Safety Lessons from Marine Incident Investigation (AMSA Report) No.10 – August 2022

No risk assessments and gate design results in passengers overboard.


On 6 November 2021, while enroute, a passenger charter (Class 1E) vessel’s inadequately secured swim platform gate opened when a passenger and toddler leant against it causing the two passengers to fall into the water. The investigation identified that there was no locking bolt on the gate, no risk assessments and no passenger verification procedures in place.  

What happened 

On 6 November 2021, a passenger charter vessel was privately hired for a twilight cruise around Sydney Harbour. There were 19 passengers onboard comprising adults and some children. The vessel had anchored to serve the passengers food and drink and then, around 1930, weighed anchor to continue the harbour cruise. The vessel cruised at six knots; the weather was good & the sea was calm. 

The master monitored passenger movement from the pilot house helm station via CCTV cameras. While the vessel was underway the master saw on a monitor a passenger holding a toddler walk from the aft deck to the swim platform. Approximately 30 seconds later, the master looked back at the monitor and saw the double gate at the stern of the vessel wide open and the passengers on the swim platform could not be seen. The master turned and looked astern and saw persons in the water 80-100 metres astern. 

The master quickly put the engines in neutral and told the crew there were persons overboard (POB) off the stern. The crew raced to the back deck where the master transferred to cockpit controls, reversing towards the POB. As the vessel approached the POB the master put the engines in neutral to safely drift up to the POB. The vessel was about 10 metres away when without warning the toddler’s mother jumped into the water also. The three POB were retrieved successfully on board. The vessel made its way back to Mosman Bay where an ambulance tended to the POB. No injuries were reported.  

Investigation findings 

The investigation identified the following contributory factors: 

  • The adult POB is assumed to have leant against the gate and it opened due to their body weight. The double gate on the swim platform had not been properly secured shut with the locking bolt prior to departure and was only held shut by a ‘flap’ cover. The gate could open both inwards and outward with no safety ‘stop’ preventer either way.  
  • A review of the vessel’s Safety Management System (SMS) identified deficiencies relating to risk assessments and passenger verification procedures. 

Following this incident, the operator engaged a fabricator to redesign the gates to prevent them opening outwards.  

Safety message 

Operators and masters of passenger charter vessels need to ensure their SMS have adequate risk assessments and procedures to cover the risks to safety of their operations. In this incident, with adults and children onboard without lifejackets, the swim platform gates were inadequately secured which presented a safety risk. Risk assessments in SMS must identify procedures to mitigate all identifiable risks to passenger safety that must be reduced to as low a level as possible. 

Last updated: 26 August 2022