Patrick Terminals had no formalised policy in place to provide clear guidance to its stevedoring employees about where they could or could not work on a ship when cargo was being loaded or discharged.
Patrick Terminals’ hazard identification process had not identified the dangers of working near or under containers being loaded.
The implementation of Patrick Terminal’s safety management system resulted in an environment where Patrick Terminal management and stevedores were disconnected in relation to the management of some of the day-to-day workplace safety risks. As a result, there was little ownership of the safe work instructions by the stevedores, and some of the more experienced stevedores were probably no longer aware of the risks posed to them when they undertook unsafe ‘workarounds’ in the workplace and these were not identified by Patrick management.
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.
The recognised safe practices of not working under or near a container being loaded is not well reflected in national and international guidance published to assist container terminal operators develop their own safety policies and guidelines.
Although passengers are routinely advised after takeoff to wear their seat belts when seated, this advice typically does not reinforce how the seat belts should be worn.
There was a limitation in the algorithm used by the A330/A340 flight control primary computers (FCPCs) for processing angle of attack (AOA) data. This limitation meant that, in a very specific situation, multiple spikes in AOA from only one of the three ADIRUs could result in a nose-down elevator command.
The existing take-off certification standards, which were based on the attainment of the take-off reference speeds, and flight crew training that was based on monitoring of and responding to those speeds, did not provide crews a means to detect degraded take-off acceleration.
A number of operators of the PZL M-18 Dromader aircraft had not applied the appropriate service life factors to the aircraft’s time in service for operations conducted with take-off weights greater than 4,700 kg, as required by the aircraft’s service documentation. Hence the operators could not be assured that their aircraft were within their safe service life.
Operation of the M-18A in accordance with Civil Aviation Safety Authority exemptions EX56/07 and EX09/07 at weights in excess of the basic Aircraft Flight Manual maximum take-off weight (MTOW), up to the MTOW listed on the Type Certificate Data Sheet, may not provide the same level of safety intended by the manufacturer when including that weight on the Type Certificate.
The lack of a designated position in the pre-flight documentation to record the green dot speed precipitated a number of informal methods of recording that value, lessening the effectiveness of the green dot check within the loadsheet confirmation procedure.
The operator’s training and processes in place to enable flight crew to manage distractions during the pre-departure phase did not minimise the effect of distraction during safety critical tasks.
The failure of the digital flight data recorder (DFDR) rack during the tail strike prevented the DFDR from recording subsequent flight parameters.
The lack of a requirement for a charter-specific risk assessment in this case meant that the risks associated with the charter were not adequately addressed.
The procedural and guidance framework for commercial balloon operations generally, did not provide a high level of assurance in regard to the safe conduct of low flying.
The Society of Automotive Engineers specification AS7477 was ambiguous in relation to the requirement to cold roll the head-to-shank fillet radius of MS9490-34 bolts.
A number of non-cold rolled bolts were installed on PT6A-67 series engines during manufacture and overhaul
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.
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.
