Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2284
Initial Report
Shortly after a 50+ meter sailing vessel set sail, an unusual amount of spray was noticed on one side of the deck. It was discovered that a shell door had been left open. This door, used as a boarding platform, had a cavity for a guest shower and storage. While it did not open directly to the yacht’s interior, it could have caused significant damage, including rupturing hydraulic hoses, if not caught in time.
Pre-departure checks (PDCs) included securing all hull openings. However, due to the hull and door shape, this opening could only be seen by leaning over the side. The shell door sensor was also sometimes faulty, giving inaccurate alarm and monitoring system readings.
Closing the shell door was a two-stage process: first, the ladder section, then the door, and these operations were often done by two crew members at different times. This contributed to the incident, as each crew member assumed the other had completed the task. The desire to be ready quickly led to shortcuts and assumptions without confirming each PDC.
CHIRP Comment
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.
Key Issues relating to this report
Communication— Closed-loop communications did not work in this incident during the pre-departure inspections due to pressure to depart on time. Do your pre-departure checklists work effectively when under pressure? Is there a chance that cross-checks on shell doors can be overlooked?
Alerting- If you know of an equipment malfunction, how easy is reporting it on your vessel? Is the reporting process thorough enough to prioritise critical alarm systems for repair?
Design—The alarm and monitoring system’s design appears temperamental and needs regular maintenance. Its unreliability created a single point of failure. This should have been addressed as a priority; otherwise, its effectiveness is rendered useless. Have you had alarm systems on your vessel that sometimes did not work? Would a camera provide the additional backup required?
Situational Awareness– The crew performed excellent visual monitoring to note an unusual spray pattern.