The poor condition of much of the ship’s container lashing equipment indicates that the inspection and maintenance regime applied to this critical equipment had been inadequate.
Before the incident, Orica Australia had advised the Australian Maritime Safety Authority (AMSA) that their packaging method for the prills was fully compliant with the IMDG Code’s provisions. However, AMSA’s IMDG Code compliance audit regime had not detected that the method was not compliant.
At the time of the incident, there was no requirement for any third party to inspect or survey the fixed and loose lashing equipment on a ship. Had this been done, the maintenance and replacement regime of such equipment on board Pacific Adventurer might have been more effective.
The ammonium nitrate prills were not packaged in the containers in accordance with the requirements of the IMDG Code. The containers were packed in a way which allowed the prills to move within the container in a way that may have contributed to the failure of the containers and/or the lashing system.
The manufacturer’s maintenance manual did not include a requirement for the routine testing of the compressor high temperature alarm/shutdown.
River Embley’s planned maintenance system did not require routine testing of the compressor high temperature alarm/shutdown.
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 ‘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.
Atlantic Blue’s safety management system procedures did not require specific off-track limits to be included in the passage plan or otherwise ensure that limits for effective track monitoring were always defined.
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.
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.
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.
United Treasure’s permit to work aloft system had not been effectively implemented on board the ship. In addition, the standard form for the permit did not ensure that the officer in charge of the work and its authoriser were not the same person and that a risk assessment was formally undertaken by at least two responsible officers.
The tower was not assembled as designed. The outriggers and intermediate planks, both key components, were missing and the work platform guard rails were not used. The manufacturer’s instructions were also missing but no attempt was made to obtain them, a parts list or the missing parts.
While enclosed space entry checklists were being filled out by the crew members on board Bow De Jin, the checklist system was not being used as a proactive means to ensure that the necessary safety requirements were being met prior to tank entries.
The Job Hazard Analysis (JHA) for disconnecting from the CALM buoy did not provide an accurate assessment of the all of the hazards and associated risks in performing the task. In addition, the crew did not use it to assess the risks associated with undertaking an unfamiliar operation and it was reviewed without any involvement from the crew. Consequently, the JHA was not an effective means for assessing and controlling the risks associated with the operation of disconnecting from the CALM buoy.
The procedures for connecting and disconnecting the import hose and disconnecting from the CALM buoy in place on board Karratha Spirit were signed off as being satisfactory and reflecting shipboard practice, but they had not been effectively reviewed on board the ship. Consequently, the ambiguities in the procedures and the discrepancies between the procedures and the ship’s practices were not identified during any shipboard review or audit and were not made known to the ship’s managers through any review process.
In this instance, the consensus of the regulatory authorities is that Karratha Spirit was not in a navigable form at the time of the accident and was therefore under NOPSA’s jurisdiction according to the OPGGSA. However, the point at which Karratha Spirit became ‘navigable’ is not clearly defined in the OPGGSA and is open to interpretation.
