Child falls overboard from passenger ferry

UK MAIB – Accident Investigation report 22/2014

The UK MAIB has issued Accident Investigation Report No.20 on theThe falling overboard and recovery of a young child from the passenger ferry SNOWDROP Seacombe Ferry Terminal, River Mersey 14 October 2013.

At 1429 on 14 October 2013, a 3 year old girl fell overboard from the promenade deck of the passenger ferry Snowdrop while the vessel was berthed alongside the Seacombe ferry terminal pier on the River Mersey. The child was quickly recovered from the water by a member of the vessels crew and taken to hospital.The child suffered minor bruising and the crew member was unharmed.

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Factors that contributed to the accident included:

The young girl was allowed to stand on the promenade deck’s outboard seating.

The position and design of the seating allowed the child to climb up the backrest and lean over, and balance on the top of the ship’s side guardrails.

The parents supervising the child were distracted by the energetic behaviour of other young children within their group.

As a result of the actions taken by Merseytravel and the Maritime and Coastguard. Agency (MCA) in response to this accident, no recommendations have been made.

Promenade deck guardrail and seating

Snowdrops promenade deck ships side guardrails were 1100mm high. They were fabricated from mild steel and had four horizontal steel rails that were supported and secured to the deck by vertical steel stanchions. Varnished hardwood capping was fitted to the upper horizontal rail.

The promenade deck passenger seats were constructed from hardwood planks and had a horizontal slat design. The outboard seats faced inward with the seats back up against the ships side guardrails. The ferry had always had seating positioned along the outboard edge of the promenade deck but there had been several different types of seats fitted since build. The seating the 3 year old was standing on had been installed approximately 10 years previously.

The deck to seat height was about 460mm with the distance between the seat and the top of the capping rail approximately 635mm. The horizontal backrest slats were about 40mm high with a space of approximately 20mm separating them. Attached to the backrest slats at varying intervals were traffolyte signs, engraved with the warning: NO STANDING ON SEATS.

Ship’s side guardrail requirements

Regulation 63 of The Merchant Shipping (Passenger Ship Construction: Classes III V1A) Regulations 1998 requires sufficient protection as to prevent any person from accidentally falling overboard.

The Maritime and Coastguard Agency (MCA) Instructions to Surveyors mandate a prescriptive minimum height for the guardrails, which include:

9.1.2 Decked ships of Classes IV to VI(A)
9.1.2.1 The height of the bulwarks, or of the uppermost rail on any deck, shall be not less than 915mm for ships of Classes IV and V,

The requirements did not specify the arrangement between passenger seating and a vessels guardrail.

Domestic Safety Management Code

Snowdrop was required to comply with MSN5 1754(M) the Safety Management Code for Domestic Passenger Ships of Classes III to VI(A) (DSM Code). The purpose of the DSM Code is to establish a common standard for the safe operation of passenger ships employed in the domestic trade. The requirements included the development and implementation of safe practices for, inter alia:

Procedures to ensure safe operation of ships in compliance with relevant rules;
Lines of communication between personnel, ashore and afloat;
Procedures for reporting accidents; and
Procedures for responding to emergency situations.

To meet these requirements Merseytravel set out its operating procedures in a Safety Management Manual (SMM). The DSM Code also required passenger ship operators to provide a designated link between its ships and its shore base. This was to ensure that in the event of an emergency there was immediate communication with the emergency services.

In order to ensure compliance with the DSM Code, Merseytravel conducted periodic internal audits on board its two ferries, and the MCA conducted bi-yearly external audits. The last MCA audit had taken place on 23 September 2011.

After the incident on 14 October 2013, the MCA conducted a DSM Code audit, which found that Merseytravel had not identified a Designated Person and therefore had not provided the required designated link.

Conclusions

The 3 year old girl fell overboard because she over balanced while leaning over the top of the ships side guardrail. She was able to do this because she had been allowed to stand on the outer deck seating to watch the ship berth, and the design of the seats enabled her to climb up the seat back to lean over and lie on the top of the rail.

The adults responsible for the child and the other children in their group were not complying with the broadcast and written safety instructions, and were distracted at the moment the girl slipped.

The mate ignored his personal safety and responded instinctively by entering the water to rescue the girl.

The girl was extremely fortunate not to suffer major injury during the fall and to be rescued unharmed after entering the water.

The ships emergency response plan was not implemented and the coastguard were not informed immediately.

Experience had shown that the controls in place on board Snowdrop to prevent passengers, particularly children, from standing on the deck seats were ineffective, but more effective positive actions to remove or mitigate the hazard had not been taken.