Patrick Terminals’ hazard identification process had not identified the dangers of working near or under containers being loaded.
The culture which existed in the Patrick terminal did not encourage the reporting of non-compliances or unsafe acts. Consequently, two critical parts of an effective safety system, which had a direct impact upon its ability to effectively manage safety in the terminal, the ‘reporting’ culture and the ‘just’ culture, were either not present or were misunderstood in Patrick’s safety system.
Ta Ann Tasmania did not follow the recommendations contained in section 2.3 of Appendix A of the International Maritime Organization’s Code of Safe Practice for Ships Carrying Timber Deck Cargo when they packaged the timber veneer for shipment by sea.
Mimasaka’s cargo securing manual did not contain any information relating to the stowage and securing of timber veneer.
The Operation Manual for Loading and Lashing of Tasmanian/Malaysian Dry Veneer, developed by NYK-Hinode Line for use by ships carrying timber veneer, did not contain any information relating to the stowage and securing of the timber veneer cargo on deck.
The instructions that were emailed to Mimasaka’s master by NYK-Hinode Line did not provide the crew with proper guidance about how to stow and secure the packs of timber veneer on deck.
The Australian Maritime Safety Authority had not inspected the packs of veneer to establish whether Ta Ann Tasmania was packaging the veneer in line with the recommendations contained in section 2.3 of Appendix A of the International Maritime Organization’s Code of Safe Practice for Ships Carrying Timber Deck Cargo.
Prior to 2 February 2011, the crew had encountered problems with the lifting wire jamming in the head of the davit when the bucket was hoisted too high. However, nothing had been done to prevent it from happening again in the future.
The training provided to the crew did not ensure they were familiar with the function or operation of the wave compensator or its safety interlock
Davit International’s fast rescue boat davit manual did not provide sufficient guidance for the crew in the operation of the wave compensator and its safety interlock
It was found that the safety interlocks on the wave compensator systems on board British Sapphire, British Emerald and British Ruby had been electrically by-passed thereby preventing the safety interlocks from functioning.. As a result, the wave compensators on board all three ships could be engaged regardless of whether the fast rescue boats were waterborne or suspended from the fall wire
Training institutions delivering approved STCW courses are not keeping up to date with the introduction of wave compensation units to ensure their courses provide students with the required knowledge to safely operate these units
British Sapphire’s fast rescue boat davit procedures did not provide sufficient guidance for the crew in the operation of the wave compensator
The planned maintenance system on board British Sapphire did not detail a procedure for a recommissioning test following maintenance on the fast rescue boat davit. As a result, any recommissioning test that was done after on board maintenance had not identified the issue with the wave compensator safety interlock prior to the incident.
There was no evidence to indicate that the operation of British Sapphire's (or its sister ships) fast rescue boat davit’s wave compensator and safety interlock had been sufficiently tested at the time of the ship's delivery to ensure safe operation
The job hazard analysis for the operation of the fast rescue boat was incomplete and did not include an assessment of the hazards associated with the operation of the wave compensator
The crew did not use resource management principles to ensure that they had a shared mental model of the task that they were carrying out. As a result there was confusion amongst the various crew members as to their roles and responsibilities at the time of the incident
The planned maintenance system on board British Sapphire did not include a specific requirement to maintain or test the wave compensator or its safety interlock on the fast rescue boat davit. As a result, the crew had not identified the issue with the wave compensator safety interlock during periodic maintenance.
Global Supplier was not fitted with the correct navigational lights for a vessel engaged in towing operations.
