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MARITIME FEEDBACK reporting system for the Maritime industry

Issue 07 SUPERYACHTS August 2024

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Leading by example Adam Parnell the loads imposed upon it, and sensors which were Director (Maritime) unreliable. It is worth noting that these are all issues we have covered before, so please pay particular attention to the design of systems and equipment

W e have previously published many reports about crew members working over the side without the correct PPE, but we again return to this topic in our first on your vessel. Permits to work also feature prominently, in cases involving working at height and working report because we have yet, as an industry, to resolve below the vessel. They are a useful tool but must this potentially lethal practice. The report highlights the be completed thoroughly. In addition, all crew need for a thorough risk assessment, which is a theme members must be aware of them and must feel you will note throughout this edition. Whether you are empowered to question their requirements and working overside, anchoring close to shore, recovering stop the work if necessary. We should constantly a tender or engaged in diving operations, it is vital that be asking whether a job is safe and whether it you conduct a painstaking assessment of the potential is necessary. risks and speak up if you believe a risk is being ignored. If these reports teach us anything, it is that we Design factors also feature several times, in can never relax our vigilance, even for a moment. the form of a design fault in a carabiner securing Until next time, stay safe, and may all your rail, lifting gear which was not capable of handling voyages bring you safely home.

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.

M2263 M2271

Vessel tender recovery Fouled anchors injures crew member Initial report A 70-meter superyacht was anchored in a very ‘tight’ Initial report anchorage with limited swing circle and depth. There was Our reporter told us, “I reported to engineers that a bilge around 3 meters of depth under the keel, and the swing pump was not working on the 9m catamaran RIB, but radius was 130m (160m would have put the vessel aground) nothing was done. I also reported that the lifting points With some bad weather expected, the master decided were slightly deformed, which allowed water to access the to put two anchors down. Once the weather cleared, both bilge. With the bilge pump not working, additional water was anchors remained deployed. added to the tender’s weight. The tender is stowed on the When the anchors were retrieved a few days later, both main deck approximately 2.5/3m from the water line. anchor chains were severely twisted and the crew had spent The RIB is used frequently, and it is recovered from the more than 12 hours trying to free them – all the while slowly water with the two crew members inside. Once it reaches dragging towards the shallows nearby. the yacht’s main deck, it is pulled alongside the main deck More bad weather was forecast so a decision was taken and the two crew members step out of the tender in turn. to release both anchors from their bitter ends to prevent the As the first deckhand got out, one – then all - of the lifting vessel from grounding. Once both anchors were released, points on the RIB failed and it fell several metres into the sea the vessel made its way to port before the weather closed with the bosun still inside. The bosun suffered a minor back in and a salvage company later recovered the anchors and injury and shock.” returned them to us a few days later.

CHIRP’s comments CHIRP Comments Both the securing points and lifting points of a tender must Anchorage locations should continuously be assessed for be adequately designed to handle the deadweight and other proximity to known hazards, including under-keel clearance and reasonably foreseeable shock loading that might arise (eg potential grounding, safe swinging distance from other nearby failure of one of the other securing points). vessels, and holding ground capability in inclement weather. CHIRP could not determine why the previously reported Although vessels will generally anchor close to the shore defects had not been addressed by the vessel’s senior for their passengers’ convenience, vessels should be ready officers, but it is good practice for defect-reporting systems to to move to a deeper anchorage if the vessel’s safety cannot assign responsibility for rectifying a defect to a named officer, be assured. In this incident the vessel was anchored only 30 who should assess and prioritize resolution, and if necessary, meters from a lee shore. Given the expected weather forecast, take the equipment out of action until this is done. this was an unacceptable and unnecessary risk. Safety is everybody’s responsibility, and CHIRP Using two anchors when expecting bad weather can wonders why crew boarded a tender with known lifting help to control the vessel’s yaw but should be considered point issues? It is only by sheer good fortune, the bosun was a temporary measure only, because of the heightened risk not killed or permanently incapacitated for life. of them being fouled. As soon as the reason for deploying Finally: we have previously reported on lifting point the second anchor has passed, it should be weighed and failures before, so it is encouraging to hear that Flag State brought home. An anchor home ready for an emergency is inspectors are now checking the SWL of the lifting points good contingency planning. during annual inspections. Factors related to this report Factors related to this report Capability – Does your bridge team have the necessary Design – The tender’s lifting arrangement was insufficient knowledge and training to understand and appreciate the use for its weight. Deformed lifting points allowed water to enter of the ship’s anchors? Given the proximity to the shore and the boat, a clear sign that they were operating at their limits. other vessels in the anchorage, a vigilant bridge anchor watch is The defect is serious and must be reported to management required. What does your SMS advise on anchoring operations? and the manufacturers. Teamwork – Continually review whether the second anchor Culture – These known faults were reported but not acted is required and weigh it when the original reason for using on, highlighting a weak safety culture at a management two anchors is no longer required. level. Would you refuse to operate the tender if you found a similar situation on your boat? Would you take the boat out Situational Awareness – While at anchor, a member of of service? the bridge team should periodically visit the forecastle to monitor the direction and weight of the anchor/s, particularly Alerting – Inform the manufacturers of the issues during changes of tide or wind direction, so that issues can encountered on the tender and seek clarification of the SWL be identified early—i.e. before the chains become twisted. of the lifting points. Engines should be ready for immediate use.

Overconfidence – All lifting equipment has a failure point, Alerting – If you were in a similar situation, would you alert mainly when operating at its limits. Take early action to the master that the other anchor should be brought home so prevent severe injury and loss of life. Never assume all is OK! it can be used in an emergency?

M2284 thorough enough to prioritise critical alarm systems for repair?

Breach of Design – The alarm and monitoring system’s design

watertight integrity appears temperamental and needs regular maintenance. Its unreliability created a single point of failure. This should have been addressed as a priority; otherwise, its effectiveness Initial report is rendered useless. Have you had alarm systems on your Shortly after a 50+ meter sailing vessel set sail, an unusual vessel that sometimes did not work? Would a camera amount of spray was noticed on one side of the deck. It was provide the additional backup required? discovered that a shell door had been left open. This door, used as a boarding platform, had a cavity for a guest shower Situational Awareness – The crew performed excellent and storage. While it did not open directly to the yacht’s visual monitoring to note an unusual spray pattern. interior, it could have caused significant damage, including rupturing hydraulic hoses, if not caught in time. Pre-departure checks (PDCs) included securing all M2282 hull openings. However, due to the hull and door shape, this opening could only be seen by leaning over the side. The shell door sensor was also sometimes faulty, giving inaccurate alarm and monitoring system readings. Lack of safety assessment Closing the shell door was a two-stage process: first, the ladder section, then the door, and these operations were often by the Master done by two crew members at different times. This contributed Initial report to the incident, as each crew member assumed the other Onboard a small motor yacht alongside the dock, someone had completed the task. The desire to be ready quickly led to dropped their radio into the water by the stern, directly under shortcuts and assumptions without confirming each PDC. the propellors. The captain directed that it be retrieved by sending someone down with scuba gear. When informed that CHIRP Comments this would require a permit to work, the captain insisted it was This report involves several critical factors contributing to not required. Despite concerns about the need for a permit or the safety issue. Firstly, a design flaw meant that it was some formal procedure, the captain dismissed the idea and difficult to see if the shell door was securely closed and requested proof of legislation that mandated a permit to work sealed. This was worsened by a faulty sensor for door for diving under the boat. When the suggestion to consult closure status, known for unreliability yet not maintained the Code of Safe Working Practices (COSWP) was made, the and thus compromising safety alarms. CHIRP has frequently captain insisted on quickly retrieving it without any permit. highlighted sensor issues, especially in exposed areas. Additionally, time pressure to complete tasks quickly led CHIRP Comments to shortcuts and assumptions, with crew members prioritising In this situation, the appropriate steps involve consulting speed over thoroughness. Each assumed the other had the Code of Safe Working Practices for Merchant Seafarers, completed their part, resulting in communication breakdowns. which provides guidelines for safe practices, including diving The two-stage closing process involved different crew operations. If unsure, calling the Designated Person Ashore members and needed clear communication and confirmation. (DPA) to seek advice on the diving risk would be appropriate. CHIRP emphasises that positive confirmation of PDC requires A stop-work authority would be the ideal tool for a cross-check, like how airlines do when placing doors to evaluating the risks. However, the company’s safety culture manual and cross-checking. must be proactive enough to implement this process. The issue was ultimately alerted not by the faulty sensor According to the latest Diving at Work Regulations, diving but by a crew member’s visual observation of unusual spray operations conducted as part of work activities require a risk patterns, indicating a problem missed due to the sensor and assessment and proper procedural adherence. The COSWP poor communication. chapter on diving operations outlines the need for permits In summary, the incident stemmed from a combination of and safety procedures for diving. The relevant excerpts factors: problematic door design, an unreliable sensor, and a indicate that before any diving operation is undertaken, a risk fragmented closing process with inadequate communication assessment must be carried out, and a diving permit must be among crew members. This underscores the need for reliable issued to ensure all safety measures are implemented. This equipment, thorough checks, and clear communication to aligns with the requirement that only a person shall dive in ensure vessel safety and watertight integrity. connection with a work activity if a suitable and sufficient assessment of the risks to health and safety has been made. Factors related to this report. Most divers on board superyachts have a Professional Communication – Closed-loop communications did not Association of Diving Instructors (PADI) certification. This work in this incident during the pre-departure inspections is for recreational diving only and is NOT sufficient to due to pressure to depart on time. Do your pre-departure undertake commercial diving; that needs a professional checklists work effectively when under pressure? Is there a commercial diving certification, which requires a higher chance that cross-checks on shell doors can be overlooked? standard of training and an equally well-trained diving support team. Alerting – If you know of an equipment malfunction, how CHIRP recognises that standing firm can be daunting easy is reporting it on your vessel? Is the reporting process when an authoritative figure pressures a crew member.

A typical rail arrangement – not the one in the report.

Safety protocols, such as contacting the Designated The requirements are straightforward: working at height Person Ashore (DPA) or a stop-work policy, are crucial for is only allowed if a risk assessment has been carried out and justifying the issuance of permits. The master’s conduct was a permit to work is thoroughly completed. unacceptable, and the company’s lack of written guidelines A permit to work at height requires that safety equipment, for diving operations reflects a tolerance for risk. including PPE, be thoroughly checked. It also requires the crew to be adequately trained and supervised. Completing it Factors related to this report is not a tick-box exercise and requires considered thought. All Culture – The crew’s attempt to influence the master’s stages of the permit need to be answered, especially by the decision to retrieve the radio using a diver was blocked, crew carrying out the work. The crew must be empowered to and there was no safety, highlighting a poor safety culture. stop the work if the permit has not been completed properly. Thinking about your experiences on your vessel and past The carabiner rail to which the line from the harness vessels, have you encountered this type of behaviour? What was attached must be inspected and form part of regular would you have done? maintenance inspections. The gap in the track system would be apparent to see if it was properly inspected. Inspections Alerting – How would your DPA respond if you contacted of the carabiner rail must form part of regular maintenance them to seek advice on this matter? You can also contact the checks. In this case, the rail should have been taken out of Flag State. The master should have made this call. service until it was repaired. CHIRP highlights the design of these frequently used Teamwork – A shared mental model of the safety risks safety rails, which require extensive maintenance due to and the usefulness of retrieving the radio was not shared their many moving parts. Retrofitted rail connections may by everyone. How good would you be at creating a shared not be as strongly connected to the superstructure as those mental model where the risks for carrying out a dive to retrieve fitted at the new building stage. CHIRP recommends that the radio could be persuasive enough to stop the operation? the class attend to advise on superstructure connections for retrofitted rails. All parts of the safety harness must be secured entirely; M2248 no buckles or straps must be left undone, as all parts of the harness play a part in absorbing the body weight in the event of a fall. The safety line or lanyard must be connected to the Fall while working aloft safety ring at the back of the harness and not on the front due to the possibility of severe spinal injury in the event of a fall. Initial report Crucially, there must always be a rescue plan to retrieve The reporter was tasked with cleaning the outboard anyone who has fallen while wearing a safety harness. windows and donned a safety harness, which was secured The time to recover a fallen crew member suspended in a by a single line to the carabiner on the rail. See the picture harness should be at most 15 minutes, as blood circulation showing a typical arrangement below: will be seriously affected and could be lethal. As they traversed the rail track from forward to aft, a gap in the track system caused the safety line to detach from Factors related to this report the rail, and the reporter fell into the water as the carabiner Alerting – No one had reported the defective safety rail, so slipped off the end of the track. no action was taken. Does your PMS system require that Our reporter stated that they had received no training; the safety rails be regularly checked? How do you report a that no permit to work was carried out; the track and safety failure? Has this been explained to you as part of your carabiner system had not been inspected or tested, and that familiarisation process? only a single securing point was available. Teamwork – If you have not received training or are CHIRP Comments uncertain about using the safety equipment, seek help from Working at height is a high-risk activity that requires an others. Never assume that everything is okay. Falling into the industry-standard permit. The number of incidents involving water versus falling to the jetty has two different outcomes! working at height is not decreasing, and Flag States and management companies are strongly encouraged to focus Pressure – Never be pressured into doing something you on