The Pilbara Ports Authority's port user guidelines and procedures did not reflect the best practice escort towage guidance detailed in the port's draft escort towage strategy and business continuity plan. The detail of these improved towage practices, designed to reduce the risk of channel blockages, were also not integrated into the Port Hedland Pilots' safety management system and were consequently, inconsistently applied by pilots.
Although Hagen Oldendorff’s steering and rudder angle indicator systems complied with the applicable rules and regulations, neither the SOLAS regulations, nor the rules of the ship’s responsible classification society, Lloyd’s Register, mandated protection of the ship's rudder angle indication systems against a single point of failure in power supply, nor did they require installation of audible or visual alerts to notify the bridge team of a power failure affecting the indicators.
Response by the Liberia Maritime Authority
Although Hagen Oldendorff’s steering and rudder angle indicator systems complied with the applicable rules and regulations, neither the SOLAS regulations, nor the rules of the ship’s responsible classification society, Lloyd’s Register, mandated protection of the ship's rudder angle indication systems against a single point of failure in power supply, nor did they require installation of audible or visual alerts to notify the bridge team of a power failure affecting the indicators.
Response by Australian Maritime Safety Authority
Although Hagen Oldendorff’s steering and rudder angle indicator systems complied with the applicable rules and regulations, neither the SOLAS regulations, nor the rules of the ship’s responsible classification society, Lloyd’s Register, mandated protection of the ship's rudder angle indication systems against a single point of failure in power supply, nor did they require installation of audible or visual alerts to notify the bridge team of a power failure affecting the indicators.
Response by Lloyd’s Register
The Pilbara Ports Authority's port user guidelines and procedures did not reflect the best practice escort towage guidance detailed in the port's draft escort towage strategy and business continuity plan. The details of these improved towage practices, designed to reduce the risk of channel blockages, were also not integrated into the Port Hedland Pilots' safety management system and were, consequently, inconsistently applied by pilots.
Regional Express did not provide flight crew or ground crew recurrent training to review the hand signals required to communicate with each other, including those used in an emergency.
Rex did not ensure its flight crews received training in the differences between passenger and freight‑configured Saab 340 aircraft, prior to being scheduled to fly freight operations.
The Pel-Air and Rex Saab 340 flight crew operating manuals did not include reference to the location and operation of the cross-valve handle or smoke curtain.
Saab did not include the smoke curtain fitment in pre-flight documentation for the cargo‑configured Saab 340 aircraft to inform flight crew of this difference from the passenger‑configured version.
Australian states and territories that engage in Large Air Tanker (LAT) operations have developed their own separate standard operating procedures (SOPs) for LATs and aerial supervision assets. This can result in safety requirements being omitted or misunderstood by the different tasking agencies, such as a minimum drop height, resulting in inconsistencies in the development and application of LAT SOPs.
The Coulson Aviation crew resource management practice of limiting the pilot monitoring (PM) announcements to deviations outside the target retardant drop parameter tolerances increased the risk of the aircraft entering an unrecoverable state before the PM would alert the pilot flying.
Coulson Aviation and the relevant Western Australian Government Departments had not published a minimum retardant drop height in their respective operating procedures for large airtankers. Consequently, the co-pilot (pilot monitoring), who did not believe there was a minimum drop height, did not alert the aircraft captain (pilot flying) to a drop height deviation prior to the collision.
Coulson Aviation and the relevant Western Australian Government Departments had not published a minimum retardant drop height in their respective operating procedures for large airtankers. Consequently, the co-pilot (pilot monitoring), who did not believe there was a minimum drop height, did not alert the aircraft captain (pilot flying) to a drop height deviation prior to the collision.
The Coulson Aviation practice of recalculating the target retardant drop airspeed after a partial drop reduced the post-drop stall speed and energy‑height safety margins.
Sydney Trains Security Control Centre Standard Operating Procedure contained conflicting instructions on incident response, which were not aligned with the Sydney Trains Network Incident Management Plan (NIMP).
Sydney Trains Security Control Centre Operator was not alerted to tampering of the cameras at Kembla Grange Station that monitored the West Dapto Road Level crossing.
Maritime Safety Queensland (MSQ) did not have structured or formalised risk or emergency management processes or procedures. Consequently, MSQ was unable to adequately assess and respond to the risks posed by the river conditions and current exceeding operating limits and ensure the safety of berthed ships, port infrastructure or the environment, and avoid CSC Friendship’s breakaway.
Poseidon Sea Pilots’ (PSP) safety management system for pilotage operations did not have procedures or processes to manage predictable risks associated with increased river flow or pilotage operations outside normal conditions. This, in part, resulted in PSP not considering risks due to the increased river flow properly and not taking an active role until after the breakaway.
Ampol’s assessment of risk to the ship and facility did not consider water speed in excess of the design and safety limits for the ship and berth mooring arrangements.
Maritime Safety Queensland (MSQ) did not have structured or formalised risk or emergency management processes or procedures. Consequently, MSQ was unable to adequately assess and respond to the risks posed by the river conditions and current exceeding operating limits and ensure the safety of berthed ships, port infrastructure or the environment, and avoid CSC Friendship’s breakaway.
