The engine manufacturer’s documents with respect to the propeller mounting flange were technically inconsistent with regard to painting and torqueing procedures.
Jabiru engines manufactured before July 2011 have reduced strength and reliability of the crankshaft/propeller flange joint, compared with the later design that incorporated positive location dowel pins.
Track walking inspections were not conducted at intervals specified by V/Line’s maintenance program
V/Line's track inspection regime did not identify the degraded condition of the mechanical rail joints.
The instructions relating to the arranging of refuelling at Parkeston contained in the Pacific National train management plan and the intermodal procedures manual were inconsistent.
The gantry crane in motion warning light nearest to the assistant electrician’s location was not operating and the warning sirens were not audible from his location. As a result, he was not provided with either a visual or audible warning of the crane’s movement.
There was a lack of mapping information available to assist the ‘triple zero’ operator in providing the emergency responders with directions to a defined location within the port area.
The on board familiarisation process did not ensure that new crew members were informed of the precautions required when working on deck while the gantry cranes were in operation.
West Coast Wilderness Railway had not developed and implemented a specification for the design, fitment and safety performance of road-rail vehicle rail guidance equipment.
The West Coast Wilderness Railway did not have documented radio communication procedures and their staff were not trained in the use of radios. As a result, radio protocols were not formalised and communications were ad hoc and casual in nature.
The training provided to the West Coast Wilderness Railway road-rail vehicle operators did not identify and incorporate local specific training requirements, such as operating on very steep grades and the use of radios.
Rinadeena Station was the only emergency meeting point between Queenstown and Strahan and the only road access point on the rack between Halls Creek and Dubbil Barril. However, the Rinadeena Station radio was not maintained in a serviceable state at all times.
The West Coast Wilderness Railway did not have a documented process of testing road-rail vehicles.
The Genesee and Wyoming Australia safety management system procedures did not provide supervising and trainee drivers with sufficient guidance or direction as to the extent of their supervisory or permitted driving roles.
Calliope’s safety management system (SMS) did not provide the crew with adequate guidance regarding passage planning, training and familiarisation. Individual crew familiarisation records and risk assessment forms were not retained on board the yacht and there was no system of auditing or checking to ensure the adequacy of the SMS or the effectiveness of its implementation.
The Cayman Islands requirements in relation to a yacht’s compliance with the Large Commercial Yacht Code and other relevant legislation are determined by the yacht’s mode of operation. As a result, a commercially operated yacht in excess of 24 m in length must comply with the requirements of the Code while a similar sized privately operated yacht that poses the same risks to safety of life at sea and the environment does not.
Calliope was not required to carry a pilot during Sydney Harbour voyages because the yacht was considered to be a recreational vessel, even though the risks it posed to the port were the same as those posed by similarly sized commercially operated vessels.
There were no facilities on board the Floating Offshore Transfer Barge Spencer Gulf that could be used to provide a safe means of access for personnel transfers between the barge and the ship. Furthermore, the barge operator’s procedures prohibited such personnel transfers.
Whyalla Launch Services’ safety management system did not provide effective guidance in relation to assessing a passenger’s ability to climb a pilot ladder or positioning of pilot launches while passengers were climbing and descending ladders. The system also referenced superseded SOLAS regulations and IMO resolutions relating to pilot ladders.
Atlantic Princess’s safety management system provided no guidance relating to actions that should be taken when persons less experienced than a pilot used a pilot ladder to board or disembark the ship.
