Fatalities

In 2022 there were no operational-related fatalities associated with DCV vessel operations.

Between 2018 and 2022, there were 11 operational-related fatalities on DCVs (9 crew and 2 passengers) associated with 11 marine incidents. Seven (63.6%) of these occurred on fishing vessels (Table 2).

Table 2 DCV fatalities by year, state and vessel class, (2018-2022) 

NSW

NT

QLD

TAS

WA

In 2022, the fatality rate (the number of fatalities per 100,000 crew employed on DCVs) was 1.8. This remains lower than the five-year average annual fatality rate of 2.7 per 100,000 crew7  and lower than the fatality rate for Agriculture, forestry & fishing and Transport postal & warehousing reported in 2021 (Table 3). 

Table 3 Fatality rate per 100,000 crew employed on DCVs compared to similar industries8

Injuries

In 2022, 18.3% (196) of incidents on DCV’s included reports of an injury to a crew member or passenger.¹⁰

Table 4 Incidents on DCVs with reported injuries to a crew member or passenger, total and as a proportion of all incidents (2019-2022)¹¹

In 2022 the total number of injuries reported to AMSA increased by 32.0% from 2021.  This is largely due to reports of injuries to passengers (Figure 5). 

In 2022 the total passenger injuries reported increased by 68.1% from 2021. This is mainly due to a single incident involving a high-speed thrill ride in which a high number of passenger injuries, including serious injuries were sustained. This single incident also accounted for a 100% increase in serious injuries to passengers in 2022 from 2021. The number of serious injuries to crew has increased from 39 in 2021 to 44 in 2022 but generally has remained more or less steady across the last 4 years. 

More than half (54.5%) of the serious crew injuries in 2022 were reported by non-passenger vessels, followed by fishing (27.3%) and passenger (18.2%) vessels.

In 2022, most crew injuries were associated with shortfalls in the control and navigation of the vessel (36.9%) followed by operational access (25.2%) and cargo handling and stores (17.5%) (Figure 6). Examples of injuries associated with the control and navigation included head injuries requiring medevac when a vessel ran aground on a reef at speed, the vessel was navigating using an old route in plotter that hadn’t been reviewed prior to sailing. In another instance a sole operator was thrown overboard and sustained serious foot and chest injuries when their attention was diverted from navigating the vessel after they dropped their phone. Whilst looking at deck to retrieve phone, the vessel made heavy contact with a navigation marker. 

Examples of injuries associated with operational access were broken fingers and hand when an unsecured hatch closed on a crew member’s hand with the hatch strap flicking onto hand and breaking fingers. There were several instances of crew members slipping on fenders or gunwales when transferring between vessels and landing in water or heavily on deck, slipping and falling heavily on engine room ladders due to oil residue on boot or on ladder. 

This pattern was similar across all classes of vessels except for fishing, where most injuries were associated with Cargo handling and stores (44.4%) followed by Dangerous fauna (22.2%) and Vessel control and navigation (Table A3).

Persons overboard 

In 2022 AMSA received 87 reports of incidents involving person overboard (POB) from DCVs representing a 19.2% increase from 2021. Passenger vessels reported the majority (50.7%) of all POB incidents. 

In 2022, 17 POB incidents were classified as ‘intentional’ and 70 were classified as ‘unintentional’.¹²  

Of the 70 ‘unintentional’ POB incidents (Figure 7, Table A4): 

• 39 involved crew members overboard
• 21 involved persons overboard not wearing a lifejacket and 22 where unknown if wearing a lifejacket
• 19 involved crew members who were wearing a lifejacket
• 6 involved passengers who were wearing a lifejacket
• 46 involved vessels between 7.5m and 35m in length, with vessels in this group making up 39.9% of DCV’s (Figure 8) 
• 6 incidents involved crew and 12 involved passengers overboard where it was reported that more than one person entered the water

Footnotes

⁷. The actual number of fatalities must be considered when interpreting the fatality rates for this data due to the difference the size of the respective workforces. As noted in Work-related traumatic injury fatalities Australia 2021 by SafeWork Australia, fatality rates are sensitive to the number of people employed in the industry. In smaller industries that employ fewer employees (such as in the DCV fleet), a small variation in the number of fatalities produces an apparent larger variation in the fatality rate. 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 317,300) and transport/postal and warehousing rates from nearly ten times (approximately 658,200). 

⁸. Safe Work Australia (SWA), Work-related Traumatic Injury Fatalities Australia, 2021, SWA, Government of Australia, 14 November 2022, accessed 6 June 2023. 

https://www.safeworkaustralia.gov.au/doc/work-related-traumatic-injury-fatalities-australia-2021; SWA 2022 data not yet available at time of publication of this report.

_⁹. Based on a calculated approximation of 66,000 crew engaged on domestic commercial vessels.

₁₀. All incidents reporting serious operational injuries to crew or passengers are classified as serious.

¹¹. Incidents may report injuries to crew and passengers. In both 2019 and 2020 AMSA received one report of an injury to a stevedore in relation to the operation of a DCV.  

¹². AMSA classifies a POB as unintentional when the persons going overboard was associated with of the operation of the vessel. 

Consequences to vessels

Over half (55.1%) of marine incidents in 2022 included a vessel consequence outcome. The three most frequently occurring consequences on DCVs in 2022 were collisions, groundings and contacts (with something other than a vessel) (Figure 9, Table A5).  

In 2022:

• Collisions, groundings and/or contacts accounted for 54.3% (75) of the total very serious and serious (138) incidents involving consequences to a vessel. This represents a 4.3% decrease from the proportion in 2021 (58.6%) (Figure 10).
• Grounding incident reports increased by 52.1% from 2021(Figure 9) and comprised the majority of serious vessel consequences (Figure 10).

The most frequently reported consequence across all severity levels for each vessel class in 2022 were (Table A5):

• Passenger: Contact (26.0%)
• Non-passenger: Contact (25.2%)
• Fishing: Foundering/sinking/loss (20.5%)
• Hire and drive: Collision (42.3%) 

Figure 10 shows the vessel consequence type for very serious and serious incidents by vessel class. 

Consistent with crew injury incidents, shortfalls in the control and navigation of a vessel were reported in 46.3% (285) of vessel consequence incidents, followed by 19.6 % (124) for weather/water conditions and 12.7% (74) for power, propulsion and steering failures. 

There were 8 very serious DCV incidents in 2022 all involving very serious consequences to the vessel resulting in a total loss or being lost at sea (Table 5).

Footnotes

¹³. Vessel lost. Unable to determine seat of fire.

Since 2020, 9.5% of all marine incidents reported shortfalls in the operation of the vessel. 

Since 2020, vessel control and navigation issues accounted for 28.3% (306) of all Operational related incidents. This is followed by cargo handling issues resulting in 26.1% (283) and maintenance resulting in 19.5% (211) of Operational related incidents (Figure 30).

In 2022, cargo handling and stores (80) for the first time surpassed vessel control and navigational (78) issues.

Figure 31 shows the most frequent issues associated with the operational occurrences for 2022. 42.5% (34) of the cargo handling incidents occurred during loading and unloading. 44.9% (35) of vessel control and navigation incidents occurred during berthing and unberthing and mooring operations and 58.9% (33) of operational access incidents occurred while climbing or descending ladders or stairs.

Between 2019 and 2022, 84.0% (12,363) of marine incidents included a Technical occurrence type. There was a steady increase in technical occurrences from 2019 to 2022, with 2022 resulting in a total of 3702 technical occurrences with 4.5% (126) of technical occurrence categorised as very serious or serious incidents (Figure 26, Table A9).

In 2022, vessel system failures comprised the majority of technical occurrence types having increased steadily from 263 in 2019 to 653 in 2022 (Figure 26). This increase is attributed to a significant increase in the reporting of ballast system failures from 57 in 2019, to 343 in 2022 (Figure 27).

In 2022, 17.3 % (639) of technical occurrences involved power, propulsion and/ steering system failures. Main engine and gearing failures were the most frequently reported technical failures and were amongst the top 3 technical occurrences for all vessel types except passenger vessels (Figure 27, Table A-10).

Figure 27 shows the top 10 failures in equipment associated with propulsion, power/steering; engineering systems, cargo and stores, and vessel access in 2022. These included: 

• 356 reported failures related to main engine and gearing, 14.3% (51) of these were categorised as serious incidents.
• 343 reports of issues with ballast systems. 82.2% (282) of these issues occurred on bulk carriers.
• 211 reported failures of mooring and anchoring systems. 69.2% (146) of these failures were reported on bulk carriers.
• 198 reported failures of pilot/combination ladder. 

Figure 28 includes the top 10 failures in equipment associated with navigation and communication for 2022. 

• 235 Radar and 110 Voyage Data Recorder failures accounted for 53.3% of the 647 navigation monitoring equipment failures reported in 2022.
• 198 reports were of issues with a vessel GMDSS. 

Figure 29 includes the more frequently occurring failures in equipment associated with firefighting and lifesaving. 

• 72 reports were of a failure of a lifeboat. One of these was a serious incident where a lifeboat capsized when being launched resulting in two crew overboard.
• 59 reports of issues with fire detection equipment. This category included reports of faults with alarm panels and detectors. 
• 59 reports of issues with rescue boats. Many of these were reports of faulty davit gears and motors or hydraulics requiring repairs.

This section presents the findings from the safety framework coding of completed DCV investigation reports. The findings provide an understanding of safety issues and identifies if, and where, greater compliance focus needs to be applied. 

Between 2020 and 2022, 178 DCV marine incident investigation reports were coded using the safety framework.¹⁴ 

From the 178 investigations coded, the majority of consequences resulted in crew injuries (19.7%) followed by contacts (13.6%), collisions (12.9%), and groundings 12.9% (Figure 16). 

A total of 804 safety factors were identified from the 178 investigation reports analysed.  

Aspects related to people (27.0%), and internal organisational issues (30.2%) continue to form the majority of safety factors (Figure 17).

The analyses presented will focus on the three primary safety factors of concern, people, onboard condition, and organisational influences (internal) for the 178 coded investigation reports.

People

People actions refer to observable behaviours such as decisions, actions and/or inaction by the crew that increased risk. 

Of the people actions identified, the 38.7% (84) were Navigation actions, followed by 36.4% (79) of Deck operation actions and14.3% (31) of Maintenance actions (Figure 18).  

Navigation actions comprised shortfalls in assessing and planning (25.0% (21)), monitoring/checking/documenting (25.0% (21)), using equipment (21.4% (18)), communicating and coordinating (13.1% (11)) and other navigation actions (15.5% (8)). 

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

Onboard conditions 

Onboard conditions include onboard conditions that impact safety such as knowledge skills and experience to perform tasks onboard, internal and external factors influencing personal performance and wellbeing and the social environment. 

Safety factors related to onboard conditions are evenly distributed with 31 (34.4%) associated with knowledge, skills, experience, 31 (34.4%) with personal factors which includes fatigue and 27 (30.0%) with task demands (Figure 19). 

Knowledge skills and experience issues identified in investigation reports included lack of knowledge in the operation of key machinery and safety systems onboard the vessel and in performing key tasks such as anchoring or responding to emergencies.

Shortage of skilled and competent crew are associated with factors including pressure to complete tasks, high workload and fatigue. 

Internal organisational influences

A significant portion of the risks to safety of vessels and crews reside at the organisational level. 

Safety management processes comprise most of the internal organisational issues, forming 65.8% (160) of the total internal organisational issues. Investigation reports identified shortfalls associated with the processes an organisation uses to establish, maintain, and otherwise ensure the effectiveness of its risk controls as factors affecting onboard safety. Poor, lack of or ineffective risk assessments continue to be major areas of concern in DCV fleet incidents and operations.  38.1% (61) were associated with shortfalls in risk assessment and 35.6% (57) related to Safety Procedures (35.6%) and both continue to represent the majority of safety management system issues (Figure 20).

Footnotes

14.Note that subsequent to the publication of the 2021 annual report, a further 39 investigations into incidents which occurred in 2020 and 2021 were coded using the safety framework.