The ship’s safety management system did not contain procedures or guidance on the proper use of GPS route plans and their relationship to the ship’s passage plans.
There was no effective fatigue management system in place to ensure that the bridge watch keeper was fit to stand a navigational watch after the loading in Gladstone.
In the 30 minutes leading up to the grounding, there were no visual cues to warn either the chief mate or the seaman on lookout duty, as to the underwater dangers directly ahead of the ship.
At the time of the grounding, the protections afforded by some of the measures currently employed in the more northern sections of the GBR were not in place in the sea area off Gladstone.
At separate pre-work briefings, there was no discussion about train running information and site protection between the Supervisor (Excavators) and the Supervisor (Track Machines).
The communications equipment available to the Supervisor (Excavators) was inadequate to effectively communicate with the Supervisor (Track Machines) and with the drivers of the track mounted excavators between Darrine and Jaurdi.
Installation of new cargo door seals resulted in the cargo door being held outside of the flushness requirement specified in the aircraft maintenance manual
There were no criteria for assessing the potential wind impact of aerodrome building developments on aircraft operations.
Two buildings were constructed north of the runway 12 threshold at a height and position that could generate turbulence affecting the approach, threshold and touchdown areas of the runway under some wind conditions.
The limited consideration of the potential wind impact of the two buildings to the north of runway 12 during northerly wind conditions has resulted in continued operations to that runway in those conditions without any alert to affected pilots about the associated risk.
The lack of both flight data and cockpit voice recorders adversely affected a full understanding of the accident by the investigation.
There was no qualified Director (or similar) of Aviation Medicine in Papua New Guinea (PNG) that could enhance the administration of the PNG aviation medical regime.
The operator did not have a published emergency recovery procedure for application in the case of inadvertent flight into instrument meteorological conditions.
The lack of a reliable mandatory occurrence reporting arrangement minimised the likelihood of an informed response to Papua New Guinea specific safety risks.
