear that can lead to internal mechanical damage and potential in-flight performance difficulties.
The CFM56-7B engine had sustained bushing and shroud wear sufficient to cause rotor-to-stator contact, after a time in service that was less than the minimum threshold period specified by the manufacturer, for an initial inspection targeted at identifying this problem
The current advice in Civil Aviation Advisory Publication 5.81-1(0) Flight Crew Licensing Flight Reviews in relation to the assessment of navigation skills, represents a missed opportunity to identify a pilot's capacity to make safe and appropriate decisions during cross country flying.
The flight planning requirements at page 88 of the Visual Flight Guide included a transcription error that inadvertently limited the application of the requirements of Civil Aviation Regulation 239.
There was no Australian requirement for endorsement and recurrent training conducted on Robinson Helicopter Company R22/R44 helicopters to specifically address the preconditions for, recognition of, or recovery from, low main rotor RPM.
There was a lack of assurance that informal operator supervisory and experience-based policy, procedures and practices minimised the risk of pilots operating outside the individual pilot’s level of competence.
