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MARITIME FEEDBACK reporting system for the Maritime industry

Issue 04 SUPERYACHTS Autumn 2023

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Plotting the course to safe waters Adam Parnell Ensuring equipment is well designed and fit- Director (Maritime) for-purpose is the subject of reports M2136 and M2137, which explain why post-installation quality assurance so important, and why even non-engineers

T he wide variety and dynamic nature of Super Yacht operations makes planning for every eventuality impossible, and we instead rely should question the lack of test certification. While it is impractical to ‘question everything’, CHIRP encourages readers to be curious about safety- on the ‘guiding stars’ of a common goal, good critical systems. communication, teamwork and a strong safety culture Maintaining situational awareness during to frame our decision-making and actions. In doing so, maritime operations is vital to prevent accidents we make certain assumptions: when we encounter or personal injuries, especially when line-handling deficiencies in the information available, we assume (M2138) or in tight spaces (M2142). Crews are that our knowledge, experience and professionalism reminded to remain vigilant, question existing will compensate; every individual is suitably practices, and respond quickly to warning signs. competent and experienced, and the equipment we One aspect of crew well-being is the use is well designed and fit-for-purpose. We may also management of food allergies and intolerances. assume that safety will be prioritised over commercial Companies must have effective policies in place for interests, and that this view is shared by owners, recording medical conditions, and such allergies need guests and leaders alike. to be declared to ensure the correct medicines are Recent incident reports received by CHIRP available and correctly administered when required. challenge each of these assumptions, which are As ever, we are thankful for the incident and addressed on the following pages. In our first report near-miss reports that companies and individuals (M2111) we tackle the fallacy that ‘the boss is always submit to us. Your reports have impact: you are right’ (they aren’t, because they’re human too!) helping to raise awareness of important safety issues, and remind leaders that constructive questioning is and by doing so, you are preventing future incidents, not a challenge to their authority. Certainly, raising and keeping others safe. Thank you. reasonable safety concerns are not grounds Yours in safety, for dismissal! Adam

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.

M2140 Teamwork – The response by the crew was excellent in ensuring the crew member’s safety- How often do you

Allergic reactions practice medivac drills using a similar scenario?

A crew member experienced an allergic reaction during a recent incident while working in the catering department. M2137 They reported feeling tingling in their gums and a tightening sensation in their throat after having lunch. They promptly took antihistamines, and the Head of Department (HOD) was notified. Personal Injury due to Although the symptoms did not worsen, the decision was made to seek further advice as a precautionary gangway malfunction measure. Medaire was contacted, and they recommended taking the crew member to the local hospital for a Initial report thorough check-up. Another crew member accompanied While walking down the gangway to receive a package them, and an EpiPen was administered as a precautionary being delivered to the vessel, the gangway swung out from measure. The crew member received two additional underneath them and they fell into the water, hitting their chin injections at the clinic and was observed for two hours and right wrist on the quayside on the way down. They were before being discharged. partially submerged under the dock but kept one hand on it. The investigation revealed that the crew member Luckily, they were swiftly rescued by a passing dock had unknowingly consumed citrus fruit juice during their worker who pulled them out of the water, and although prepared lunch, which they were allergic to. The tingling they had a sore head, neck, and arm, they could easily have gums, throat tightness, and difficulty breathing matched the suffered much more significant injuries. symptoms of an allergic reaction. A post-incident investigation found that the gangway had not been correctly installed and that this was due to CHIRP Comments: poor supervision. Although the company ensured that chefs were aware of the allergic effects of some foods, neither they nor the CHIRP Comments master knew that someone on board was allergic to citrus. This incident highlights the importance of proper equipment Persons who know that they are allergic or intolerant installation and safety certification for superyachts. CHIRP to certain items are encouraged to declare this when they discovered several critical flaws. sign on. While such information is ‘medical in confidence’, it Firstly, the design of the securing arrangement was needs to be recorded somewhere so that effective first aid inadequate and had likely been this way since build. The can be given should they be incapacitated and unable to securing bolts were only screwed into the GRP fairing communicate this. because the backing plate (into which they should have To ensure your safety, your manning agents must be been affixed) was misaligned. This seriously compromised aware of your allergies, and your medical chest should the structural safety of the gangway fixing arrangement. carry sufficient medication in case of a reaction. Additionally, Secondly, there was no Safe Working Load (SWL) plate ensure you know your medical response contact details, next to the fixing point, so the crew could not know the especially when you are not in or near a port. gangway’s maximum capacity or working limitations. CHIRP would like to commend the officers and crew The incident raises questions about the quality assurance of the motor yacht for their excellent response in seeking of the vessel’s build, and whether differences between the advice and promptly getting the crew member to the local vessel ‘as designed’ and ‘as built’ were properly identified clinic for further assessment. The company’s commitment to and documented. It is imperative that these are discovered a strong safety culture, prioritising the crew’s well-being, is in during the building because they can significantly alter highly commendable. operating limitations. Once the vessel has been handed over to a crew, it is highly likely that such deficiencies will only come CHIRP would like to commend the officers to light when the equipment catastrophically fails. Readers may detect similarities with the report in our previous edition and crew of the motor yacht for their about the failure of a lifting eye when hoisting the seaboat. excellent response in seeking advice and Collaboration among the shipyard, classification society, promptly getting the crew member to the and contractors is crucial. Managers for the superyacht need to work closely with all parties involved to ensure local clinic for further assessment. proper communication and coordination throughout the construction and installation processes. All equipment Factors identified in this report should be certified as safe according to the appropriate Alerting – Ensure you alert your managers and the crew design specifications before being put into service. you work with about your allergies. It can save your life! For newly built superyachts, an experienced new-build team should work closely with the shipyard, class, and Communication – Does your company have a policy on contractors to identify and rectify potential issues during allergy reporting? Society has more allergic reactions construction. It is noted that not all owners use a new-build than ever, so we must be more mindful. Does your SMS team during the construction and fitting-out phases. If this is health and safety section have a section on allergies and the case, management must be responsible for verifying the their response? testing and sign-off for the equipment.

Factors identified in this report According to our reporters, escape from the vessel was Capability – Always check out the capabilities of contractors hampered by missing handles on one of the emergency employed to carry out work on safety critical or access escape hatches, and missing handrails on the stairs between equipment. Seek assurances that they have the experience decks made it extremely difficult to get out of the vessel. to carry out the work and always check the result by The lack of securely fastened furniture, including unsecured someone experienced to sign off the job as being carried out beds, also created a hazardous environment with floating competently. Consult with the shipyard and class society to debris obstructing escape routes. None of the passengers check if they have signed off on the installation. This cannot received a safety briefing upon boarding the vessel. be left to the crew to do!

Local practices – When commissioning new vessels or equipment, question and challenge everything (yes, we know this can be very tiring and time consuming, but it can save your life! Has the installation been completed according to the specification and testing requirements? A member of the management team or new build team should be responsible for ensuring that the work has been completed and tested. The fact that there was no SWL plate on the gangway indicates that proper sign-off for the installation was not carried out. Despite the passengers raising concerns on several occasions, it is troubling that the M2136 crew neither recognised nor reacted to the obvious warning signs Capsize of a Dive Safari Vessel and Rescue of CHIRP Comments Significant structural changes invariably affect stability, and Tourists and Crew inclining tests must be conducted to update the vessel’s stability curve data. Despite the passengers raising concerns on several occasions, it is troubling that the crew neither Initial Report recognised nor reacted to the obvious warning signs. At best, Two additional decks had recently been added to a large this indicates a lack of training and at worst, the company liveaboard diving vessel which was subsequently chartered put commercial interest above crew and passenger safety by a diving group for a trip to do both wreck and reef dives. by continuing the voyage. Although the vessel had Early in the voyage, members of the dive group noticed significant safety design defects e.g., lack of handrails on that the vessel had a consistent list to port of approximately the steps between decks, the crew also demonstrated a 2 to 3 degrees. They raised this with the crew, who assured complacent attitude to safety: items were not correctly the divers that this was most likely due to the unbalanced secured for sea, nor were basic safety items such as the life filling of the freshwater tanks for the voyage. raft painter correctly fitted. These, and the lack of a safety The vessel departed in the morning, and group briefing for the guests, all point to a poor safety culture completed two guided dives before the vessel went to compounded by inadequate crew training and competency, anchor overnight. It was a calm night, but the group noticed The successful rescue of all passengers and crew is a that the list had increased to 4-5 degrees. Again, the crew testament to the diving guests’ exceptional bravery and quick reassured the group that all was well. thinking. CHIRP has maintained contact with the dive team At first light, the vessel got underway and set off to following the traumatic rescue. Many of them, including the another dive site – this time with a list of 5-6 degrees. passengers, are now receiving trauma counselling therapy. As it approached the main shipping lane at 10 knots, the vessel heeled over to starboard and over the next hour the Factors identified in this report list progressively worsened until it capsized onto its side Design – Poor design choices when installing the in less than 30 seconds. One of the vessel’s life rafts was additional decks significantly affected the vessel’s stability. released but did not inflate as the painter was not secured Scrutiny of the stability requirements should have occurred to the vessel. It was later manually inflated but could not before the refit; and after the work had been completed, it be righted. The 2nd life raft was released and inflated, and should have undergone an Inclining test overseen by the the vessel’s tender boat, despite being slightly damaged, Class society and Flag. was used to tender passengers and crew to the life raft. Flares were released, and other nearby dive vessels came Pressure – Commercial pressure to return the vessel to to assist. The dive team on board carried out dangerous service meant that stability tests and sea-trials were not and courageous rescues within the vessel to free trapped conducted. And once it had begun its fee-earning voyage, passengers and crew. passengers’ concerns were ignored, which ultimately led All passengers and crew (35) were eventually accounted to the vessel’s capsizing and endangering the lives of all for and taken back to port, where further assistance from the passengers and crew. Commercial considerations must navy was provided to the traumatised survivors. never be at the expense of safety. If you are a crew

member joining (or on) a vessel that has had substantial CHIRP Comments structural change, ask to see evidence that stability tests and The reporter informed CHIRP that a pre-departure meeting sea trials were correctly carried out. was conducted before they left the tight berth. Due to the narrowness of the berth, the proximity of the ground lines Situational awareness – The crew did not recognise that and the limited space ahead, manoeuvring took a lot of the unexpected list was a sign of potentially inadequate work. The reporter also mentioned that this incident marked stability, nor did they react when this got worse during the the second time they had encountered difficulties while voyage. This is most likely due to insufficient training. departing from such a tight berth. Our Advisory Board members discussed whether Culture – The operating company and the owners additional mitigation measures might have further assisted lacked care for the passengers and crew, as reported to the master and crew during the departure. These included CHIRP. They were not offered any counselling following asking the port to temporarily relocate some of the other their traumatic ordeal and had little in the way of any small boats to provide more clearance or the use of mooring compensation despite losing all their equipment and lines to warp the vessel until it is clear of potential hazards. possessions. Their lives were only saved because of their It is best practice to discuss problematic departures professionalism as divers. the port authorities, and an illustrated departure plan is very helpful in such situations. These plans must consider the vessel’s specific requirements and consider potential M2142 hazards like the presence of ground lines. Escalating the issue to the port’s management well in advance can ensure adequate attention and resources are allocated to address Contact with ground your (un)berthing concerns effectively. CHIRP emphasises the significance of thorough lines while departing planning, clear communication, and situational awareness when manoeuvring in and out of challenging berths. The a repair berth master’s skill in positioning the vessel to allow the removal of the ground lines from the stabiliser fin played a crucial role in The reporter informed CHIRP of an incident during departure preventing a much worse outcome. from the berth. The vessel was med-moored (berthed stern-to) in a Factors identified in this report challenging location. It was positioned between another Local Practices – Engage with port authorities: employ yacht on the port side and a dock of small sailing vessels open communication and, when appropriate, seek approximately 50 meters ahead on the starboard bow. The assistance early. If this practice is not common, challenge departure manoeuvre required careful controlling, with only the status quo. 1 meter of clearance on either side and numerous ground lines present. Pressure – Avoid letting pressure drive decisions. Prioritise During the departure, the starboard stabiliser fin safety above all else and avoid making decisions solely snagged a ground line belonging to one of the smaller based on external pressures or tight schedules. Conduct sailing vessels. This incidental contact caused a slight thorough risk assessments and carefully consider the movement among the adjacent yachts, resulting in a slow potential consequences of not exercising caution during collision between the yacht’s hull and the vessel whose manoeuvring operations. If a situation feels unsafe, insist on ground line was entangled. receiving support from the port before proceeding. Upon realising the situation, the master held the vessel steady in an awkward position while the entangled ground Teamwork – Embrace teamwork and encourage challenges: line was safely removed. The shipyard was promptly foster a culture of teamwork and collaboration among contacted, and they confirmed that no evident damage was all involved personnel. Encourage team members to observed except for the snagged line. The stabiliser was also continuously question existing practices and propose assessed and proved to be operational with no damage. improvements to enhance safety and efficiency. Even seemingly minor contact damage can escalate into more severe incidents, making teamwork and cooperation crucial.

M2138

Personal Injury during mooring operations Initial report During mooring operations, and while a 25’ tender was simultaneously being secured alongside the superyacht, the yacht’s aft spring line unexpectedly came under pressure. The Chief Officer’s fingers were caught between the mooring

line and the deck cleats, resulting in three broken fingers and planned track buts still grounded because of a combination nail and skin lacerations. The chief officer was working alone. of shallow water, speed and squat. This resulted in the The incident prompted the company to introduce safety vessel dry-docking for several weeks for significant repairs. improvements during mooring operations to prevent such The reporter explained that the master created all accidents in the future. passage plans,