Safety Lessons from Marine Incident Investigation (AMSA Report) – No.9 – July 2022

Handover procedures and distraction contribute to channel marker collision.


On 16 March 2022, a class 2B landing barge collided with a starboard channel marker. The investigation identified that the previous swing engineer did not inform the incoming engineer that the port main engine cooling water suction valve was shut. After getting underway, the engine began to overheat. This distracted the master from monitoring the vessel’s intended track. The vessel’s safety management system did not have an appropriate engineering handover procedure.  

What happened 

At about 9pm, the landing barge was approaching a wharf when the master noticed that the port main engine was running at a very high temperature and reduced the revs on that engine.  Though the engine revs were reduced, the high-water temperature and low oil pressure alarms sounded in the wheelhouse. The master called the onboard engineer to alert them to the overheating engine, and they went to investigate. The master took a handheld spotlight to the port bridge wing to check if the engine had cooling water coming from the port engine's outlet in the hull. While on the bridge wing, the master realised that the vessel had drifted to the port of its intended track due to the reduction in thrust from the port engine. The autopilot had corrected, however the vessel was on a collision course with the channel marker. The master rushed back inside the wheelhouse and turned to starboard to avoid the collision, however the marker was too close and struck the vessel just aft of the port bow and slid down the vessel's port side.  

Investigation findings 

The investigation identified the following contributory factors: 

  • The vessel’s engineers swapped their swings at the last moment before sailing. The previous swing engineer forgot to inform the incoming engineer that the port main engine cooling water suction valve was shut. Just after departure, the engine started overheating.  
  • The vessel did not have any formal handover or takeover procedure under the vessel's safety management system. Also, the vessel did not have clear information and procedure for cooling water systems change over from one to another. The vessel did not have a procedure for manoeuvring with one main engine in the safety management system. 
  • Though the vessel had the other main engine fully functional and running during the time of the incident and could of been navigated safely with one engine, the master concentrated their effort to find the problem with the port engine.  
  • This distracted the master and resulted in a loss of control of the vessel and the collision.  

Safety message 

Masters of all vessels need to be mindful of the consequences of being distracted from the primary role of safe navigation, including keeping a proper lookout. A short loss of situation awareness, can result in loss of control of the vessel and result in a collision.  

The safety management system is a documented approach to managing safety for the vessel, where the nature of operational risks and the actions required to mitigate their impact are captured for a vessel and understood by all crew members. All situations that can impact the safe operation of the vessel, such as engineering handovers, engine cooling systems operation, and loss of propulsion should be included and addressed. A safety management system is not just a document—it must be put into practice and be effective.

Last updated: 25 July 2022