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 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.
Electrical enclosures in MPV Everest's engine rooms allowed the ingress of fuel into the enclosures and did not meet the responsible classification society fluid ingress protection standards intended to reduce the associated risk of harmful effects and damage.
While fire drills conducted on board MPV Everest exceeded the minimum number required by regulations, none practised an engine room fire, nor was there was any evidence of onboard training and instruction being provided in the use of the engine room water mist fixed fire‑extinguishing system. Consequently, several crew members were unfamiliar with the operation of the system and opportunities to evaluate the ship's emergency preparedness and remedy areas in need of improvement were lost.
The illumination of the joystick steering panel’s ‘joystick on’ light indicated which panel was selected (or last selected) for use and bore no relation to the steering mode selected. This increased risk as it was misleading and contrary to the understanding of the ship’s officers who believed that the illumination of the light was only possible when the joystick steering mode was selected.
Neither the master nor the second mate had undertaken required bridge resource management training. This probably contributed to the ineffective implementation of bridge resource management on board, which resulted in the single person errors that contributed to this accident not being detected.
On board routine inspection and maintenance of fixed cargo securing devices on APL England was ineffective. Over an extended period of time, the significant proportion of the devices that were unfit for purpose were not identified and made good.
A significant proportion of the fixed cargo securing devices on the deck of APL England were in poor condition. The heavy wastage of the devices significantly reduced their load carrying capacity and compromised the effective securing of cargo.
The insecure loading of high cube containers into bay 62 was contrary to the ship's cargo securing manual and not identifiable by the cargo computer software in use at the time. Consequently, forces generated during the heavy rolling resulted in dislodging of all containers above the cell guides and the loss of 16 overboard.
BBC Rhonetal’s managers had not effectively implemented the shipboard safety management system procedures in place to prevent the fire. This was the tenth such fire on a company ship in the past 14 years, and the fourth investigated by the ATSB, identifying similar contributing factors.
Regulatory safety oversight of Iron Chieftain, which comprised flag State audits, surveys and inspections had not identified safety deficiencies with respect to the ship’s fire safety, risk management, emergency preparedness and emergency response.
