Investigation report: Misleading pool safety information leads to 10-year-old drowning

The Incident

The Bahamas registered passenger ship Genting Dream was conducting a four days and three nights cruise with 3275 passengers and 1844 crew members onboard. The vessel departed Singapore on 17th November 2019 and was calling at Langkawi, Malaysia and Phuket, Thailand. It was scheduled to return to Singapore on 20th November 2019.

On November 18, while the vessel was sailing alongside Langkawi, a 10-year-old passenger along with his mother, sister and other companions entered the pool area on deck 16.

After 30 minutes, the 10-year-old kid entered the hot tub and pool area on deck 16 multiple times, accompanied by his younger sister (7-year-old).

Upon entering the main pool, the victim showed signs of struggle, which went unnoticed until six minutes later when his sister saw that her brother was submerged, face down and motionless.

One of the on-duty Deck Steward recovered the victim from the water and commenced CPR before being relieved by the ship’s medical team. Resuscitation was unsuccessful and at 1840 the victim was declared deceased by the ship’s Doctor.

The report highlights that the victim entered the pool not accompanied by an adult, on the contrary to the pool safety procedures and policies onboard.

Following, the investigation reached to a number of human factors that caused the incident. Accordingly:

• Swimming pool safety information not followed or enforced.
• Risk assessment identifying the hazards associated with the use and operation of the main pool was not conducted.
• The policy and procedure for safe operation of swimming pools was not sufficiently implemented.

In addition, the investigation revealed that the pool safety information was inaccurate and misleading.

Due to the size of the text, the safety information could not be read a distance greater than one meter and the information was not available anywhere else on the vessel.

Also, the actual main pool depths were found to be inconsistent with the depth markings next to the pool and on the main pool safety information board.

According to safety information, children below the age of 12 years must be accompanied by an adult. This rule was not enforced by the Deck Stewards at the time of the incident, the guardians of the victim were seated at the starboard side seating area on the pool deck with restricted visibility of the pool, those in the pool and were not accompanying the victim in the pool.

Referring to the deck stewards onboard, the investigation noted that their training was not maintained according to the company’s SMS.

Lessons learned

The investigation concluded that:

1. Swimming pool safety information should be enforced and followed onboard at all times
2. Accurate pool safety information should be readily available to all passengers. The safety information familiarizes the passengers with potential hazards related to the pool and facilitates in reducing the associated risks.
3. An adequate risk assessment shall be conducted to identify the hazards and risks associated with swimming pool operations. Appropriate safeguards can then be put in place to eliminate the identified risks.
4. Having standard operating procedures and policies is a fundamental requirement in achieving safe operational practices onboard. The Company should develop adequate operating procedures for swimming pool operation and familiarize the crew members with these procedures.

Recommendations                         

#1 Recommendation for the operator:

Consider developing and familiarizing the crew members with:

• Documented risk assessment identifying the hazards and mitigating the risks associated with the swimming pools.
• A procedure outlining the general operational requirements, safety of guests using the pool and emergency action plan for the pool.

#2  Recommendation for the BMA:

Consider implementing a regulation requiring passenger ships with swimming pools to have qualified lifeguards on duty to ensure the safety of occupants during pool operating hours.

Actions Taken

After revealing the factors that caused the incident and the lessons learned, the investigation report issued actions to be taken by the interested parties.

Genting Cruise Lines post incident:

Each vessel in the fleet has submitted a risk assessment covering pool operations. The Company SMS has been updated with regards to safe pool operations.

The training requirement for Deck Stewards has been defined. All ships have a ship specific pool safety plan outlining the preventative measures and actions to be taken in case of an emergency.

A fleet-wide standard operating procedure for pool operations has been created and implemented. This covers work methods and enforcing regulations.

The swimming pool onboard Genting Dream has been made shallower and is now at a depth of 1.20 meter. Similar initiatives are also planned for sister vessels. A fleet-wide initiative to provide all ships in the fleet with personal floating devices has been implemented. The floating devices will be offered to younger guests as a precaution.

To learn more about the Investigation Report click herebelow

Report of the marine safet investigation into a 10-year-old passenger fatality