Both the securing points and lifting points of a tender must be adequately designed to handle the deadweight and other reasonably foreseeable shock loading that might arise (eg failure of one of the other securing points).

CHIRP could not determine why the previously reported defects had not been addressed by the vessel’s senior officers, but it is good practice for defect-reporting systems to assign responsibility for rectifying a defect to a named officer, who should assess and prioritize resolution, and if necessary, take the equipment out of action until this is done.

Safety is everybody’s responsibility, and CHIRP wonders why crew boarded a tender with known lifting point issues? It is only by sheer good fortune, the bosun was not killed or permanently incapacitated for life.

Finally: we have previously reported on lifting point failures before, so it is encouraging to hear that Flag State inspectors are now checking the SWL of the lifting points during annual inspections.

Anchorage locations should continuously be assessed for proximity to known hazards, including under-keel clearance and potential grounding, safe swinging distance from other nearby vessels, and holding ground capability in inclement weather.

Although vessels will generally anchor close to the shore for their passengers’ convenience, vessels should be ready to move to a deeper anchorage if the vessel’s safety cannot be assured. In this incident the vessel was anchored only 30 meters from a lee shore. Given the expected weather forecast, this was an unacceptable and unnecessary risk.

Using two anchors when expecting bad weather can help to control the vessel’s yaw but should be considered a temporary measure only, because of the heightened risk of them being fouled. As soon as the reason for deploying the second anchor has passed, it should be weighed and brought home. An anchor home ready for an emergency is good contingency planning.

This report involves several critical factors contributing to the safety issue. Firstly, a design flaw meant that it was difficult to see if the shell door was securely closed and sealed. This was worsened by a faulty sensor for door closure status, known for unreliability yet not maintained and thus compromising safety alarms. CHIRP has frequently highlighted sensor issues, especially in exposed areas.

Additionally, time pressure to complete tasks quickly led to shortcuts and assumptions, with crew members prioritising speed over thoroughness. Each assumed the other had completed their part, resulting in communication breakdowns. The two-stage closing process involved different crew members and needed clear communication and confirmation. CHIRP emphasises that positive confirmation of PDC requires a cross-check, like how airlines do when placing doors to manual and cross-checking.

The issue was ultimately alerted not by the faulty sensor but by a crew member’s visual observation of unusual spray patterns, indicating a problem missed due to the sensor and poor communication.

In summary, the incident stemmed from a combination of factors: problematic door design, an unreliable sensor, and a fragmented closing process with inadequate communication among crew members. This underscores the need for reliable equipment, thorough checks, and clear communication to ensure vessel safety and watertight integrity.

In this situation, the appropriate steps involve consulting the Code of Safe Working Practices for Merchant Seafarers, which provides guidelines for safe practices, including diving operations. If unsure, calling the Designated Person Ashore
(DPA) to seek advice on the diving risk would be appropriate.

A stop-work authority would be the ideal tool for evaluating the risks. However, the company’s safety culture must be proactive enough to implement this process.
According to the latest Diving at Work Regulations, diving operations conducted as part of work activities require a risk assessment and proper procedural adherence. The COSWP chapter on diving operations outlines the need for permits and safety procedures for diving. The relevant excerpts indicate that before any diving operation is undertaken, a risk assessment must be carried out, and a diving permit must be issued to ensure all safety measures are implemented. This aligns with the requirement that only a person shall dive in connection with a work activity if a suitable and sufficient assessment of the risks to health and safety has been made.

Most divers on board superyachts have a Professional Association of Diving Instructors (PADI) certification. This is for recreational diving only and is NOT sufficient to undertake commercial diving; that needs a professional commercial diving certification, which requires a higher standard of training and an equally well-trained diving support team.
CHIRP recognises that standing firm can be daunting when an authoritative figure pressures a crew member.

Safety protocols, such as contacting the Designated Person Ashore (DPA) or a stop-work policy, are crucial for justifying the issuance of permits. The master’s conduct was unacceptable, and the company’s lack of written guidelines for diving operations reflects a tolerance for risk.

Working at height is a high-risk activity that requires an industry-standard permit. The number of incidents involving working at height is not decreasing, and Flag States and management companies are strongly encouraged to focus on this aspect of superyacht safety.

The requirements are straightforward: working at height is only allowed if a risk assessment has been carried out and a permit to work is thoroughly completed.

A permit to work at height requires that safety equipment, including PPE, be thoroughly checked. It also requires the crew to be adequately trained and supervised. Completing it is not a tick-box exercise and requires considered thought. All stages of the permit need to be answered, especially by the crew carrying out the work. The crew must be empowered to stop the work if the permit has not been completed properly.

The carabiner rail to which the line from the harness was attached must be inspected and form part of regular maintenance inspections. The gap in the track system would be apparent to see if it was properly inspected. Inspections of the carabiner rail must form part of regular maintenance checks. In this case, the rail should have been taken out of service until it was repaired.

CHIRP highlights the design of these frequently used safety rails, which require extensive maintenance due to their many moving parts. Retrofitted rail connections may not be as strongly connected to the superstructure as those fitted the new building stage. CHIRP recommends that the class attend to advise on superstructure connections for retrofitted rails.

All parts of the safety harness must be secured entirely; no buckles or straps must be left undone, as all parts of the harness play a part in absorbing the body weight in the event of a fall. The safety line or lanyard must be connected to the safety ring at the back of the harness and not on the front due to the possibility of severe spinal injury in the event of a fall.

Crucially, there must always be a rescue plan to retrieve anyone who has fallen while wearing a safety harness. The time to recover a fallen crew member suspended in a harness should be at most 15 minutes, as blood circulation will be seriously affected and could be lethal.

This incident underscores the importance of rigorous communication, adherence to safety protocols, and the need for all crew members to be fully informed of ongoing operations to prevent similar near-miss events in the future.

The hoisting of the Alpha flag is a requirement when a diver is down but ineffective on board the vessel when key crew members are omitted from the work planning meetings. In this case, the lock-out tag-out try-out (LOTOTO) barrier control is required, to ensure all ship’s staff are alerted to the work activity that is planned for this time.

CHIRP wonders who ‘owned’ the permit to work in this incident. The permit needed to be completed fully. It is also clear that this work was communicated to only some crew members, and there was a communication breakdown.

Consider this work activity from the point of view of the diver tasked with carrying it out. How confident would you be that your safety is being adequately managed?

The officer assigned to look after the diver spoke with the master on the telephone, an apparently dangerous distraction. At the same time, the master had requested that the engineer, unaware of the diving operation, conduct tests of the vessel’s propulsion systems, a conflicting work activity given the diving operation being carried out.

We repeat our emphasis on the level of education and qualifications of the diving crews that sail on super yachts concerning their levels of qualification and reiterate that if you do not possess the necessary diving qualifications for the work activity, you must not carry out the work. If you have the required qualifications, you must take ownership of the permit to work and insist that its requirements have been thoroughly implemented and resourced. Otherwise, no diving operation takes place.