An independent and confidential

MARITIME FEEDBACK reporting system for the Maritime industry

Issue 01 SUPERYACHTS Winter 2023

SUBMIT A REPORT ONLINE

CHIRP always protects the identity of our reporters. Reports can be submitted easily through All personal details are deleted from our system once our encrypted online form a report is completed. www.chirp.co.uk

Welcome to Superyacht FEEDBACK!

Adam Parnell you really are helping to improve safety outcomes Director (Maritime) by doing so; so thank you. We believe that our safety newsletters differ to many others because we focus on the primary

W elcome to the first edition of Superyacht FEEDBACK! This is a new editorial that complements our established but more general human-factors that contributed to incidents and near misses. These are listed at the end of each report for ease of reference and to stimulate conversations Maritime FEEDBACK newsletter which covers the about safety. CHIRP believes in a ‘just’ reporting entire maritime industry. Firstly, we want to say a culture, so while we may highlight failures of process huge ‘thank you’ to those of you who asked us to and procedure, we never ‘name or shame’ and go to produce a separate and distinctive publication with great lengths to ensure that individual people, ports or particular focus on safety issues encountered on vessels cannot be identified. board superyachts. We hope that we’ve met your We hope you find this an interesting and expectations – let us know either way! informative read, and please do let us know your And thank you to everyone who submitted thoughts (both good and bad) so that we can make safety reports to us, either through our website future editions even better. And do please keep your reporting portal or via our app. We recognise that reports coming! reporting can often be a difficult step, but we rely on Yours in safety, your reports to raise awareness of safety issues, and The CHIRP Maritime team

Please note all reports received by CHIRP are accepted in good faith. Whilst every effort is made to ensure the accuracy of any editorials, analyses and comments that are published in FEEDBACK, please remember that CHIRP does not possess any executive authority.

M2084 Use the hierarchy of controls diagram-eliminate the hazard.

Entrapment in running Toolbox talks are not standard in the super yacht sector of this industry, but CHIRP recommends adopting them,

equipment causes serious including Stop Work authority. CHIRP feels the owners have a duty of care to look after

personal injury and support the injured crew until they fully recover.

Factors identified in this report Initial report Communications: Use closed-loop communications for “On the dock, pulling on the running backstay requires safety-critical evolutions such as lifting. someone pulling the block forward to keep lines off the teak deck. The supervising officer operated the winch at high Teamwork: Better coordination between the speed, and the crew member on the block got their hand winchman and the block handler would have reduced caught in it. As the block lifted, it hoisted the crew member the risk of entrapment. roughly 5m high. It suddenly stopped, catapulting the crew back to the deck, missing the mainsheet track by 10cm. The Local practices: Where possible, reduce entrapment risks casualty suffered a broken wrist, required stitches to the lip by looking for alternative methods to achieve the aim. A floor and chin, and was knocked unconscious for 5 minutes. The covering would have been a safer option. crew member had to pay for their flights home and was off work for a month.” Culture: The report that the casualty had to pay to repatriate themselves suggests poor personnel and welfare standards CHIRP comment on board, which is also an indicator of a poor safety culture. There needed to be better coordination between the supervising officer and the person working the block. Clear verbal warnings that the hoist was about to start would M2083 have alerted the crew member to keep their hands clear. The use of closed-loop communications in such circumstances should be considered, e.g., the crew person responding “Clear!” to the officer’s alert of “Operating winch!” or similar. Tender grounding Large super yachts are fitted with powerful equipment Initial report items, and understanding their power must be part of the “I was asked to take guests on a sunset cruise on a jet drive familiarisation process for all crew. CHIRP also asks whether tender around the island in the South Pacific. I warned the the crew person was even needed. If the concern was that captain that multiple shallow spots on the main yacht’s the block might scratch the teak deck, wouldn’t a canvas ECDIS were not shown on the Tenders. I was told to try, so cover or other covering have sufficed? we set off but halfway around the island, and as the sun

Most effective Physically remove Elimination the hazard

Replace Substitution the hazard

Engineering Isolate people Controls from the hazard

Administrative Change the way Controls people work

PPE Protect the worker with personal protective equipment Least effective

went down, it became harder to see the unlit posts, which that the captain had not developed a good working indicated the safe routes around the reef. relationship with the guests. A formal brief upon their arrival I decided to turn around, and on the return trip, we that “safety supersedes everything else” would have missed one post, and the tender went aground on a reef and prevented the captain from putting themself under pressure could not refloat as the tender as the tide was dropping. We to accede to the guests’ wishes. had no radio or phone signal, but a passing local fisher gave us a lift back to the yacht, and we returned with the fisher on Teamwork/Planning: a thorough risk assessment, a the high tide that night to recover the tender.” better route choice, or a prior recce would all have prevented this incident. CHIRP comment The captain intentionally deviated from safety procedures Communications: When working remotely, assume that in directing the tender trip to go ahead despite knowing that communications will be difficult. Does your vessel have the charts were inadequate for safe navigation, particularly a ‘tender overdue’ procedure to take proactive action to at night. This placed the reporter in a difficult ‘no win’ launch a search or rescue, even without communications? A position: either to disobey their captain or undertake a trip tracking device fitted on the tender should be considered. against the rules of good seamanship. The reporter did challenge the captain, but the captain prioritised the guests’ wishes ahead of theirs and the crew’s safety which suggests M2085 a poor safety culture on board. It also means poor planning – had the trip been organised more thoroughly in advance, the inadequacy of the charts would have become known sooner, and an alternative route away from the reefs might Lack of familiarity with have been possible, or the course reconnoitred by day and saved into the tender’s ECDIS. The Master’s standing orders equipment puts the vessel should state that no tender should leave the mother ship without adequate communications equipment. in danger Similarly, a comprehensive risk assessment would have identified that VHF coverage would have been inadequate Initial report once out of sight of the parent vessel. A patchy phone signal Our reporter served on a >500 GT yacht as part of a newly should always be expected in remote areas. assembled crew. They were employed to take the vessel out of the dry dock and sail to the delivery destination. During Factors identified in this report the passage, an off-duty officer went onto the bridge and Culture: The captain’s order to launch with inadequate noticed a crossing vessel on the starboard bow. The officer charts was a safety violation. on watch was asked if they were going to take action. The

Pressure: the authority gradient between the captain and reporter meant that the latter probably couldn’t refuse the order. Putting guests’ wishes before their safety indicates

D O RME Y INF EAS INGL The Hudson INCR Safety Ladder Generative safety is how we do Proactive business round here we work on the Calculative problems that we we have systems still find

Reactive in place to manage safety is important, all hazards Pathological we do a lot every time who cares as long we have an accident as we’re not caught ST NG TRU EASI INCR

officer responded, ‘Yes, using the autopilot. The off-duty Factors identified in this report officer advised that the vessel was too close to use the Situational Awareness: Situational awareness can be autopilot and that the manoeuvre should be made using seriously affected when stress is high. While getting back hand steering. The officer of the watch appeared to struggle on board, the tender may have been more accessible via the to make the change over to engage hand steering and was stern drive props; it was the most dangerous access point. quickly assisted by the off-duty officer to make the change over to hand steering and take avoiding action. Pressure: Under time pressure to get out of the water, the training officer chose the most dangerous option to climb CHIRP comment out. Even when the engine is in neutral, propellors can An officer must only take over a watch if they are fully sometimes turn sufficiently fast to cause significant trauma. aware of the functions of the bridge equipment. Familiarity with equipment, particularly that essential to safely Complacency: Before making an approach, it is advisable control the ship, must be undertaken during initial to check that the control systems and steering are familiarisation training. functioning as expected. The tender’s controls should If not sure, always ask for clarification. There is a lot always be tested at the commencement of any operation to take in when being familiarised on joining, and some and verified as functioning. operations for the equipment can be complicated and quickly forgotten. M2087 Factors identified in this report Capability: The OOW was unfamiliar with the steering

of this equipment. Maintain control… right to controls and would be considered not competent in the use

Teamwork: Good teamwork relies on knowing the strengths the bitter end and weaknesses of yourself and your team members. In Initial report this case, the duty officer had not requested any support, A motor yacht was in a maintenance shed while work was probably through fear of looking incompetent. carried out on the anchors and chain locker. On the shed floor, a deckhand stood below the hawse pipe to lay out the Culture: When assembling a new team, especially on a chain onto a pallet as it was ‘walked out’ on the windlass by short-term contract where everything and everyone is a deckhand under the Bosun’s supervision. The plan was to new to the team, it is essential to develop a safety culture. detach the bitter end and then walk it forward on deck so This is best achieved through basic emergency exercises, that a messenger line could be attached. However, as the confirming that the emergency systems work as expected. bitter end was walked forward, a bight was created, and this The master is responsible for ensuring that all officers and then fell through the hawse pipe under its weight, narrowly crew can respond to emergencies and support each other. missing the deckhand on the shed floor.

CHIRP comment M2086 Dry-dock work is fraught with hidden safety risks due to the unfamiliarity of the working environment the crew find themselves in. A toolbox talk given by the officer or crew that Dangerous recovery of a has carried out this type of work before to highlight the risks associated with this work should have taken place before the person in the water work commenced. A job like this must not be rushed. Friction and the chain’s weight had probably stopped it Initial report from slipping across the forecastle. However, as the end of During tender training in port, while making an approach, the chain was walked forward, the chain’s weight (and thus the helm discovered that the controls did not respond as friction) would have reduced sufficiently to allow the chain expected because the throttle actuator had broken. The helm to surge forward under gravity. applied astern propulsion to slow the tender; this resulted in It is not clear if the chain had been removed from the greater forward motion. The tender inevitably collided with windlass or whether the windlass brake had not been applied. another moored vessel, and the force of the impact threw the An independent means of controlling the chain, such as a training officer into the water. They recovered themselves ‘stopper’, would have prevented the chain from surging forward. back into the tender by climbing up the stern drive props, These are quick and easy to rig and would have secured the which could have caused the trainer serious injury. chain while the messenger was attached to the bitter end and connected to the drum. As an additional safety precaution, the CHIRP comment deckhand on the shed floor should have been directed to stand Although the trainer was undoubtedly in shock having been away from the chain while it was being ranged. thrown overboard, the decision to get back onboard by climbing up the stern propulsion system was exceptionally Factors identified in this report dangerous, particularly given that the actuator had failed. Communication: Communicate the risks associated with The helm that remained on board should have directed the this work and check that the agreed safety measures are in trainer away from the stern to get back on board the tender place. This includes ensuring that no one is standing in the from the side of the tender using a recovery ladder. direct line of the anchor cable.

Complacency: Seamanship still applies even in the prohibited. Even if the owner had sacked the captain on maintenance shed! A stopper would have reduced the risk of the spot, once they had sobered up, they would most likely an accident. have realised that the captain was speaking objectively, not subjectively. However, even when it could place others in danger, it can still be hard to refuse a request or order by an M2088 owner, particularly if they are used to getting their way or see refusal as a challenge to their authority. In this instance, the owner bullied the captain into launching the jet ski Pressurised to make a against their professional judgement. However, a captain’s first duty is the safety of crew and passengers, and they fatal decision should have refused, no matter the circumstances. To avoid such scenarios, captains are encouraged to Initial report confirm with the vessel’s owner that they are empowered to The superyacht was anchored in a bay where jet skis refuse requests that put people or the vessel at risk of harm – had been prohibited due to the density of traffic in the and, crucially, that they will be listened to. Ideally, this should anchorage and a spate of previous incidents. be done as early in the professional relationship as possible – The owner was on board with a fellow guest who drank potentially even at the interview. Shrewd owners will accept heavily. They requested that the jet ski be launched. The that the captain is looking after their interests. Where such captain explained that using jet skis was prohibited and assurances are not forthcoming, this should be a ‘red flag’ to ill-advised when inebriated. The owner and his guest were the captain that safety on board is at some point likely to be insistent, and this conversation escalated until the captain compromised. Better to seek alternative employment at that was given the ultimatum of either launching the jet-ski or point than find oneself being threatened with the sack in the being dismissed. heat of the moment. CHIRP wants to state that the master The captain yielded to this threat, and the jet ski has other places to report this coercion, which should be launched. Shortly after, the owner’s guest had a high-speed made known to the master. collision with a nearby vessel. The casualty was recovered from the water, unconscious and severely injured; the crew Factors identified in this report found he was not breathing and commenced CPR, but the Fit for duty: Drink had impaired the judgement of both the casualty died before emergency services arrived. guest and the owner. The result was one death, a traumatised crew and owner, and the captain losing his job. He remained out of Pressure/culture: The owner bullied the captain into work for the following two years while under investigation going against their professional judgement. On board, such and threat of criminal prosecution. behaviour was reflected in the safety culture (and probably Superyacht owners are often demanding and “no” is the welfare culture). unfamiliar to them and seen as an insult. Captains who stand their ground risk being side-lined for their professional conduct, and those that do yield to such demands potentially Yacht crew can contact the International Seafarers’ face even more dire consequences. Welfare and Assistance Network (ISWAN) via WhatsApp (+44 (0)7514 500153) for 24-hour help and support for CHIRP Comment issues such as bullying and harassment, unpaid wages, The drink had clouded the judgement of the guest and the and mental health support. See. owner, but the captain knew that jet-skiing in the bay was

Mariners Medico Guide A real breakthrough for seafarers’ medical awareness. The team at Gard and the Bergen University Hospital are to be congratulated for this excellent App, the Mariners Medico Guide. The App (MMG) is easy to download and has an excellent index allowing you to easily navigate where a medical problem or injury has been identified. The Medico Guide is very comprehensive and easy-to- use that will assist all seafarers and the Master with getting the proper treatment for an ill or injured seafarer, including a telemedical assistance service (TMAS) which provides free worldwide contacts to access qualified medical