An independent and confidential

MARITIME FEEDBACK reporting system for the Maritime industry

Issue 03 SUPERYACHTS Summer 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

CHIRP Maritime – There For Everyone

Adam Parnell ensure the equipment is always in good condition Director (Maritime) and ready for use in an emergency. The issue of mental health in the maritime industry is addressed in report M2127. It highlights the pressures and

W elcome to the Summer edition of Superyacht FEEDBACK, a safety newsletter that explores topical safety issues based on your submitted reports. stresses faced by seafarers and the need for support systems to help manage these challenges. The report encourages the industry to prioritize mental health In report M2124, CHIRP Maritime highlights the and well-being and provide access to resources such risks associated with mooring operations. The report as counselling services. emphasizes the importance of proper planning, Finally, report M2128 highlights the importance communication, and coordination between the ship’s of effective communication between the bridge crew and the shore team to prevent accidents during team and the engine room team. It emphasizes the mooring. Report M2125 focuses on the dangers of need for clear and concise communication to avoid working aloft. It highlights the importance of adequate misunderstandings and prevent accidents. safety measures, such as safety harnesses and Don’t forget that CHIRP Maritime is there for proper training for crew members, to prevent falls and everyone in the maritime community, at sea or ashore injuries while working at height. and we welcome reports from all roles and trades, M2126 discusses the importance of proper not just deck, navigation or engineering but chefs, maintenance and inspection of safety equipment, crew managers, housekeeping, stewards, surveyors, such as lifeboats and rescue boats. It stresses the training staff, too! need for regular inspections and maintenance to Until the next edition – stay safe!!

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.

M2125 make sure that the sampling is representative of the space to be entered- several sample points must be obtained,

No gas detection often at different heights off the deck. The Advisory Board also recommended that the

equipment carried 2-monthly entry and rescue drills required by SOLAS should not only focus on the physical drill and the rescue

on board but raise awareness during the drill of what constitutes an enclosed space. It is best practice to identify these spaces eg with signage or similar (We recommend “Enclosed Initial report space - no entry allowed until all entry RA and PtW Our reporter worked on a commercial yacht under 500gt requirements are met”) where allegedly there were no enclosed spaces, even though there were compartments below decks that were not ventilated. No gas detection equipment was carried on The importance of proper board and it was impossible to determine whether bilge recording of the maintenance spaces, chain lockers, steering flats etc, were safe to enter or work in. of the equipment is essential and cannot be overstated. CHIRP Comment This reporter is to be praised for raising this matter and for showing a high level of safety awareness. Enclosed spaces Factors identified in this report kill an average of 10 seafarers every year. Culture – Underestimating or ignoring hazards are signs of The definition of an enclosed space can be found a poor safety culture. In this incident there appears to have in SOLAS Regulation XI-1/7 as well as The Code of Safe been no thought given to ensuring that enclosed spaces on Working Practice (COSWP) chapter 15: the super yacht can be ventilated and tested for safe entry. A space which is not designed for continuous worker The reporter has challenged this culture by raising this report, occupancy and has either or both the following which is commendable. characteristics: limited openings for entry and exit and/or inadequate ventilation. Capability – Identifying enclosed spaces is not always easy; Enclosed spaces do exist on super yachts, and can are you confident in your ability to do so? include areas such as chain lockers, bunker tanks, paint lockers, battery lockers, peak tanks, cofferdams, sail lockers Local practices – Owners are recommended to commission and void spaces. Arguably non-tank spaces are more an external safety audit to ensure that hazards are correctly dangerous as crews are less aware of the risks. Never identified and that minimum safety management standards assume that a space is not an enclosed space- always check! are being applied. If access to any of the above spaces is required, then proper entry procedures must be followed. These include a risk assessment (RA), a test of the atmosphere using M2124 properly calibrated portable atmosphere testing equipment and the completion of a permit to work (PtW). If the testing equipment is not on board, then entry must not be attempted. The testing equipment should be capable Lifting eyebolts failed of testing and displaying the amounts of oxygen, carbon monoxide, hydrogen sulphide and flammable gases. Vessels while launching a Tender which do not have properly approved and calibrated gas Initial report measuring equipment and portable gas-freeing fans should Our reporter was part of a team launching the tender from obtain them before any enclosed space entry is undertaken, the shell door opening in calm weather conditions. After and in any case the compartment should be thoroughly checking the hoist arrangement and securing the forward vented for several hours prior to entry. and aft lifting arms, the tender was lifted off the chocks. Although there are some exemptions to the rules for Another crew member went around to lower the outboard carrying gas measuring equipment, CHIRP’s Superyacht side of the tender chocks. Once they were back inboard, Advisory Board were united in their belief that it should the crane arms were extended, but when the tender was always be used, particularly as it is relatively cheap (many halfway out, the bow suddenly dropped to the deck and slid models cost less than $500 USD). The crew must also into the water. Meanwhile, the aft end of the tender hit the receive training in calibrating and using the equipment. deckhead, sending ceiling panels flying. Calibration can usually be carried out on board, although The cause was a sheared eye bolt thread. No additional some models can only be calibrated ashore. The importance loading was introduced while lifting the tender until the point of proper recording of the maintenance of the equipment is of failure. The eyebolt conditions appeared to be in good essential and cannot be overstated. condition, although there was some uncertainty about when Concerning gas-freeing fans, they should be sourced they were replaced last. to ensure that the largest space can be thoroughly vented with enough force ventilation to ensure that no pockets of CHIRP Comment atmosphere with insufficient O2, toxic and/or flammable Such incidents are not uncommon, and failure under load gases remain. When sampling the atmosphere, always is often caused by inappropriate eyebolt design or weight-

Representative image: Shutterstock

This cautionary report reminds us all never to stand or pass under any suspended load, as failure can occur unexpectedly either with inadequate or poorly maintained lifting equipment.

carrying capacity. When lifting, we naturally focus on the Local Practices – As the eyebolts were replaced, it is type and rating of the lifting strops used, but often the fixed essential that the original equipment parts were replaced lifting points are overlooked. Lifting eyebolts should have with the same specification eyebolts. Thoroughness in the their capacity and test-date stamped on them or on a metal procurement process is critical to ensure that the tender test certificate affixed immediately adjacent to them. Be sure can be lifted each time safely. How thoroughly do you to check your lifting arrangement for the tenders and work procure original spare parts? Does your management have a boats on your vessel! procurement policy? This information will be available in the new building spec for the tender. The tender’s crane and lifting equipment should also have been subjected to a proof test, like M2127 commercial vessel lifeboats. When eyebolts are replaced, it is important to replace them with the same specification as the original, and properly fixed back in position. Another contributing factor Inappropriate risk can be the angle that the eyebolts make with the lifting shackles. If the lifting eyebolt and lifting strops are not in assessment alignment, a shear force is produced which can cause failure Initial report of the eyebolt/s. During a passage through a busy straight at night, the This cautionary report reminds us all never to stand vessel started to vibrate heavily. Weather conditions were or pass under any suspended load, as failure can occur uncomfortable, with two-meter swells and high winds. The unexpectedly either with inadequate or poorly maintained general alarm was sounded and the vessel stopped. The lifting equipment. position was checked, with no apparent signs of grounding, as the vessel was in the deepest part of the straits. There Factors identified in this report was minimal traffic in the area. Overconfidence – Often there is an expectancy that the When the engines were reengaged, significant eyebolts will ‘just work’. Be aware of such single points of vibrations were felt on the port side, indicating an object failure in a lifting rig and pay particular attention to these around the prop. While investigations were carried out in the areas, such as deformation, pitting or wear and tear. engine room and the rest of the vessel, the engines could not be used to keep the vessel pointed into the weather, and Capability – During our investigation we heard anecdotes she began rolling heavily. from yacht crews that eyebolts were sometimes changed The captain asked the deckhand/dive instructor if they locally, with a different design e.g. to be less obtrusive. Given could dive under the hull to carry out an external inspection. the criticality of the eyebolts for safe lifting, maintainers Despite the conditions, the deckhand- who was the only must ensure that the eyebolt specification is safe and qualified diver- agreed. Preparations were made and all aft meets the original design requirement, which will have an machinery was isolated. The bow thruster was used to keep additional safety margin for shock-loading lifting forces. If the vessel head to wind. Lots of lighting gear was used, and you’re not certain that the eyebolts on your vessel are ‘as a safety line with a quick release was attached to the solo originally designed’ then seek expert advice! diver who entered the water.

The pitching hull struck the diver several times and an attached safety line, a lifejacket, and a helmet. After doing they quickly aborted the dive for safety reasons, but it took his buddy checks, he went outboard to inspect the windows. 10-15 minutes to recover the diver onto the swim platform He realised he was missing one carabiner and grabbed because the vessel was moving so violently. Once onboard, a quick-release shackle, which was used as the primary the vessel continued its passage to harbour using the point for connecting to the vessel. A little while later, a starboard engine only, where a large tree trunk was found deckhand found the chief officer swimming behind the boat. stuck between the port shaft and the vessel’s hull. The chief officer reported that during the inspection, he had accidentally knocked the quick-release shackle, which CHIRP Comment released the safety line causing him to fall into the water. Many aspects of this report are disturbing. An objective risk

X assessment would have identified that the sea and weather conditions were out of limits to carry out diving operations safely. The safest option was to head back to port on a single engine, where an inspection could safely be carried out in daylight. Although the deckhand held a recreational diving instructors’ licence, they were not a qualified commercial diver. Commercial diving requires a diving team in attendance so that a diver can be rescued if they get into difficulty. There was no back-up here; this was a clear demonstration of the ‘overconfidence effect’.

✓ The ‘overconfidence effect’: where a person’s subjective judgement is greater than the objective accuracy of those judgements. Finally, the captain should have recognised that the authority gradient between themselves and the deckhand placed unspoken pressure on the deckhand to agree to the task. No crew should feel pressured to carry out a task which is clearly unsafe and dangerous.

Factors identified in this report Situational awareness (SA) – Intentionally isolating propulsion machinery and making the vessel ‘not under command’ in a busy strait at night and in poor weather demonstrates poor SA by the captain CHIRP Comments The chief officer was following the permit-to-work Overconfidence – In seeking to employ a recreational requirements and used a crew member (buddy) to ensure diver on a commercial diving task outside of safe weather that the gear was being worn correctly in accordance with limits, the captain should have recognised their own the PtW, which is commendable. However, picking up a overconfidence bias. This was poor judgement. quick-release shackle instead of a carabiner and using it as the main securing point created a single point of failure Pressure – The authority gradient pressurised the deckhand which inevitably led to the fall from height. to dive in obviously dangerous conditions. CHIRP stresses that working at height PPE should be kept separate from other lifting or securing gear. This Teamwork – Did the crew feel empowered to challenge to the gear should be stored in clean, secure compartments and decision to undertake the dive, or was “group think” involved? regularly scrutinised for damaged. The PtW requirements were not followed properly Capability – The diver was not qualified to undertake this because anyone working at height must be fully supervised task, nor were the crew capable of mounting an effective during the work. No other work activity should be undertaken rescue operation. which takes away that essential duty. It’s important to ensure that the crew are trained on the full requirements of the PtW system so that the full process is followed. In previous M2128 FEEDBACK editions, CHIRP has emphasised that when crew are working aloft a rescue plan must always be prepared as part of the risk assessment. Crew members who fall and are Permit to work checks not suspended by their safety harness must be rescued within 15 minutes to avoid serious injury or even death due to blood thoroughly completed circulation being constricted.

Initial report Factors identified in this report While at anchor, the chief officer went outboard to inspect Communications – Clear communications must be provided the windows as part of a routine maintenance check. to the crew who is spotting the person working aloft. When He wore the appropriate PPE in accordance with the your crew work aloft, do you have crew spotters who know requirements of the Permit to Work (PtW), a harness with what to do if a person is suspended by the safety harness?

Distractions – Nothing should distract the person attending executive team: no crew member should ever be inside the to the crew working aloft. Use additional crew who have chain locker when a cable is about to be lowered or dropped. been briefed about the work and the PtW if the spotter can A chain hook or other wooden device must be used to only sometimes be there. flake out the cable to prevent it from piling up and stowing in the chain locker, and the crew member attending to this task Teamwork – Work as a team and share what will happen must leave the locker once it is complete. with those assigned to the work. Making sure that the There appears to be a design issue with the chain equipment that is going to be used for the job is correct and locker: either the locker is too small to accommodate the in good condition. cable pile when the anchor is stowed, or the spurling pipes are not adequately designed to allow the cable to self-stow. Pressure – the chief officer placed pressure on themselves Design modifications should be considered to eliminate this to carry out the task with inappropriate equipment – a quick- unnecessary risk before the next docking. release shackle is not a suitable replacement for a caribiner! Crew training should be provided on anchoring procedures and the risks outlined. The wearing of ear defenders is questionable when clear audible M2126 communications for anchoring operations are required, and a clear means of communications must be found.

Anchoring Angst Factors identified in this report Design – The poor design of the anchor system created Initial report an unnecessary risk which required a crew member to The owner was unhappy with the anchorage location and manually flake the cable to prevent it from piling up. wanted to move. The anchor was weighed, and the deckhand Redesigning the spurling pipe in the chain locker to went into the chain locker to stow the cable. They wore ear allow the cable to self-stow and not pile up is highly defenders due to the noise of the cable in the chain locker. recommended. The anchor was weighed to the water line and the vessel was relocated to the new anchorage position where Communications – Communications failed, which created the order was given to drop the anchor again. this potentially severe near miss. The deckhand was still in the chain locker and was either Good operational safety relies on everyone knowing not informed or did not hear that the anchor was about to what is going on so that everyone can contribute to a safe be let go, and still had