Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2126
Initial Report
The owner was unhappy with the anchorage location and wanted to move. The anchor was weighed, and the deckhand went into the chain locker to stow the cable. They wore ear defenders due to the noise of the cable in the chain locker.
The anchor was weighed to the water line and the vessel was relocated to the new anchorage position where the order was given to drop the anchor again.
The deckhand was still in the chain locker and was either not informed or did not hear that the anchor was about to be let go, and still had their hands on/near the chain as it dropped. Had they become entrapped, the consequences of this near-miss would most likely have been fatal.
CHIRP Comment
Poor communications were a significant factor in this incident, and situational awareness was lacking in the executive team: no crew member should ever be inside the chain locker when a cable is about to be lowered or dropped.
A chain hook or other wooden device must be used to flake out the cable to prevent it from piling up and stowing in the chain locker, and the crew member attending to this task must leave the locker once it is complete.
There appears to be a design issue with the chain locker: either the locker is too small to accommodate the cable pile when the anchor is stowed, or the spurling pipes are not adequately designed to allow the cable to self-stow. Design modifications should be considered to eliminate this unnecessary risk before the next docking.
Crew training should be provided on anchoring procedures and the risks outlined. The wearing of ear defenders is questionable when clear audible communications for anchoring operations are required, and a clear means of communications must be found.
Key Issues relating to this report
Design- The poor design of the anchor system created an unnecessary risk which required a crew member to manually flake the cable to prevent it from piling up. Redesigning the spurling pipe in the chain locker to allow the cable to self-stow and not pile up is highly recommended.
Communications- Communications failed, which created this potentially severe near miss.
Good operational safety relies on everyone knowing what is going on so that everyone can contribute to a safe operation. Before any anchoring operation, do you hold a toolbox meeting to discuss what will happen?
Situational Awareness- Nobody thought to check if the crew member was clear from the chain locker. The anchor was at the water line, ready to be let go, but nobody challenged whether the crew was clear of the chain locker. Why?