Published on Australian Maritime Safety Authority (

Safety Lessons from Marine Incident Investigation (AMSA Report) – No.7 – May 2022

Passenger sustains injury from poorly rigged gangway.


Strong northerly winds and high tide caused a berthed class 1D passenger vessel, which was taking on passengers at the time, to move transversely in and out of the berth resulting in the slackening of mooring lines. The gangway which was not properly rigged to the vessel deck slipped off the deck injuring a passenger.

What happened

At about 1020 on 27 June 2021, the Master of a class 1D passenger vessel was on the jetty checking passengers in, due to the crew being short-handed that day. All other crew members were occupied with loading duties. Normally, given the prevailing strong northerly wind blowing the vessel away from the berth, the Master would be in the wheelhouse to keep the engine in gear and push the vessel up hard alongside the berth. The vessel moved transversely in and out of the berth and, whilst loading passengers, the end of the gangway slipped off the vessel. The gangway was then at an incline, being supported by the steps in the recess on the quay only. Five passengers were on the gangway at the time. The passenger nearest the vessel fell over injuring their foot but did not fall into the water. This passenger received medical treatment for injuries to their foot and back.

Investigation findings

The investigation identified the following contributory factors:

Safety message

Masters/operators of passenger vessels need to maintain situation awareness of the dynamic nature of potential risks to safety that bad and deteriorating weather can bring.

Given the prevailing wind conditions and high tide in this situation, taking the time to identify and mitigate against the risks to the mooring lines loosening and gangway movement would have ensured a safer outcome.

The safety management system is a document where the nature of operational risks and the actions required to mitigate their impact is captured for a vessel and understood by all crew members. Regular crew training on safety management system is essential for continued vessel safety.

Links to safety information on this topic

Safe access to moored domestic commercial vessels (

NT WorkSafe: Safe Access/Egress to Marine Vessels in Port

Last updated: 25 May 2022