The pilotage system used by Atlantic Blue’s pilot did not define off-track limits or make effective use of recognised bridge resource management tools in accordance with the Queensland Coastal Pilotage Safety Management Code and regular assessments of his procedures and practices under the code’s check pilot regime conducted over a number of years had not resolved these inconsistencies.
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.
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.
Information contained in the approved flight manual and pilot's operating handbook was not applicable to the engine that was fitted to the aircraft.
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.
The Registered Operator's maintenance control practices did not ensure compliance with all Airworthiness Directives.
There was the potential for the incorrect use of the dipstick to result in the over-reading of the fuel quantity.
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 aircraft operator’s documented design objectives did not explicitly require the protection of non-structural systems from liquid contact or ingress.
The operator’s flight crew quick reference handbook did not include sufficient information for flight crew to manage the emergency.
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.
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.
Maintenance processes did not identify or correct the deterioration of the galley floor sealing
Maintenance processes did not identify or correct the corrosion in the generator control units.
The United States Federal Aviation Administration regulations and associated guidance material did not fully address the potential harm to flight safety posed by liquid contamination of electrical system units in transport category aircraft.
ATSB comment
