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MARITIME FEEDBACK reporting system for the Maritime industry

Issue 06 SUPERYACHTS May 2024

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Questions of integrity Adam Parnell crew to join a new vessel can carry out a thorough Director (Maritime) risk assessment by inspecting every part of the yacht and asking themselves how everything will work in practice and what potential dangers might have been

I f there is a common theme running through this new edition of Superyacht FEEDBACK it concerns integrity. introduced as a result of the design. Then there are issues around operational integrity – are there sufficient crew numbers, is the proper PPE We start with two cases where watertight provided, and is it used? integrity, or its absence, was the main contributing Finally, we consider system integrity. Naming the factor. Fortunately, in both cases the crews responded master as the DPA is wrong in principle, contravenes in a very professional manner and a major disaster the requirements of the ISM Code, and is also was avoided. obviously a bad idea! Several cases involve what we might call design There are some excellent reports in this edition integrity – inadequate alarms, poorly-positioned and much food for thought. We thank all our reporters heating lamps, and areas where explosive vapours for bringing the issues to our attention so we may all can build up to name a few. We strongly believe in learn the safety lessons they have raised. the benefit of having senior officers present during Yours in Safety, construction. Still, even if this is not possible, the first The CHIRP 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.

M2242 Alerting – How well do your alarms alert you to a problem? Can you recognise the alarm from its sound

Near miss - breach of or light function? Are you shown these alarms as part of your familiarisation?

watertight integrity Situational Awareness – During your motor yacht’s operational service, ask questions to identify potential single Intial report points of failure for operational and personal safety. While underway during a busy trip, the lookout performed their deck rounds. They found the shell door fully open when they entered the tender bay, which is located on the lower M2243 deck, approximately 8” above the waterline. Water entered the tender bay due to the vessel’s movement and swell. This caused the loss of some equipment but, fortunately, the vessel’s stability was not severely affected. The issue Explosion in the was quickly reported, and the door was secured safely. Upon investigation, it was found that there was severe engine room salt build-up inside the controls of the door, which had Intial report caused a ‘short’ of the ‘open door’ button. This caused the The incident occurred on a relatively small motor yacht (70ft) door to operate and open without any human control. with just three crew members. After approximately six hours The bridge has indicators for the door status, but they at anchor, the guests decided to head back to the marina. After are inconspicuous and inaudible. There is also an isolation stowing all the water sports equipment onboard and securing switch, but the Standard Operating Procedure (SOP) did not the aft platform, the master engaged the main engines. include using it at sea. With contacts on, the starboard engine exploded in the Subsequently, the company installed a Deadman switch engine room, located aft, under the area where the guests into the door system to eliminate the single point of failure, were. By checking the CCTV, the master could see only updated the SOPs, informed the fleet (especially the sister misty air. None of the alarms were activated. ships), and reviewed the risk assessments for similar issues The master switched the contacts off, and the elsewhere on the vessel. ventilation system was cut off automatically. The master went down and didn’t know what to expect, as no alarms CHIRP’s comments were raised. After looking through the viewing port, the door This incident highlights a critical flaw in the design of the to the engine room was opened to ensure there was no fire, vessel’s tender bay doors, requiring immediate action to but the engine room was full of contaminated air. The door prevent potential accidents. CHIRP commends the crew was closed immediately. members for their vigilance in detecting and averting a The guests were notified that a tow was requested to severe malfunction and notes that good old-fashioned return the vessel to the marina. safety rounds brought this to the master’s attention before the amount of water being taken on board seriously affected the superyacht stability. The vessel’s alarm systems and reliance on a single point of failure raise concerns about the thoroughness of consultation concerning the ergonomics of alarms and controls during construction. Alarms placed in inconspicuous places that cannot be seen and are inaudible due to normal background sounds are useless. Management’s proactive steps to eliminate this single point of failure and update safety procedures in the Safety Management System (SMS) are commendable. However, CHIRP also recommends prioritising enhancements to the weatherproofing and sealing mechanisms of the tender bay doors, alongside measures to combat corrosion. Not actual event, for reference only. Maintaining watertight integrity in vessel design and operation is paramount, and CHIRP feels that implementing CHIRP Comments these measures and enhanced crew maintenance training A starting battery explosion is a regular occurrence on some is necessary. This incident highlights the importance of superyachts, where the necessary knowledge of battery addressing vulnerabilities in vessel design, particularly maintenance is lacking. concerning environmental factors and technical failures. From a technical perspective, CHIRP highlights that the maintenance of the starting batteries requires a good Human Factors knowledge of them to ensure that they are safe to operate Design – There was a latent defect that meant the equipment and adequately charged. Venting hydrogen during any was not fit for purpose either on the bridge for alerting or on charging operation is vital to provide a safe atmosphere. the tender deck against exposure to the weather. Do critical There was a lack of knowledge or a lack of knowledgeable controls for your vessel’s opening and closing appliances rely crew to check that the batteries were in good condition and on a single point of failure? Have you checked? safe to use.

From a crew resource perspective, a risk assessment The failure to secure the tender for towing during pre- based on assessing the hazards and threats to the departure checks and procedures underscores the importance vessel should be carried out to determine the number of thorough preparation and adherence to good seamanship. of crew members to employ to cover maintenance and Implementing a checklist that cross-checks the towed emergencies safely. vessel’s watertight integrity could prevent similar incidents There appears to be no minimum manning level for a in the future. Additionally, considering weather conditions yacht of 21 meters, and it is based on the owner’s financial and setting appropriate limits for towing operations are other willingness to employ the minimum number of crew for the essential safety measures which must be considered. service being provided rather than being able to respond to CHIRP recommends rigging a camera on the tender for an emergency. visual monitoring during towing. This would enhance safety CHIRP advocates that Flag States should have a and situational awareness, allowing for timely adjustments say on the minimum manning level based on the risks to course and speed and interventions if necessary. of the vessel’s operations and the number of guests being carried. Human factors Capability – The crew checking the tender before towing Human Factors paid insufficient attention to its watertight integrity. The Capability – The vessel did not have adequate inspection flooding of the engine compartment shows the consequences and maintenance schedules to ensure the batteries were of this omission, which could have been much worse. Do you safe. Does your motor yacht have a maintenance schedule have a checklist for your towing operations? for items of critical importance? Situational Awareness – When towing, consider the bigger Culture – Organisational culture needs to change, and picture and conduct a risk assessment to ensure all hazards safety should be managed using a risk-based approach. are considered. Is towing a tender part of your SMS? How many crew members does your vessel carry compared to a similar-sized vessel? M2167 Teamwork – With only three crew members, including the master, the feeling of teamwork can be challenging to achieve. Galley fire M2240 Intial report During a final clean-up, a chef was leaving the galley area and noticed smoke seeping from a door in a smaller, Damage to a tender less frequently used section of the galley. Concerned, the chef investigated and found that several pizza boxes under tow had caught fire. These boxes had been stored under heating lamps, which, unknown to anyone, had been Intial report inadvertently switched on during the cleaning process. Upon approaching an anchorage with a 38ft tender in tow, Acting promptly, the chef immediately reported the fire the crew noticed the tender sitting low in the water and to the bridge using the radio communication system, assumed it was sinking. The master was notified by radio, then turned off the heating lamps and retreated to a safe and the chief officer ran to the aft to assess. The chief distance near the doorway. officer noticed that the speed reduction (when approaching Responding swiftly, the duty deckhand arrived at the the anchorage) was causing the tender to sink, so he scene without delay. Their initial attempt to suppress the requested that the captain increase speed again and not fire using the high fog system was met with challenges enter the anchorage. due to the fire’s growing intensity. Meanwhile, another chef Another yacht’s tender noticed the problem and came joined the effort, moving the burning pizza boxes away from over to offer assistance. Two crew members were transferred other items to contain the fire’s spread. With the escalating to the other yacht’s tender, taking fenders and a pump. situation, the duty deckhand used a foam extinguisher to As the crew approached the towed tender, it was effectively put out the flames on the pizza boxes and the apparent that the side boarding door was slightly ajar. A area surrounding the heating lamps. crew member was transferred to the towed tender and was Additional crewmembers quickly arrived and took able to shut the door. With the boat’s movement through decisive emergency measures, shutting down all electrical the water, the tender soon emptied via the aft scuppers systems and ventilation in the galley to prevent the heat and freeing ports. The tender was saved, although the from the fire from spreading. Simultaneously, nearby doors engines were flooded. were promptly closed to curtail the spread of smoke to other parts of the ship. CHIRP Comments The ship’s engineers discussed the manual operation The crew on the towing vessel and the response team are of the ventilation system from the engine control room to be praised for their good actions, especially the officer’s (ECR), aiming to extract the lingering smoke from the galley quick thinking and seamanship skills, preventing a more area efficiently. serious situation. As demonstrated in this case, proper From the moment the fire was reported to the bridge, training and expertise onboard are crucial for handling the containment and control of the fire took approximately unforeseen incidents effectively. six minutes.

CHIRP Comments fire. It is a valuable lesson for maritime safety and emphasises CHIRP wants to praise the crew and management for having the importance of continuous training and preparedness. a well-trained crew which handled a potentially dangerous situation swiftly. However, there are a couple of points Human factors that CHIRP wishes to highlight. The bridge was notified by Situational awareness – The crew response to the radio, and the incident was responded to. Still, the fire alarm, emergency was excellent. The probability that the heat lamp including a loud vocal alarm (LVA), if fitted, should always be switch could be accidentally switched on during the vessel’s sounded to alert everyone to the existence of a fire, and the lifetime and create a heat source to contact packaging ventilation should be stopped if not done automatically. The stored in the galley store was high. use of high fog as an extinguishing medium could have been more effective and, in this case, raises the question of whether Communication – This switching arrangement was it is the proper application for a fire that has taken hold. likely similar to that of other ships of the same class. Heat energy transference from an energy light source Communicating the possible hazards to other ships of the can be extremely high, and direct contact is not necessary to same class by labelling the switch and providing safeguards start a fire. Materials such as cardboard and plastic coverings for preventing contact with flammable materials is required. will quickly smoulder or melt, even in close contact with regular shipboard lighting sources. A minimum distance Design – Better design at the new building stages with built- warning sign should be positioned near any heat lamp so in safeguards for heat contact and switches in the same that flammable material cannot be heated to combustion, room as the lamps would help prevent accidental use. or a suitable guard should be placed around the lamp to provide a physical barrier that meets the minimum safe distance if applicable. M2236 Light switches should be labelled appropriately and positioned in sensible locations close to the storerooms they serve. They should also be clearly labelled. If in doubt, ask the electrical officer to check the function of the switch Working at height in question. Storage of any material should always be considered without any PPE from the point of view of fire risk and how to control that risk. Intial report Eliminating the hazard is the best way to reduce risk. If, after Our reporter sent a photograph of a crewmember working at the debrief for this incident, the heating lamps are found to height outboard of the vessel, engaged in window cleaning. serve no operational function, consideration should be given They were not wearing any fall arrest equipment, and if they to isolating the circuit. Hence, they become non-operational had slipped, they would have fallen approximately 10m to the and labelled as such. concrete quayside below and been seriously injured or killed. The incident underscores the importance of crew They were contacted by a nearby crew on another members’ vigilance, effective teamwork, and everyone’s yacht to wear protection, but they refused to take any action. critical role in ensuring the ship’s and its occupants’ safety and security. Different crew members’ collaborative and CHIRP Comments swift actions—from the chef’s initial discovery to the CHIRP has raised concerns about the incident with the coordinated response efforts—ultimately contained and appropriate Flag State for the vessel and received a very extinguished the fire. positive response. An investigation was carried out, and the ISM Code Section 8, Emergency Preparedness, DPA investigated the incident. mandates regular emergency exercises and drills. This CHIRP was notified that equipment was available and concise response highlights its value. While there were areas that training had been provided to all the crew. However, for improvement, the crew contained and extinguished the safety gear was not worn, and no permit to work or operational supervision was evident. The crew member in question was dismissed from the vessel because of not adhering to the requirements. There is never any comfort in learning that a crew member was dismissed from the The incident vessel, as it usually implies a failure in the management underscores the system on board. importance of crew The investigation revealed that the DPA was, in fact, the Master of the vessel, which is entirely wrong in terms of members’ vigilance, defining the DPA’s role according to the ISM Code. effective teamwork, The DPA serves as a crucial link between the ship and and everyone’s shore management. Their primary responsibilities include ensuring that the safety management system is implemented critical role in and maintained effectively, providing support and guidance ensuring the ship’s to the ship’s management, conducting audits and reviews of and its occupants’ the system, and serving as the liaison with external parties, including flag states and classification societies. safety and security In this case, the revelation that the DPA was also serving as the vessel’s Master represents a conflict of interest and a violation of the ISM Code. The DPA’s role is to

be independent of operational duties aboard the vessel to Only three crew members were on board, and the maintain impartiality and oversight. owner of this private boat refused the master’s request to employ additional crew for a vessel of this size, which, Human factors according to industry practice, should be approximately Culture – This incident highlights a poor safety culture seven people. As a result, the three crew members (captain, where senior management does not drive safety. There was motorman, and stewardess) ended up in a near-miss a lack of operational supervision. The work being undertaken situation, which could have been much worse. by the crew falls under the category of working at height Fortunately, using good seamanship, they brought and necessitates a Permit to Work. the vessel into the marina using only engines and the emergency steering system. Alerting – When third parties warn you about how unsafely you are operating and nobody from your vessel raises CHIRP Comments any concern, there is something clearly wrong with your It’s concerning to hear about the unsafe situation onboard the shipboard safety