I think it is the classic Swiss cheese model for how accidents are allowed to happen. Policy and procedures are developed to try and ensure that all the holes never align and thus prevent incidents such as this happening, but;
Land Cruiser hand brakes have never been the best, this one by all accounts is basically a rental that does (well, did) the Fraiser run
a lot so it is a fair bet maintenance wasn't a terribly high priority.
Barge working to do as many trips as it can in peak season, so they cut a few corners to increase the trips they can do in a day.
Weather is calm and the trip across the channel is only a short one, so fewer precautions are taken.
Old mate deckie didn't lift the ramp as high as he should or hook the safety chain across as it slows down the cycle times.
The driver of the Cruiser leaves it out of gear, probably with the motor running and the air con cranking because it was so bloody hot.
Driver is probably inexperienced and probably isn't aware of the idiosyncrasies of the vehicle.
Ferry accelerates and hits a small rolling swell.
All the holes align and conspired to create a small artificial reef.
http://andrew.mcgiffert.id.au/blog/reasons-organisational-model-of-system-accidents/And Yes, the Master and the Mantaray crew will have a long chat with the transport inspectors and probably Workcover.
Yes, the driver
should have secured the vehicle, but you are driving into their workplace, so they have a duty of care to ensure that the passengers make it across to the island (regardless of teh disclaimer on the ticket) and recorded procedures on how they will achieve that.
Deviations from or omissions of procedures just to speed up cycle times is really frowned upon as the reason they have been adopted in the first place is for safety. Most times people have died or been injured learning those lessons in the first place.
It is a bit of an inconvenience that a bunch of wallets went to the bottom, but only by the grace of god that it wasn't a wagon with a kid or two asleep and strapped into their child seats. It certainly counts as a near miss in my book, especially as it is a direct result of not following procedures. This shot is a dead giveaway.
