Punch marks were not made on the rail and documented with references to monuments at the 9 km mark following the realignment of track west of the Ashley Street rail bridge. This omission precluded the detection of rail creep that may have been present during the October 2008 maintenance inspection.
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.
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 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.
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.
There was the potential for the incorrect use of the dipstick to result in the over-reading of the fuel quantity.
Information contained in the approved flight manual and pilot's operating handbook was not applicable to the engine that was fitted to the aircraft.
The Registered Operator's maintenance control practices did not ensure compliance with all Airworthiness Directives.
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.
The galley drain operation and maintenance processes did not adequately prevent blockage and overflow of the aircraft’s drain lines.
Maintenance processes did not identify or correct the deterioration of the galley floor sealing
Maintenance processes did not identify or correct the corrosion in the generator control units.
The floor sealing around the forward galley was not of sufficient extent to prevent liquids from passing through to the under floor area.
The Aerial Agricultural Association of Australia suggestion that an additional hazard identification check be carried out prior to a cleanup run was not routinely practiced by the pilots, or monitored by the operator.
The aircraft operator’s documented design objectives did not explicitly require the protection of non-structural systems from liquid contact or ingress.
