Safety Lessons from Marine Incident Investigation (AMSA Report) No.26 – March 2024

‘Experience’ fails to prevent vessel capsize, which a proper risk assessment could have identified


A powered barge with a mounted crane became unstable and capsized in 3.5 metres of water during lifting operations of a concrete structure. The master exceeded the crane’s operating limits. There was no safety management system (SMS) in place and no risk assessment was conducted for the work itself. This incident shows that no amount of on-the-job experience can make up for a lack of risk assessment, control measures and safe operating procedures.

What happened

A 12-metre powered barge was operating in inland waters near shore. The work involved moving a concrete structure using a vessel-mounted crane. As the master was slewing the crane jib, it became overextended for the weight it was lifting. The vessel listed to starboard and took on water over the side. The vessel capsized and sank.

Investigation findings

The investigation identified the following factors in the overall safety outcome:

  • The master stated that they had been doing this type of work for many years without such an incident occurring.
  • There was no SMS for the vessel. 
  • There was no risk assessment for crane operations.
  • All lifesaving appliances were damaged and not serviced as per manufacturer’s specifications.
  • No stability assessment was completed for the vessel. Without stability information the Master did not have the information necessary to conduct safe lifting operations. A risk assessment of the type of work conducted would have required a stability assessment as a general safety duty.

Safety message

A compliant SMS is required for all domestic commercial vessel operations. An effective SMS safeguards people, the vessel(s) it applies to, and the environment from harm by considering the risks associated with the operation and ensuring procedures and control measures are in place to ensure safe operations. While this incident occurred in shallow, inland waters, the outcome could have been more serious. A risk assessment and SMS should have identified and prevented this incident through stability assessment and operating procedures that addressed the risk of overextending the crane.

Safety information on this topic

Guidelines for a safety management system

Risk management in the national system

General safety duties for domestic commercial vessels

Last updated: 15 April 2024