View the Ferry Safety Investigation Report
What happened
On the night of 12 December 2021, charter vessel Rockfish 3, rounded Millers Point, travelling in an easterly direction on its way towards its berth in Lavender Bay.
At approximately the same time, the charter vessel John Cadman 3 was travelling from east to west on the northern side of the Transit Zone. When Rockfish 3 was in the vicinity of Walsh Bay, the master altered course to port and towards the vessels berth in Lavender Bay.
This alteration of course resulted in Rockfish crossing the bow of John Cadman 3 in close quarters. The two vessels collided, with the Rockfish 3 becoming entangled on the bow of the larger vessel.
The John Cadman 3 suffered minor damage to its bow. The Rockfish 3 suffered significant damage to its starboard hull and superstructure, the mast and associated rigging were also significantly damaged in the collision.
No injuries were reported from the collision.
What we found
The operators of the involved vessels did not identify all relevant risks and mitigation strategies when operating in the Sydney Harbour Bridge Transit Zone at night. Neither operator identified the increased risk of collision or the associated visual limitations, including their respective vessel viewing constraints. This resulted in both Masters sighting the other vessel when it was too late to take action to avoid a collision.
Contributory Factors
Neither vessel involved in the collision saw the other vessel so did not adhere to the relevant COLREGS Rules.
- The give-way vessel in the crossing situation, did not take early and substantial action to keep well clear.
- The stand-on vessel in the crossing situation, did not respond in time to the close quarters situation resulting from the give-way vessel’s failure to give way.
John Cadman 3’s Master was focused on the overtaking traffic and did not see the approaching Rockfish 3 on the port bow.
John Cadman 3’s Master was alone in the wheelhouse, which limited their ability to maintain a proper look-out in a recognised high traffic location.
John Cadman 3’s wheelhouse window structure created significant blind spots for the Master, which likely concealed Rockfish.
Rockfish 3’s Master was navigating the vessel with lowered clears and internal cabin lights illuminated. Light reflecting off the clears would have significantly reduced the Master’s ability to maintain a proper look-out.
Rockfish 3’s deckhand was primarily focused on preparing the vessel for overnight shut down and was unaware of the approaching hazard.
Actions taken by directly involved parties during the investigation
JC III Pty Ltd
Following the collision, the company and crew conducted a review of their safety management system (SMS) and risk register. This review resulted in several procedural changes and vessel modifications. These included:
- modifications to the wheelhouse window framing to reduce blind spots
- the addition of double row party lights down both sides of the superstructure to increase the conspicuity of John Cadman 3 to other vessels
- changes to crew induction procedure to include the confirmation of competency, through assessment criteria and a questionnaire
- the development and inclusion of a Transit Zone and reduced visibility look-out procedure. The procedure calls for a lookout to be in the wheelhouse to assist the Master when travelling through the Transit Zone (day or night). It also instructs Masters to utilise extra lookouts as required in time of reduced visibility.
Rockfish Charters
Following the collision, the company reviewed their SMS and in February 2022 incorporated a revised policy for night-time charters. The new policy - Deck Watch – Evening Charter, highlighted that Sydney Harbour was busy. It recommended that both the Master and deckhand (when carrying one) maintained a lookout for hazards and complied with the collision regulations, while operating during dusk and evening conditions. The policy did not detail how this was to occur.
Recommendations
OTSI made the following recommendations:
JC III Pty Ltd
Review their Safety Management System to ensure that:
- the risk register includes relevant risks encountered during charter operations, specifically identification and mitigation for night operations and look-out
- relevant competency-based crew induction and ongoing refresher training are included.
Rockfish Charters
Review their Safety Management System to ensure that:
- the risk register includes relevant risks for charter operations, specifically identification and mitigation for extended hours of work, night operations, cabin lights, clears and look-out
- onboard procedures are relevant to the vessel
- relevant competency-based crew induction and ongoing refresher training are included.
Domestic Commercial Vessel Operators
Review their Safety Management System to ensure that the risks involved in operating in high traffic density areas such as the Sydney Harbour Bridge Transit Zone are assessed for all operating conditions, day and night. Implement mitigation strategies to reduce risks for any of the identified hazards.