Safety Lessons from Marine Incident Investigation (AMSA Report) No.20 - July 2023

Poor risk assessment contributes to charter vessel running aground.


A charter vessel with passengers was conducting a cruise around Sydney Harbour when it narrowly missed an unlit runabout at night. The vessel ran aground, and two attempts to tow the vessel off the sandbank were unsuccessful.

The investigation found that the master did not risk-assess the route and respective conditions. The vessel safety management system provided the master with no clear direction on safe routes to follow. The command, control, and communication with and between the crew in relation to emergency procedures and response was ineffective. 

What happened 

On 29 January 2022, a 1E vessel was chartered for a birthday party cruise around Sydney Harbour with 77 passengers, 4 hospitality/security staff and 3 crew onboard.

About 21:50, the charter was heading east at about 4 knots southwest of Cockatoo Island when the master stated they saw a runabout with no navigation lights approaching from starboard. The master put the engines astern and steered to starboard to avoid collision. Due to 15 knot winds from the northeast, the vessel’s bow was pushed around and missed the runabout.

The master went starboard ahead and port rudder to avoid known sandbanks but ran aground at a speed of approximately 2 knots. The master put the engines astern, however, the vessel was stuck fast. The tide was midway through its ebb.

The master briefed the crew and passengers, and lifejackets were donned as a precaution. Sydney Vessel Traffic Service was alerted, and a Sydney Marine Area Command vessel attended to assist.

Two attempts were made to tow the vessel from its position but failed. All passengers were transferred onto a sister vessel without incident and nil injuries. The vessel was re-floated at 04:30 the following morning and returned to its berth for inspection.  

Investigation findings 

The investigation identified the following contributory factors: 

  • The master did not understand the risks involved in navigating the vessel to a windward position on a lee shore in narrow channel close to a known shallow reef in 15 knots of wind.  
  • The owner did not include in the vessel’s safety management system areas to be avoided and left this decision at the master’s discretion. 
  • The command, control, and communication during the passage and emergency response was poorly executed. The crew were undertaking hospitality duties instead of assisting with safe navigation of the vessel. Crew were casually employed and had not worked together often. Radios were not in use and the crew had to yell to each other between decks. Crew did not report to the master until nearly 5 minutes post incident and one crew member thought the vessel was sinking, creating panic amongst passengers before this was clarified by the master. The PA system needed to be connected via the DJ booth to make announcements to passengers and operations were conducted in darkness. 

Safety message 

This near-miss of the runabout and subsequent grounding highlights the importance of clear risk assessments, procedures, inter-crew communication and understanding of roles and responsibilities in emergency response situations. 

Whilst the grounding was a reportable marine incident, near-miss incident reports can also provide valuable data and opportunities to discuss safety management system related topics with industry, and these are encouraged along with reporting of incidents which have resulted in impact. 

Safety information on this topic 

Marine Order 504 – certificates of operation and operation requirements – national law

Last updated: 

Tuesday 29 August 2023