Ferry Safety Investigation Report - Children overboard at Riverview College Ferry Wharf - 16 February 2023

Read the Ferry Safety Investigation Report

What happened 

On 16 February 2023, passenger vessel Violet McKenzie conducted a timetabled public passenger ferry service from Hunters Hill, on the Lane Cove River, to Circular Quay, NSW. At the Riverview College Wharf, the crew experienced difficulties berthing the vessel. 

During disembarkation, the vessel moved away from the wharf which resulted in the gangway separating from the wharf and falling into the water along with two school students. The gangway overturned as it entered the water, with the two students underneath. One of the students managed to free themselves and climb onto the gangway. The second student remained under the gangway with their backpack, between the submerged handrails. 

As the ferry crew commenced preparations to retrieve the students, another student jumped into the water from the open gangway door. The three students were subsequently retrieved from the water by the crew. The Master positioned the vessel back to Riverview College Wharf and disembarked passengers without further incident. 

What we found 

The interface between the Super Rocket Class vessel and Riverview College Wharf was not effectively managed by the involved crew. The crew’s management did not have full consideration of the tidal conditions present at the time of the incident, the berthing method of running engines astern and the limited ability of the Master to maintain the vessel stability on the small berthing face offered by Riverview College Wharf. 

The crew did not effectively manage the disembarkation of students at Riverview College Wharf, with ineffective crowd management and late identification of the movement of the vessel away from the wharf, resulting in gangway displacement and students falling. 

The actions and decision making of the involved crew on the day was likely influenced by limited operational experience in their roles, crew pairing, time pressure, competing task priorities and the local conditions (tidal and wharf interface). 

The vessel operator did not adequately identify and subsequently control risks associated with Riverview College Wharf ferry operations for the Super Rocket Class vessels.  

Actions taken by directly involved parties during the investigation 

Captain Cook Cruises (CCC) 

Key actions documented by the operator included: 

• Reviewing the company procedures which outline the Master's responsibilities when a vessel is alongside a wharf.  
• The implementation and installation of signage 'Crew only, no passengers past this point until gangway is secured' on the rocket fleet forward cabin doors to aid crowd control. 
• The implementation of an immediate change in process for the Deckhand, by removing the passenger counting procedure to ensure focus is on the passengers and the gangway’s position during boarding/disembarking. 
• Passenger count to be maintained during deck patrols in between wharves. 
• To ensure vessel cameras are free from obstructions to aid in the safe operation of the vessel, equipment and personnel. 
• To ensure all employees receive the required training in line with their ability along with the company's documented procedures. 
• An assessment of all wharfs on the Lane Cove River Service was conducted and procedures to mitigate identified risks were developed.  
• A further assessment of Lane Cove River Service wharfs was commissioned against the TfNSW Guideline for the Assessment of Public Wharf Safety (2016). 
• As an outcome of the wharf risk assessments, CCC developed procedures compiled into a single document titled ‘Lane Cove Operational Manual’. This Manual included individual procedures for berthing at each of the wharves in the Lane Cove River Service.  
• The Manual identified that the service was popular with school children and that crew had to carry out extra tasks to ensure passenger safety. These extra tasks included: 
• Children to remove their back packs from their backs before crossing the gangway. 
• The working deck to be kept clear of children by ensuring the cabin doors remain closed until the vessel was secure and gangway in place. 
• A reminder that crew were to remain extremely vigilant during passenger embarkation or disembarkation, halting passenger progress if overcrowding or unsafe. 
• Master not to run the vessel in astern propulsion unless in extreme circumstances. 
• Vessels to be secured with two mooring lines where possible. 
• The use of handheld portable radios for crew issued for the purpose of improving communication. 

Saint Ignatius’ College Riverview 

Following the incident, the owner of the involved wharf conducted a wharf upgrade program which resulted in the following changes: 

• addition of two ladders (one either side of the wharf) for emergency egress/access (no ladders on wharf at time of incident) 
• addition of life rings onto wharf (no life ring in close proximity to wharf face at time of incident) 
• lighting upgrade 
• repainted the yellow markings on the wharf face and steps 
• installation of mooring points. 
• Saint Ignatius’ College also reported that they implemented several additional risk controls including: 
• the orientation of new students to expectations associated with the use of the ferry services, with a particular lens on safety 
• school bags being carried on one shoulder when embarking and disembarking the ferry on the wharf 
• the appointment of senior students to the role of Student Monitors, who will hold responsibility for monitoring behaviour, safety concerns, and reporting them to senior staff at the College should they emerge. 

Transport for New South Wales 

TfNSW reviewed the CCC Lane Cove River wharf assessment report producing a wharf maintenance and upgrade program in response to the identified deficiencies. TfNSW reported that remedial action was undertaken on all wharves under their management. 

Recommendations 

Captain Cook Cruises 

• Review its SMS crew training and competency assessment requirements to further detail the competency assessment elements of its practices and techniques necessary to carry out safe berthing and gangway operations. 
• Consider a further review of the remaining sections of its SMS crew training and competency assessment requirements to further detail any additional competency assessment elements of other marine practices and techniques. 
• Review fleetwide SMS related procedures to consider the risks posed to passengers wearing backpacks over both shoulders whilst traversing gangways. 
• Review a Master’s capability for monitoring berthing and gangway operations on Super Rocket class vessels. The review should consider a Master’s line of sight restrictions and the supporting CCTV system to assess if any additional improvements in the monitoring system could be achieved. 
• Identify a program of monitoring its ferry operations on the Lane Cover River using a risk-based approach. The program should consider ongoing monitoring of its crews to provide a level of assurance that safe berthing and gangway practices are consistent with the safety management system procedures. This program should consider a review of the crew’s; management of the running ahead practice, communication with each other, monitoring of gangway stability during the berthing, passenger control on the working deck, passenger safety over the gangway and management of any other risks associated with fixed structure wharves. 

Ferry operators 

• Ensure that the hazards and risks associated with the berthing and embarkation/disembarkation of passengers at wharves on individual operators’ services are identified and assessed, and effective risk control measures implemented to ensure safe passenger operations.  
• Consider human factors and ergonomics in the design of vessels for ferry operations to ensure that wheelhouse visibility supports effective management of safety in the target operating environment (including berthing and gangway operations). 

Saint Ignatius’ College Riverview 

Finalise its proposed safety review and assessment of wharf and berthing operational risk controls that have been identified to cover; 

• consideration of wharf improvements to achieve compliance with the Disability Discrimination Act 1992 (DDA) standards and codes of practice 
• parent webinars to provide education/safety awareness on the ferry service/operation 
• consider the installation of dolphin pylons to facilitate vessel berthing at Riverview College Wharf. 

Transport for New South Wales 

• Using a risk based approach, assess if additional means of obtaining assurance that safe berthing and gangway practices are being achieved for the Lane Cove River public passenger ferry service are practicable. The assessment should consider how the known risks associated with fixed structure wharves have been addressed by the ferry operator. 
• Consider the outcomes of its risk based assurance review of ferry services operating on the Lane Cove River for all contracted public passenger ferry services. Taking into account the TfNSW Health and Safety Risk Management system that requires the review of control measures to determine if they are implemented and working as planned. The risk based assurance review should also consider if the wharves are upgraded or replaced, improved berthing arrangements and full compliance with the Disability Discrimination Act (NSW) is included. 
• Consider requiring the designers of future vessels intended for public passenger ferry services take account of human factors and ergonomics, to ensure that a Master’s line of sight from a wheelhouse supports effective management of safe operations (including berthing of vessels and gangway use). 

Australian Maritime Safety Authority 

• Review its criteria for the assessment of a ferry operator’s safety management system using a risk based approach. This review should consider if that criteria could be improved to further detail the extent to which a ferry operator has risk assessed their specific vessels and operating environment. 
• AMSA should consider whether targeted risk based random inspections could improve compliance outcomes in line with established principles of deterrence.