Atlantic Blue’s safety management system procedures did not require specific off-track limits to be included in the passage plan or otherwise ensure that limits for effective track monitoring were always defined.
The ‘shallow water alert’ generated by the Great Barrier Reef and Torres Strait Vessel Traffic Service’s (REEFVTS) monitoring system did not provide adequate warning of Atlantic Blue entering shallow water because the boundary of the defined shallow water alert area was too close to dangers off Kirkcaldie Reef.
The REEFVTS monitoring system did not provide an ‘exiting corridor alarm’ when Atlantic Blue exited the two-way route that it was transiting because the route had not been defined as a navigational corridor.
Petra Frontier’s safety management system contained procedures outlining how fire and abandon ship drills should be carried out in accordance with SOLAS and Marshall Islands requirements. However, it also contained a drill schedule that provided some contradictory information.
The Registered Operator's maintenance control practices did not ensure compliance with all Airworthiness Directives.
While Petra Frontier had undergone an initial flag State inspection on 4 May 2009 and routine class surveys, the most recent being a class survey completed on 12 August 2009, neither authority was aware that the ship was unseaworthy in relation to critical safety equipment when it departed Singapore.
There was the potential for the incorrect use of the dipstick to result in the over-reading of the fuel quantity.
Information contained in the approved flight manual and pilot's operating handbook was not applicable to the engine that was fitted to the aircraft.
The galley drain operation and maintenance processes did not adequately prevent blockage and overflow of the aircraft’s drain lines.
Maintenance processes did not identify or correct the corrosion in the generator control units.
The floor sealing around the forward galley was not of sufficient extent to prevent liquids from passing through to the under floor area.
The location of the decompression panel and absence of cabin floor sealing above the main equipment centre increased the risk of liquid ingress into the aircraft’s electrical systems.
The priority level of the battery discharge messages that were provided by the engine indicating and crew alerting system did not accurately reflect the risk presented by the battery discharge status.
Maintenance processes did not identify or correct the deterioration of the drip shield.
The removal of fluid quantity markings from, and unapproved modifications to the helicopter’s spray tank by the operator increased the risk of overweight operations
The Aerial Agricultural Association of Australia suggestion that an additional hazard identification check be carried out prior to a cleanup run was not routinely practiced by the pilots, or monitored by the operator.
