Purpose of report

Each year, the Australian Maritime Safety Authority (AMSA) receives marine incident notifications involving domestic commercial vessels (DCVs). The reporting of these marine incidents assists AMSA in regulating safety, with the data analysis used to identify emerging trends and issues. The analyses of marine incidents is used to support AMSA’s data driven approach to identifying risks and inform our compliance focus in the coming year. 

This report covers an analyses of the 2020 calender year with a comparative trend included for some of the 2019 marine incident data. 

Key information

Domestic commercial vessels are categorised by vessel use as per the table below:

Marine incidents are classified by AMSA into one of three severity levels which include the following:

The anayses of trends includes a breakdown of the vessel categorisation and incident classification.

Each year, the Australian Maritime Safety Authority (AMSA) receives marine incident notifications involving domestic commercial vessels (DCVs). Marine incident reporting is an important source of information that informs regulation and approaches to managing safety. AMSA continues to improve the collection, coding and analyses of marine incident data to better support a data driven approach. AMSA’s data driven approach informs safety education and compliance activities which are laid out in the annual National Compliance Plan. 

This report uses marine incident information reported over the last two years (January 2019 to December 2020) with a particular focus on 2020 data. Detailed analysis provides an insight into current and possible future maritime safety trends and takes a detailed look at the consequences and resulting safety factors that contributed to these incidents. As indicated this information is used together with other safety data (such as inspection data) to support the identification of focus areas of concern to allow for more effective targeting of our compliance activities. The outcome of the targeted activities for 2021-2022 financial year are laid out in the National Compliance Plan. 

Marine incident and safety concern reporting

Marine incidents are defined by relevant Australian laws and include different types of incidents. Generally, a marine incident includes any occurrence that has affected, or is likely to affect, the safety of persons or vessels.

Marine incidents that are required to be reported to AMSA are detailed in the Marine Safety (Domestic Commercial Vessel) National Law Act 2012¹. A list of these is included on the AMSA website. Depending on the seriousness of the incident, these are categorised as either:

1. immediately reportable matters (through an incident alert) and include deaths, serious injuries, loss of vessel, loss of person from a vessel or significant damage to a vessel. The incident alert informs AMSA that a very serious incident has occurred. An incident alert may not include all the information required to close the incident.
2. other marine incidents through an incident report. The incident report is a more detailed, follow-up report. Although this includes all other incidents, all incident alerts must be followed up by an incident report.

Visit the AMSA website to find out more.

AMSA also processes reports relating to marine safety concerns, similar to marine incidents. Anyone can report a safety concern, such as observing incidents that may endanger, or if not corrected could endanger, the safety of a vessel or persons on board. 

Marine incident statistics are updated and published annually by AMSA.

Footnotes

¹ Sections 88 and 89 of schedule 1 of the Marine Safety (Domestic Commercial Vessel) National Law Act 2012(National Law).

Vessels by class

DCVs operate within Australia’s Exclusive Economic Zone (EEZ)   for commercial, research or government purposes and are classed into one of four categories, depending on the vessel’s use.

There are approximately 31,000 active DCVs operating across the four vessel use classes. This includes approximately 7000 human powered and sail vessels. These are primarily hire and drive (Class 4) and under 7.5m in length (such as kayaks). These vessels are excluded from the fleet demographics in the remainder of this report as they are exempt from a unique vessel identifier and are used in connection with recreational activities.

Non-passenger (Class 2) represents the largest proportion of vessels in the DCV fleet, followed by fishing (Class 3) vessels.

Vessels by location (State)

The largest proportion of the DCV fleet with a certificate is located in Queensland (35.3%%) followed by New South Wales (26.7%) and Western Australia (11.2%).

The largest proportion of vessels in each state/territory operate as non-passenger (Class 2), except for South Australia and Tasmania where the largest proportion are fishing (Class 3).

Vessels by length and class

More than half (58.8%) of the active DCV fleet is under 7.5m in length with most being non-passenger (Class 2).

Footnotes

² Source: AMSA MARS system (May 2021). This data excludes human powered or sail vessels operating that are not uniquely identifiable

³ Source: AMSA MARS system (May 2021). This data excludes human powered or sail vessels operating that are not uniquely identifiable

In 2020, 758 marine incidents involving DCVs were reported to AMSA. 

This represents a slight increase of 1.9% in the total number of incidents reported in 2019 (744 reports). 

Each month AMSA publishes a summary of very serious and serious incidents reported that involve DCVs. This published information includes a brief description of the incident.

These are published on the AMSA website here.

Incident reporting trends by vessel class

Comparing the last two annual reporting periods (2019 and 2020) there were fewer reported incidents from passenger vessels (class 1) and more from non-passenger vessels (class 2) in 2020 when compared to 2019.  

The impact of COVID-19 and subsequent reduction in passenger vessel operations during this period may have impacted reporting rates in 2020.

Reporting by vessel length

The data also suggests that operators of larger vessels (>24m) report proportionally more incidents than those of vessels <=24m in length.  For vessels over 45 metres in length, 25.8% of the fleet submitted at least one incident notification in 2020.

Incident trends by severity

Marine incidents are classified by AMSA into one of three severity levels which include: 

• Very Serious; 
• Serious; and 
• Less Serious incidents. 

While the total number of incidents reported were similar in each year, there was an increase in the number of very serious and serious incidents from 103 in 2019 to 225 in 2020.

In 2020, the proportion of less serious incidents was 70.3% in relation to all incidents reported (Figure 9). This represents a decrease in the proportion of less serious incidents reported in 2020 when compared to 86.2% of the incidents reported in 2019. 

Fishing vessels (Class 3) reported a much higher proportion of very serious and serious incidents (53.1%) than any other class of vessel. This was also an increase from 2019 when only 21.5% of incidents reported by Class 3 vessel were very serious or serious.

AMSA classifies each reported incident into one or more categories to consistently describe what happened. Classifying incidents in this way helps to understand patterns of what has taken place and identify potential areas for safety improvement.

This classification does not explain why a marine incident happened, but rather provides a description of what occurred. Our analysis of why the marine incident occurred is described later in this report. 

The classification includes six primary categories:

Since multiple classifications can be applied to one incident, there were 924 consequences to the vessel, people, the environment or infrastructure in the 758 incidents reported in 2020. The distribution of incident categories for 2020 is consistent with the 2019 data with consequence continuing to form the largest proportion of categories in 2020. The second most common category is Operational.

The next sections of this report will focus on Consequence, Operational, Technical and Environment groupings. The Infrastructure and Non-operational will not be discussed individually due to the limited amount of data associated with these categories (17 and 27 incidents respectively).

Some marine incidents result in consequences to the passengers or crew on board. These consequences can include fatalities, person overboard and/or injuries.

Fatalities (2016 to 2020)

Between 2016 and 2020, there were 26 fatalities (24 crew and 2 passenger) associated with 18 marine incidents. While there has been an increase in fatalities between 2019 and 2020, overall the number of fatalities has been trending downward since 2016.

Fishing vessels (Class 3) accounted for 20 of the 26 fatalities (76.9%) during this period.  

Most of the fatalities (73.1%) between 2016 and 2020 occurred in Queensland (Figure 13). The majority (41%) of fishing vessels  are also based in Queensland.

In 2020 there were four fatalities, all involving a crew member going overboard. Three crew fatalities occurred on fishing vessels and involved (1) a tender (<7.5 metres), (2) a solo operator and (3) a crew member working over the side. The fourth fatality occurred on a charter vessel (class 2) and involved a person being knocked overboard by a sailing boom. In all these incidents none of the persons involved were wearing a life jacket.

In 2020, the fatality rate (the number of fatalities per 100,000 crew employed on DCVs) was 6.1. This is lower than the five-year average annual fatality rate of 7.3⁴ per 100,000 crew as per Table 1.

Whilst this fatality rate of 6.1 is lower than Australia's transport/postal and warehousing rate of 7.5 and agriculture/forestry and fishing rate of 13.9, it is higher than the Australian national workplace fatality 5-year average rate of 1.5. 

However, as also noted by SafeWork Australia⁵, fatality rates are sensitive to the number of people employed in the industry and this may be particularly evident with small variation in the number of fatalities for smaller industries that employ fewer employees (such as in the DCV fleet). Compared to the estimated 66,000 crew engaged in the DCV fleet, agriculture/forestry and fishing fatality rates are calculated from nearly five times the number of workers (approximately 329,600) and ten times the number of workers in transport/postal and warehousing (approximately 666,700)⁶. Therefore, the actual number of fatalities needs to be considered when interpreting the fatality rates for this data.

*Data not yet available at time of publication of this report.

Since AMSA took service delivery in mid-2018, the 3-year average fatality rate per 100,000 crew on domestic commercial vessels is 3.5 (2018-2020).

Persons Overboard - 2020

In 2020, there were a total of 44 marine incidents reported involving 56 persons overboard. 52 of these persons were recovered and four were fatal incidents. Of the 56 persons overboard, 42.9% fell overboard from passenger vessels. 

Person overboard incidents resulted from vessel capsize/sinking (28.8%), collisions (13.5%), boarding/disembarking (11.5%), vessel handling (9.6%) and loss of balance (9.6%).  

There were also a total of 14 passengers that deliberately jumped overboard (this data is excluded from Figure14 below). In almost all of these circumstances alcohol/drugs or an altercation were involved.

As shown in Figure 14, most person overboard incidents (35.7%) occurred on vessels less than 7.5 metres in length. More than 50% of reported person overboard incidents were on vessels less than 12 metres in length. The significant risks associated with persons overboard from smaller vessels is supported by research⁸. Additionally, the effectiveness of using a lifejacket appears to correlate with vessel size⁹. This means that wearing a lifejacket has been shown to provide better safety outcomes on smaller vessels. 

Injuries in 2020

In addition to fatalities and persons overboard, injuries are a third possible consequence to people. In 2020, a total of 146 injuries were reported to AMSA, with 83 being crew and 63 passengers. As shown in Figure 15, this is 11% lower than the 2019 data.

AMSA classifies injuries into serious and minor injuries. Serious injuries include injuries that require emergency treatment, in most cases leading to an emergency medivac from the vessel, and/or hospitalisation. Minor injuries do not require emergency treatment but may require first aid treatment on the vessel. Crew can continue working on the vessel without taking time off for a minor injury.

In 2020, the majority of reported injuries were minor (54.8%) with the remaining (45.2%) constituting serious injuries. It is anticipated that serious injuries are more likely to be reported by the owner/operator than minor ones due to the visibility of the event. 

As shown in Figure 17, most injuries (minor and serious) occurred on non-passenger (class 2) vessels (43.2%). Non-passenger vessels represent 33% of the DCV fleet and 41.3% of the total reported incidents in 2020.  

The proportion of reported serious injuries to minor injuries is highest on fishing vessels (65.5%) followed by non-passenger vessels (55.6%).  

Passenger vessels reported proportionally more minor injuries, many of which involved passenger trips and falls while the vessel was underway.

Figure 18 breaks down the circumstances under which these injuries occurred (noting that one incident may fall into multiple categories).  

The most people were injured in incidents in the category vessel control and/or navigation at 27.3% of incidents. This category includes issues with the handling or loss of control of the vessel, issues with lookout and collision avoidance. In these incidents, people are often injured due to sudden movement of the vessel, contact with an object or collision with another vessel.

The second most common (22.6%) category resulting in injuries was related to vessel access. These injuries occurred around the vessel and included people losing balance, falling/tripping on stairs, slipping due to wet floors or railings and falling while getting on or off the vessel.

Working in poor weather conditions was identified as a contributing factor in 16.7% of the reported incidents in which people were injured.

Most of the dangerous fauna incidents (12 out of 15) involving crew injuries occurred while on Class 3 fishing vessels. Eight of these incidents occurred while working on board the vessel. The other three dangerous fauna incidents involved passenger injuries and occurred while snorkelling/diving. Two involved contact with whales and one with a jellyfish.

Footnotes

⁴ As a comparison the five-year average fatality rate (2015-2019) for the agriculture/forestry and fishing industry was 13.9 and for the transport/postal and warehousing industry it was 7.5. All other industries in the safe work report had a five-year average fatality rate of 3 or less. (Work-related traumatic injury fatalities, Australia, 2019. Safe Work Australia). 

⁵ See Safe Work Australia Work-related, traumatic injuries fatalities 2019 Report.

⁶ Number of workers in Agriculture, forestry & fishing and Transport, postal & warehousing industries calculated from the number of fatalities and fatality rates per 100,000 workers in Safe Work Australia Work-related, traumatic injuries fatalities 2019 Report.

⁷ Based on a calculated approximation of 66,000 crew engaged on domestic commercial vessels

⁸ Mayhew, C. “Fatalities among fishing workers: does size matter?” Journal of Occupational Health Safety - Aust NZ, pp. 245-251, 2003.

⁹ Viauroux, C. and Gungor, A. “An Empirical Analysis of Life Jacket Effectiveness in Recreational Boating,” Risk Analysis, pp. 302-319, 2016.

In 2020 there were 457 reported marine incidents that involved a consequence to the vessel. This is down slightly from 468 incidents in 2019  The most common vessel consequence was contact (with an object), which accounted for 27.4% of vessel consequences and 16.5% of total reported incidents.  This was followed by collisions, which accounted for 21.7% of vessel consequences and 13.1% of total reported incidents. Groundings, accounting for 13.1% of vessel consequences and 7.9% of reported incidents. Contacts, Collisions and Groundings were also the top three occurring vessel consequences in 2019.

Operational

Most (75.7%) Operational incidents were related to control and navigation of the vessel. Control and/or navigation issues represents 42.7% of all incidents reported in 2020 compared to 35.6% of all incidents in 2019. Control and/or navigation operational shortfalls also resulted in 56.7% of the vessel consequences (457 incidents). 

Operational access, which involves the movement of people on and around the vessel, was the second most common operational shortfall in 2020. This frequently resulted in the injury of a crew member or passenger.

Technical

In 2020, there were 176 reported incidents that involved a technical failure, which represents 23.2% of total reported incidents. The most frequently reported technical issues were related to power propulsion and steering (51%), engineering systems (16.5%) and vessel systems (14.5%). 

Figure 22 presents the top 10 most frequently occurring equipment/system failures related to the above technical issues. The most frequently reported were related to the main engine/gearing, which represents 50% (51) of the power propulsion and steering failures.

Environmental conditions

In 2020, there were 105 reports in which weather and/or water conditions had a direct impact on the vessel and/or personal safety. This is 13.9% of reported incidents. 43.8% of these were classified as very serious and serious.

As shown in Figure 24, these conditions resulted in collisions, groundings, contact (with an object) and crew injuries amongst others.

The consequences to vessels and to people onboard that resulted from weather and water conditions highlight the importance of checking weather and tides and adjusting plans and operations accordingly.

Checking weather and tides should be part of the vessel’s safety management system.

The Bureau of Meteorology's marine forecasts and warnings provides information on five vital checks which should be considered as part of trip planning: Warnings, Weather, Winds, Waves, and Tides. 

Head to the Bureau’s website for more information on marine weather.

In addition to classifying the types of incidents based on what happened, AMSA also reviews incident investigation reports to identify how and why the incident occurred. Marine incidents can be caused by many factors and underlying safety issues that often are not directly linked to the incident – such as organisational issues.

To ensure we capture these underlying safety factors, AMSA has developed an investigation safety framework (Figure 26) to classify investigation findings based on research and our data. 

This safety framework helps in identifying the critical systemic factors that influence safety, taking into consideration the entire system that can impact the outcome, rather than just focusing only on the crew at time of incident. This allows for more effective safety improvements to be made by allowing the identification and targeting of underlying safety issues. 

Safety framework 

The safety framework is used for coding investigation reports within AMSA (Figure 25). It maps decisions and actions at six levels (people, onboard conditions, environment, technical/equipment, and internal and external organisational influences). 

The safety framework shows that safety factors¹⁰ and risk controls (controls in place to manage safety risks) may be present across all levels of the system. When there is a breakdown across these levels, the marine incident is the final event, which sits at the bottom of the safety framework (Figure 25).

The identification of safety factors is important as it provides an indication of what contributed to the incident and allows for more targeted safety interventions to be developed.

Investigations coded using the safety framework

AMSA reviews all incident reports it receives and responds according to the principles outlined in the AMSA Compliance Strategy 2018 - 2022. In 2020, AMSA commenced a total of 79 formal investigations. 

After conducting preliminary inquiries, a decision may be made to conduct a formal investigation. Some considerations for commencing an investigation include: the existence and extent of fatalities/serious injuries and/or structural damage; the anticipated safety value of an investigation; the likelihood of safety action arising from the investigation and the relevance to an identified and targeted safety campaign.  In 2020, 100% of very serious; 22.1% of serious; and 4.5% of less serious incidents resulted in the commencement of a formal investigation.

Of the 79 formal investigations commenced in 2020, 52 include an investigation report which were coded using the safety framework.

Footnotes

¹⁰ Safety factor is defined as an event or condition that increases risk.

This section of the report presents the findings of the analysis of safety factors identified from completed investigation reports using AMSA’s safety framework. The results of this analysis help to understand risks and identify if, and where, greater compliance focus needs to be applied. 

This analysis also provides the risk basis for AMSA’s National Compliance Plan and helps to target our compliance focus. 

The majority of Consequences (figure 28) from the 52 investigations coded were contacts (25%); crew injuries (21%); foundering/sinking (11.5%) and grounding (11.5%). 

A total of 266 safety factors were identified from the investigation reports analysed. 

The majority of safety factors were related to people (27.1%), followed by internal organisational issues (25.9 %) and onboard conditions (17.3%). 

The analyses presented in the next sections will focus on these three primary safety factors of concern.

People

Overall, People actions was the most common primary safety factor identified from the 52 investigation reports analysed. People actions refer to observable behaviours such as decisions, actions and/or inaction by the crew that increased risk. 

Of the 72 people actions identified, about half (47%) were navigation actions, followed by deck operation (26%) and maintenance action (19%).

Most navigation actions related to assessing and planning (26.5%), monitoring/checking/documenting (23.5%), or using equipment (20.4%). 

Typical assessing and planning issues included no passage planning, incorrect assessment of the safety risk when taking certain actions or course and making inappropriate plans to rectify the situation. Problems with monitoring/checking/documenting include poor monitoring of the status of the voyage, poor lookout and lack of monitoring of environmental conditions. 

These decisions, actions and/or inaction by the crew usually result from onboard and/or organisational conditions which influence the final outcome.

Onboard conditions

Onboard conditions can influence decisions, actions, inaction or events that may increase risk. Onboard conditions are categorised into three primary safety factors and include knowledge, skills and experience; personal factors (such as drugs/alcohol, fatigue, preoccupation); and task demands (such as distractions, time pressures, incorrect task information). Figure 31 shows a further breakdown of the personal factors and task demands. 

As per Figure 31, issues related to knowledge, skills and experience of crew made up about one third (35%) of onboard conditions. Most were related to situations where the crew did not have the required knowledge and/or skills to effectively use equipment. Personal factors (32.6%) and task demands (32.6%), similarly each comprised a third of onboard conditions. 

Personal factors included a wide variety of safety factors with most being due to drugs/alcohol (33%); preoccupation (20%),fatigue (13%) and motivation/attitude (13.3%). Task demands were usually due to distraction (40%) or time pressure (20%). 

This data provides evidence of fatigue as contributing to some investigation outcomes.

Long working hours with restricted rest, broken or poor quality sleep, and long voyage lengths are detrimental to operational performance and possibly longer term wellbeing of the crew. A fatigued crew is much more likely to make a mistake, possibly a serious one.

Fatigue is an important part of crewing assessments and ensuring that the vessel is being crewed safely. AMSA has developed resources to support operators in managing fatigue on their vessels. 

See our guidance about managing crew fatigue.

To help manage this, AMSA will commence an education campaign focusing on fatigue to support the DCV industry. 

Internal organisational influences

Internal organisational influences comprised a large proportion (25.9%) of safety factors identified. This is an indication that a significant portion of the risks to safety reside at the organisational level. 

Shortfalls in safety management processes was identified as forming the largest percentage of internal organisational issues. This includes problems associated with the processes an organisation uses to establish, maintain and otherwise ensure the effectiveness of its risk controls. Safety procedures (39.5%) and risk assessments (34.9%) comprised the majority of safety management processes issues. 

A separate analysis of safety management assessment data carried out by AMSA shows that poor, lack of or ineffective risk assessments are and continue to be major areas of concern.

Safety factors related to people management formed the second largest (20.3%) Internal Organisational issues. Within the people management, training and assessment (50%) was identified as the most frequently occurring safety factor. 

This section of our website has resources to help you develop a safety management system and tools to assess the health of your safety management system.

Through a comparison of marine incident data across DCV class and operations, AMSA is able to develop a more complete picture of the DCV maritime industry to identify emerging trends in safety, identify further areas for research and recommend safety compliance actions. 

This report highlights the importance of effective and timely marine incident reporting to allow for further research and analysis. While there has been a slight increase in marine incident reporting in 2020 when compared to 2019, it is clear that an active reporting culture continues to remain a challenge for domestic maritime industry. AMSA, in partnership with industry stakeholders, will continue to strive to identify ways to improve reporting culture and subsequent safety outcomes for the DCV fleet.

Whilst incident reports provide a good measure on the nature and frequency of marine incidents in terms of what happened we also need to identify the underlying safety issues that lead to dangerous occurrences. We need to know not just what went wrong, but why it went wrong, how it went wrong and more relevantly how we can prevent recurrence. AMSA has done this through the use of a safety framework to better understand what drives human behaviour and performance at sea. This supports our risk-based approach in the identification of the focus areas of primary concern. By doing so we can prioritise our compliance approach and design tailored compliance initiatives to ensure we allocate our resources in the most cost-effective way, relative to the outcomes we aim to achieve.

This information has also been used to inform targeted engagement activities throughout the year such as the recent tender safety campaign. These campaigns are included in the 2021-2022 National Compliance Plan and are broken down into educational¹¹ and safety¹² compliance campaigns. Focus areas in the next year which have been informed by incident data and included in the National compliance plan include the following:

• Incident Reporting: We will commence an education campaign focusing on incident reporting. AMSA will work with industry and other relevant State/Territory jurisdictions in delivering an outcome.
• Fatigue: We will commence an education campaign focusing on the risks associated with fatigue and develop associated guidance. We will work closely with Work Health and Safety (WHS) State/Territory authorities in developing and delivering this campaign.
• Safety Management Systems (Risk Assessment): AMSA will commence a safety campaign focusing on risk assessment which is a critical aspect of the Safety Management System. 
• Passenger Safety: AMSA will continue with an education campaign and a second focused inspection campaign to reinforce passenger safety monitoring requirements.
• Construction Barges risk assessment (Class 2): AMSA will commence a safety campaign focusing on construction barges with a particular emphasis on risk assessment. We will work jointly with WHS State authorities in delivering this campaign.

AMSA also leverages information from marine accident reports and incident data to publish a range of safety information such as Safety Alerts and other publications.

AMSA will continue to work with our stakeholders in the delivery of education and safety campaigns as identified in the 2021-22 National Compliance Plan.

Footnotes

¹¹ Educational Campaigns: These are purely educational and may include a combination of communication (through social media, website and print) content and facilitated workshops. Educational campaigns do not include focused inspections/audit activities. 

¹² Safety Compliance Campaigns: These include a combination of education and focused inspections and audits. In all cases AMSA will commence with education which will be followed up by a focused inspection campaign to identify and measure the level of compliance.