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Safety Lessons from Marine Incident Investigation (AMSA Report) No.22 - October 2023

Passenger vessel flooded after access door was left open.

Overview 

A passenger ferry was returning from its scheduled service when an unanticipated wave raised its stern and caused its bow to dive under the water. Water rushed over the bow and a significant amount came through the forward portside access door and into the passenger compartment. The master immediately reduced speed, which expelled most of the water overboard.  

The forward portside access door had been left open by a crew member who was attempting to alleviate sea sickness among some passengers. The action of leaving the door open during the voyage was contrary to the vessel’s survey requirements. Signage requiring the door to be kept closed when underway was reportedly not seen by crew members. This resulted in water entering the vessel creating a potentially unsafe situation.  

What happened 

At about 14:45, a Class 1 vessel was ferrying passengers back to its city quay on a scheduled service. This service was busier than usual as it was covering for an unavailable service. The conditions were reported as about 1.25 to 2.5m wave height with the vessel speed about 20 knots.  

A significant amount of water entered the vessel over the bow and through the open forward portside access door. The master stated that conditions at one point were such that the stern of the vessel lifted out of the water higher than expected, pushing the bow lower in the water. 

The water ingress lasted 10 seconds in total. There were no injuries to passengers or crew and subsequent inspection identified no damage to the vessel. A crew member had left the access door open to alleviate passenger sea sickness, which allowed water to enter the vessel. 

Signage was in place above the forward portside door, cautioning crew that the door was to remain closed ‘when underway’. The crew member reported having not seen the signage. The action of leaving the forward portside access door open during the voyage was contrary to the vessel’s survey requirements and the master was not aware that the crew member had left it open. 

Investigation findings 

The investigation identified the following contributory factors: 

  • A review of crew member induction records identified that crew members were made aware of the location of the vessel’s safety management system (SMS), however they were unlikely to know all the requirements in the SMS unless provided with guidance from master/s. 
  • The master’s handling of the sea state was deemed to be within acceptable parameters. However, the master had been recently certified competent and was new to the vessel, which may have impacted vessel handling.  

The company was advised to consider putting in place risk control measures to ensure doors remain closed, including the installation of sensors with visual/audible alarms in the wheelhouse monitored by the master/crew, and signage on the door at a suitable visual height.

Safety message 

Owners must ensure that all crew, including new employees, are provided appropriate training on the vessel’s SMS and understand the practical application and their responsibilities in relation to this. This requirement is addressed in s6D, Schedule 1 of Marine Order 504 - onboard induction, familiarisation, and training.  

Owners must ensure that crew also understand the vessel’s certificates of survey and any conditions in which the vessel is operating under.  

Safety information on this topic 

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

Certificates of Survey (CoS) 

Last updated: 

Tuesday 5 December 2023