Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2137
Initial Report
While walking down the gangway to receive a package being delivered to the vessel, the gangway swung out from underneath them and the crewmember fell into the water, hitting their chin and right wrist on the quayside on the way down. They were partially submerged under the dock but kept one hand on it.
Luckily, they were swiftly rescued by a passing dock worker who pulled them out of the water, and although they had a sore head, neck, and arm, they could easily have suffered much more significant injuries.
A post-incident investigation found that the gangway had not been correctly installed and that this was due to poor supervision.
CHIRP Comment
This incident highlights the importance of proper equipment installation and safety certification for superyachts. CHIRP discovered several critical flaws.
Firstly, the design of the securing arrangement was inadequate and had likely been this way since build. The securing bolts were only screwed into the GRP fairing because the backing plate (into which they should have been affixed) was misaligned. This seriously compromised the structural safety of the gangway fixing arrangement.
Secondly, there was no Safe Working Load (SWL) plate next to the fixing point, so the crew could not know the gangway’s maximum capacity or working limitations.
The incident raises questions about the quality assurance of the vessel’s build, and whether differences between the vessel ‘as designed’ and ‘as built’ were properly identified and documented. It is imperative that these are discovered in during the building because they can significantly alter operating limitations. Once the vessel has been handed over to a crew, it is highly likely that such deficiencies will only come to light when the equipment catastrophically fails. Readers may detect similarities with the report in our previous edition about the failure of a lifting eye when hoisting the seaboat.
Collaboration among the shipyard, classification society, and contractors is crucial. Managers for the superyacht need to work closely with all parties involved to ensure proper communication and coordination throughout the construction and installation processes. All equipment should be certified as safe according to the appropriate design specifications before being put into service.
For newly built superyachts, an experienced new-build
team should work closely with the shipyard, class, and
contractors to identify and rectify potential issues during
construction. It is noted that not all owners use a new-build
team during the construction and fitting-out phases. If this is
the case, management must be responsible for verifying the
testing and sign-off for the equipment.
Key Issues relating to this report
Capability – Always check out the capabilities of contractors employed to carry out work on safety critical or access equipment. Seek assurances that they have the experience to carry out the work and always check the result by someone experienced to sign off the job as being carried out competently. Consult with the shipyard and class society to check if they have signed off on the installation. This cannot be left to the crew to do!
Local practices – When commissioning new vessels or equipment, question and challenge everything (yes, we know this can be very tiring and time consuming, but it can save your life! Has the installation been completed according to the specification and testing requirements? A member of the management team or new build team should be responsible for ensuring that the work has been completed and tested. The fact that there was no SWL plate on the gangway indicates that proper sign-off for the installation was not carried out.