Documentation supporting the training and competency assessment of launch coxswains was limited in detail and training records were incomplete.
The safety management system for Corsair did not include detailed guidance and reference material for the safe navigation of Port Phillip Heads, the effective use of launch navigational equipment and the role of the launch deckhand in supporting safe navigation.
The ship's managers' (CMA CGM) safety management system procedures and guidance for steering gear operation across its fleet were ambiguous and did not clarify the different terminology to those commonly used by the industry. This increased the risk of incorrect configuration of the steering gear, which occurred on board CMA CGM Puccini.
Maritime Safety Queensland and Poseidon Sea Pilots did not have a process to jointly and effectively identify and risk assess the hazards to shipping and pilotage that were outside normal environmental conditions.
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.
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.
The check pilot system was ineffective in providing the Australian Maritime Safety Authority (AMSA) assurance of the competency of coastal pilots, mainly due to the inconsistent and unreliable application of assessment standards between different check pilots. Further, AMSA had not implemented a system to identify the inconsistent application of standards or the trends in assessment outcomes readily apparent in the data that it had held for many years.
Response by the Australian Maritime Safety Authority
The Australian Antarctic Division's pre-charter due diligence arrangements were ineffective at accurately assessing the suitability and level of preparedness of MPV Everest, its crew and its safety management system for operations in Antarctica.
MPV Everest's safety management system (SMS) was neither sufficiently mature for its operations nor had it been implemented effectively or consistently on board the ship at the time of the fire. Further, safety oversight by Fox Offshore, the ship’s managers, had not been effective in monitoring and ensuring compliance with the SMS.
MPV Everest’s managers at the time of the fire, Fox Offshore, had not ensured that the ship was adequately manned, equipped or prepared for the hazards of operations in the Southern Ocean and Antarctica.
Bureau Veritas’ (the classification society responsible) design approval processes had not identified any potential risks associated with the positioning of the fuel oil settling tank air vent pipe termination within MPV Everest's engine room ventilation casing. Consequently, it approved this design and siting of the air vent pipe that, in concert with other contributing factors, resulted in overflowing fuel from the pipe being directly introduced into the ship’s machinery spaces.
Inconsistent, incorrect or missing information related to aspects of MPV Everest’s water mist fixed fire-extinguishing system, including the spaces covered by the system and its design/operation, in multiple ship’s documents increased the risk of the crew incorrectly responding to a fire.
The engine room water mist fixed fire-extinguishing system on board MPV Everest was incorrectly installed. This increased the risk of an ineffective response in the event of a bilge fire.
