Belgium’s Federal Bureau for the Investigation of Maritime Accidents (FEBIMA) issued an investigation report on a fatality of a crew member while boarding on the fishing vessel Z.15 – ZILVERMEEUW, at Milford Docks, Wales, UK, in November 2019. The report identified absence of a safe access point to the vessel and consumption of alcohol as key causes of the accident.
The incident
After spending some time ashore, a crew member boarded the moored vessel at the forecastle, since the available access ladder was awkward to use and hindered by a chain, and fell into the water.
A colleague whom he arrived with at the vessel together, entered the ship’s accommodation to alarm the other crew members.
After a laborious recovery of the man overboard, no pulse or respirations was detected and it was decided to perform CPR.
The crew member was subsequently transported to a hospital, where his death was confirmed.
Probable causes
The absence of a safe access point to the vessel caused the fall into the water. Boarding at the forecastle was considered safer/more comfortable than boarding by the quay side ladder at low tide and considering the distance between jetty and vessel.
The amount of alcohol consumed by the victim adversely affected his performance (risk perception, reaction time, co-ordination) and so contributed to the accident.
As the water temperature was low and no floating safety devices were available, the victim could not reach the quay side ladder before he lost consciousness due to hypothermia.
CPR was only administered when casualty recovered onboard, and could have started earlier if and when the emergency preparedness and response time onboard were better.
Conclusions
- No or little efforts had been made to make the access to the vessel as safe as practically possible. Different access points were used depending on the tide and the distance between the vessel and the jetty. These access points could not be considered safe as access was hindered by chains, guardrails and fishing gear.
- The quay side ladder was used as access point to the vessel, as the vessel had no means of access available. This ladder was not considered user friendly and awkward to use. No handles were in place at the top of the ladder. Crawling on your knees was necessary to get on the ladder.
- The safety instruction cards on board described that a pilot project concerning safe access was running in 2010, but no outcome was made available. No results improving safe access to the vessel were visible on board. The card did not mention practical guidelines to assess/improve the access to the vessel.
- Emergency procedures in case of a MOB were described in the safety instruction cards on board. The effective implementation of these procedures on board were never tested. The victim was lifted out of the water by means of a strop connected to the winch wire. Effective, but not comfortable.
- Both the access to the vessel as the emergency response indicate that there is a higher need for vessel specific safety assessment, training and follow-up of implementation of procedures and instructions. No ship specific risk assessment was in place.
- The consumption of alcohol when off-duty in port is a common phenomenon, but the tragic consequences of this accident demonstrate that drinking to excess significantly worsen the risk of life for crew that live on board ships when in port.
Actions taken
-The Port of Milford Haven:
1. Conducted a thorough review of safety, access ladders, services and fendering within the docks. This led to the following changes:
- Commenced repair/replacement of the quay ladders within the port, which will include the addition of ‘over the top’ hand holds at the top of the ladder to allow the user to safely step from the quay side on to the ladder
- New ladder for K4 (Zilvermeeuw berth on the night of the accident) and recessed off the Quay Wall
- Minor maintenance works completed on current hand rails on J Wall & K Wall.
- Signed off on design for a fixed handrail on K Wall and J Wall for ease of access – as per Newlyn Docks,
- Heavy duty fendering will be fitted on all ladders along K Wall.
- Additional emergency ladder will be fitted on K Wall (K5).
- All grab holds (fixed between the emergency ladders on the quay) replaced on J Wall.
2. Increased the number of quayside lifesaving appliances. As part of the Health, Safety and Welfare funding of the European Maritime and Fisheries Fund, the following changes will see the provision of:
- lifebuoys every 25m rather than 50m;
- fire extinguishers sited on the berth; and,
- a quayside defibrillator for use in an emergency.
- 4 x Portable Embankment Ladders.
- Marine Crane located on J Wall (in situ, but requires commissioning).
3. Will issue a revised leaflet issued to all fishing vessels on arrival. This colour leaflet details the position of the various berths within the port, the telephone numbers to call in case of an emergency.
- Revised A4 Arrival Form with location map and safety guidelines incorporated for agents and masters. Operatives meet the vessel on the quay to ensure the Master has a copy of the arrival form.
- The Pierhead Operator communicates to all vessels entering the lock of the Dock tidal range and advises the Master to adjust mooring lines accordingly.
4. Improved safety signage within the port. A contract has been let to produce improved safety signage for display within the port.
- A0 Signage (Map and Safety Guidelines) will be erected on J Wall, K Wall and in the Lock Barrel (Milford Haven Port Authority Marketing department have submitted planning permission for the signage).
5. Will issue a crew member health and safety card. The provision of small plasticised cards to crew members highlighting safe practices to be followed within the port.
- A5 Flyer printed in cellophane attached plastic and given to all crew members at Milford Fishing Docks.
Recommendations
-The owner of the vessel is recommended to:
1. Assess the vessel’s operational safety risks and to take appropriate action. Such actions may include, but do not have to be limited to: vessel specific instructions concerning safe access and vessel specific training regarding emergency procedures.
-PREVIS is recommended to:
2. Further develop and roll-out the action plan regarding alcohol and drug consumption, up to a level where the information is available on board and understood by the crew.
3. Develop a vessel safety management system for all Belgian fishing vessels together with other parties involved.
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