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MARITIME FEEDBACK reporting system for the Maritime industry

Issue 09 SUPERYACHTS April 2025

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Drugs, Design and Dry-docks! Adam Parnell Director (Maritime) We also feature reports highlighting instances where fatigue and insufficient familiarisation training are factors, and we learn about a crane missing a vital

M any of the reports in this excellent edition possess a sense of familiarity, as they resemble recent reports published in Maritime FEEDBACK or in safety sensor. Equally unsafe was a yacht where the crew were expected to live on board during dry docking despite the dreadful conditions. earlier super yacht bulletins. Two reports are especially worrying – one where One familiar theme is that things often go wrong a super yacht claimed to have no enclosed spaces at during or shortly after drydockings, and it is worth all, and one where some officers and crew appear to bearing in mind that management and crew may not have had drug problems. have very much experience of dockings, so everyone On a positive note, several reporters said they felt needs to remain alert and anticipate problems. Even emboldened to report to us because they had read fewer people have experience of taking delivery of similar reports by CHIRP, so they knew something a newbuilding vessel, where design problems can was not right. We are delighted to learn that our become apparent and where owners and managers efforts are bearing fruit. must make every effort to change things which are Finally, we thank all our reporters for their not safe, even if they have been accepted by other commitment to safety and for making this such an owners, class or flag state surveyors. interesting edition.

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.

M2319 result in an overreliance on shoreside resources. Once these resources are withdrawn, the ship’s crew must be completely

Fire on a large motor yacht prepared to regain operational control. Findings indicate that some crew members were

at the end of dry-dock unfamiliar with critical safety equipment, and specific equipment had not been adequately maintained. This highlights a broader issue that requires a cultural shift Initial report in management’s approach to safety. Regardless of the After the dry-dock period, the motor yacht was moved vessel’s luxury features, it remains a ship that must support to the repair berth, where shore power was unavailable, its crew at sea. Prioritising the enhancement of training and necessitating the use of the ship’s generators. Before dry dock safety management is essential. the relocation, the vessel underwent a pre-sale survey, A dedicated pre-departure dry-dock checklist should and the ventilation dampers were closed. This raised enhance safety, distinct from the standard port departure the temperature in the engine room. The master was checklist. This checklist should confirm that all systems and not informed about the switch from shore to ship power. equipment are fully operational, guaranteeing that the vessel According to practice, the ER door was shut after working is returned safely and seaworthy before leaving the shipyard. hours, while the emergency escape hatch was left open for ventilation. Later, the ER fire alarm was activated. The Factors relating to this report captain briefly inspected the ER, noted haziness but no Capability – The vessel lacked the necessary experience strong odour or visible fire source, and closed the door. to perform dry docking. It eventually departed the drydock The fire team disabled technical ventilation and fuel unseaworthy and could not re-enter service. supply to the ER, prepared fire hoses for boundary cooling, and donned fire suits with breathing apparatus. The Communications – It was unacceptable not to advise engineer and deckhand entered the ER, discovering smoke the master about the lack of shore power supply, as the near Generator No. 1, but not directly from it. They shut emergency generator was inoperable. down the generator, leaving the vessel without power, and secured the emergency hatch. Alerting – Given the situation on board with non-operational Significant issues hindered the response: the essential safety appliances, would you have spoken up? emergency fire pump was challenging to operate, the emergency generator was inoperative, smoke detectors and Pressure – The pressure to get the vessel from the atmosphere testing equipment were absent, and the fire drydock to the layup berth following a pre-sale inspection system’s UPS battery had failed. Unable to monitor the ER, meant that the ship’s staff did not restore the vessel to a the master activated the CO2 system. However, unfamiliarity seaworthy condition. with its release procedure and difficulty accessing the CO2 cabinet led to incomplete activation. Culture – The lack of communication about shore power and Emergency services intervened, dispersing the misunderstanding of emergency procedures reflect a weak accumulated gas and ensuring safe re-entry. Investigations safety culture in which critical issues are not addressed. revealed that the fire was caused by the accumulation of exhaust gas due to a leak in the exhaust system and a malfunctioning exhaust valve. Closed dampers that M2325 restricted air circulation exacerbated the situation. The failure of the CO2 system resulted from a misconnected compressed air hose linked to the emergency quick-closing system of the fuel valve, resulting in the manual release of MLC Living conditions the CO2 bottles. While manually releasing the CO2, the crew Initial report was unaware that the CO2 cylinder valves must be held open Our reporter stated that during a recent dry-docking period, until fully discharged. The vessel remained incapacitated the crew were compelled to remain on board while the until the CO2 system was recharged. vessel underwent substantial repairs, raising serious safety and welfare concerns. Open fuel tanks were situated in crew CHIRP Comments living areas, and essential services such as air conditioning, As highlighted in previous CHIRP feedback, drydock water, and sewage were intermittently shut down for operations pose significant risks, requiring the crew to prolonged periods. Galley refrigerators were switched off, remain vigilant and well-prepared. necessitating chefs to store food in domestic fridges on the A critical safety protocol is the immediate mustering aft deck. Hazardous work, including antifouling, painting, of all personnel before CO2 is released, especially given and grinding, occurred throughout the vessel, while smoke the presence of shore workers who may still be on board. detectors were disconnected to facilitate the removal of However, this report highlights a lack of exposure to drills ceiling panels, compromising fire safety. Despite these and training. Management is responsible for ensuring crew issues, no action was taken by management, prompting the members receive adequate training to protect themselves crew to report the situation to CHIRP. and the vessel. Serious safety concerns were identified, including the CHIRP Comments lack of a functioning emergency generator and challenges in CHIRP emphasises that crew living conditions were found operating the emergency fire pump—issues that could render inadequate during essential service repairs. According the vessel unseaworthy. Furthermore, drydock periods may to the Maritime Labour Convention (MLC), management

must provide suitable alternative accommodation, whether CHIRP appreciates Flag State’s strong support for this issue. commercial or private, and health, safety, and environmental If you encounter similar levels of danger, please report them (HSE) regulations take precedence during dry-docking to CHIRP. periods regardless of vessel size or purpose. Moreover, the master has a duty of care toward the Factors related to this report crew, always ensuring their well-being. During dry dock, the Culture – A dangerous level of safety is being demonstrated vessel encountered hazardous operations that management by the company by allowing the use of banned drugs to be should have addressed promptly. The owner’s and used in everyday work operations involving passengers. manager’s lack of response to crew concerns highlights a poor safety culture within the company. Local practices – Local practices have become the norm on It’s important to emphasise that standards must be board this large superyacht, resulting from feeble leadership strictly applied whether the vessel is MLC-compliant or a from management and senior officers. private yacht. If a proper assessment of the work during the dry Teamwork – The reporters exhibited a shared mental model dock had been planned, the planned work could have been that prompted them to address the deteriorating safety carefully managed. Management must ensure an experienced situation, which is commendable. If you are facing a similar team of officers is brought in to manage the dry dock. issue, please get in touch with CHIRP if you cannot express your safety concerns through the onboard leadership team Factors related to this report or management. Culture – Management does not show a duty of care to the crew by not providing appropriate accommodation during a phase of the drydock when living conditions become unacceptable. Our reporters have offered an excellent example of active Situational awareness – Management has not examined the dry-dock operation in its entirety. It has either failed to involvement in operational recognise or ignored that the crew will face unacceptable living conditions as work progresses on the vessel. safety for the crews working on Capability – The management has not supported their crew, superyachts, and CHIRP wants and they appear to lack the knowledge and experience to to thank them recognise the work requirements during the dry dock.

Communications – Management has not conveyed their M2353 expectations regarding the living arrangements during the drydocking period. Working aloft: unsafe M2352 by design? Drug use on board Initial report Our reporter had recently joined a vessel during construction. super yachts They had read several CHIRP reports that mentioned the need to wear a harness when working at height, so they Initial report made a point of checking if their vessel had enough ‘pad Our reporters sought to illuminate a potentially hazardous eyes’ (strong points) in the right places on their vessel so situation aboard a sizeable superyacht. The issue reported that a crewmember could work aloft in safety once the to CHIRP pertains to the levels of drug consumption vessel was operational. occurring among the crew and passengers, fostering a In their opinion, more pad eyes were needed but when drug-fuelled environment that presents a considerable they raised this with the shipyard, they were told that the risk to everyone on board. It starts with the senior officers design had been approved by the owner, the architects down, making tender operations dangerous, especially and the Classification Society, so they saw no need to after hearing about recent incidents. make a change. The reporters stated that it is just nerve-wracking and wrong because they know how much drug use occurs on CHIRP Comments board and how unsafe it can be. The reporters wish to raise Once a design is approved, getting shipyards to implement their concerns with CHIRP. changes becomes nearly impossible due to the high costs and complexity of the reapproval process, which inevitably CHIRP Comments delays delivery schedules. Additionally, since shipyards CHIRP wishes to thank the reporters for highlighting this often construct multiple vessels based on the same design, serious safety issue. The situation on board has escalated the absence of a formal feedback loop from operational and compromised safety. CHIRP has addressed this matter vessels back to the architects and Classification Society with the Flag State, which has taken steps to investigate. results in future hulls having the same deficiencies, too. It is

therefore imperative that architects seek and incorporate the lowered the tender with the crane fully extended and lifted experiences of operators alongside the wishes of the owner the hook clear to stow it. during the design process. However, the bosun became distracted and CHIRP urges all authorities involved in superyacht inadvertently increased the hoisting speed. The hook struck design to consider the safety implications for crew and its stop-stowed position with excessive force, breaking free passengers from the outset and to introduce a formal from its clamped arrangement. The 10kg hook then fell 12 feedback process so that experiential learning can be metres, narrowly missing a deckhand by just 20cm before incorporated into future hull builds. striking the inside of the sponson. The impact sent the hook Owners, classification societies, and flag states should flying to the side of the boat, causing significant damage to actively participate in this process during the design phase. the fairing. Similarly, crews must provide feedback to the flag states Fortunately, no injuries occurred. The captain’s regarding design issues. In this context, our reporters have investigation revealed that the crane’s safety sensor— offered an excellent example of active involvement in designed to stop the hook from contacting the job head— operational safety for the crews working on superyachts, was missing. While the crane’s wire remained intact, and CHIRP wants to thank them. the lack of this critical safety feature contributed to the incident. Factors related to this report The deck crew received a full debrief to address the Culture – A calculative rather than proactive safety near miss, review proper crane operation protocols, and culture prevails. The owners do just enough to meet emphasise the importance of functional safety systems. essential compliance. Would your superyacht benefit Immediate corrective actions include verifying all safety from installing additional safety features, particularly when sensors before operations and reinforcing strict adherence working at height? to controlled hoisting speeds.

Local Practice – Just because a superyacht design is built CHIRP Comments with limited securing points does not mean it cannot be The late Professor James Reason devoted his life’s work to reconfigured to incorporate additional safety features. understanding how such failures occur. His Swiss Cheese Model is a potent reminder that accidents are seldom caused Communications – Do you have your say on safety by a single error but rather by multiple weaknesses in a design? Is there engagement with the flag state, the system aligning to create the perfect storm. His contributions classification society, and the designers? to safety and human factors will continue to guide industries in preventing incidents like this, ensuring that every barrier is reinforced before disaster strikes. M2362 Factors relating to this report Communication – A replacement was urgently required Near Miss- fatality avoided when the sensor failed or was missing. To prevent its further use, an out-of-service label was also needed. How well do Initial report you deal with a critical safety equipment failure? Two crew members were onboard during a routine launch of a crew tender in port while the bosun operated the crane Distraction – A significant issue in many incident reports. from the bridge deck. Following standard procedures, he Given the crane’s missing sensor, heightened awareness

Missing or Organiszational failed defences influences

Unsafe supervision

Preconditions for unsafe acts Latent failures Unsafe acts

Latent failures

Latent f i ailures ACCIDENT! Active failures

was demanded while the crane’s hook was stowed. The the importance of proper familiarisation training—especially bosun’s distraction allowed the hook to be stowed in a when handling essential equipment. non-controlled manner, resulting in a situation where a Securing the bitter end of the anchor should be a part crew member was nearly killed and damage was sustained. of the mindset for any anchor operation — it’s the last line of defence to prevent it from running free if something goes Situational awareness – Everybody involved in the lifting wrong. Therefore, discovering that a brand-new vessel operation should be focused on what is happening. This was delivered without a safety pin raises serious questions was a routine tender lifting operation, but the same applies about quality control and oversight during the building and to all lifting operations. Maintaining heightened situational commissioning process. awareness, where you constantly evaluate your status, is Supervision is crucial, especially during high-risk tasks demanding and requires teamwork. like anchoring, where even a moment’s inattention or confusion can result in significant consequences. CHIRP Teamwork – Effective teamwork serves as a strong strongly encourages vessel operators to prioritise thorough barrier and can prevent the alignment of errors when familiarisation for all crew, ensure clear and consistent everyone collaborates. marking systems, and maintain robust oversight of critical procedures. It’s not about assigning blame; it’s about learning and M2361 improving. These issues are preventable, and with the proper focus, they can be resolved.

Anchor operations Factors relating to this report. Fatigue – Long hours and pressurised work can lead to a compromised by loss of clear thinking, as cognitive ability is lessened and risk-taking increases. unfamiliarity and Situational awareness – Standing near anchor equipment tiredness create a during an anchor operation is hazardous, and the risk of injury can be severe. This was a close call for the operator

hazardous situation and should alert management to current working practices.

Alerting – Given the inexperience and fatigued operator, Initial report having another crew member available for the anchoring In the month leading up to the incident, the deck would provide a cross-check. crew, including the reporter, had been extremely busy, often exceeding the required hours of rest. Fatigue was a persistent issue. The reporter, a relatively new M2358 deckhand on the vessel, had only dropped anchor once or twice. On this occasion, the crew hurried to anchor. Due to inexperience with the vessel’s anchor markings, the Identification of Eclosed reporter misjudged the length of the deployed chain, thinking that four shackles had been dropped when, in spaces on a Super Yacht fact, there were five. The final warning markings were Initial report very short and close to the chain’s Our reporter worked on a commercial end, making them unclear. As a result, yacht under 500gt that claimed to have the bitter end unexpectedly emerged no enclosed spaces onboard. Therefore, it from the chain locker. At that moment, didn’t have gas detection equipment, and the reporter was positioned near the it was impossible