M2768 - Operation: Tender launched while under way, resulting in personal injuries

Initial Report

While sailing off the coast, the crew attempted to launch the vessel’s tender while the yacht was underway at approximately 6 knots. The tender was launched from the schooner rig’s forward boom.

Prior to the launch, the tender launch team prepared the equipment and informed the captain that they were ready. It was understood that the vessel would be slowed before the tender was lowered. The captain subsequently gave the order to proceed. The vessel’s SOP was to launch the tender without a bow line because setting it up was considered too time consuming. The lifting hook used was not a quick‑release type found on commercial shipping.

At the time of launch, the chief officer (CO) and bosun were inside the tender.

When the tender became partially waterborne, the engine did not start in time, and the lifting hook failed to release. This resulted in excessive load remaining on the hoist while the tender was partially waterborne.

The tender then capsized with the engine still running, throwing both crew members into the water.

The abnormal load placed significant strain on the rigging. The boom preventer line failed under load and parted, narrowly missing some of the crew members on deck and posing a serious risk of fatal injury.

Shortly afterwards, the captain identified what had occurred and reduced the vessel’s speed. The bosun and the chief officer were recovered from the water, with one suffering a dislocated knee and the other a fractured ankle. The crew were badly shaken, and the guests were visibly shaken by the incident. Fatalities were narrowly avoided.

CHIRP Comment

This incident highlights a high-risk transfer operation conducted while the vessel was still making way, during which multiple safety barriers were either weakened or absent. The loss of control of the tender, its capsize, and the resulting injuries were not due to a single error but to the interaction of procedural, technical, operational, and human factors. Launching the tender at approximately 6 knots significantly increased dynamic loading and reduced the crew’s ability to recover when the operation did not proceed as planned.

Although there was an assumption that the vessel would be slowed, this was not enforced as a clear go/no-go condition immediately prior to release. The accepted deviation from safe rigging practice, notably the absence of a bow line due to perceived time pressure, removed an important stabilising and recovery control. Time pressure is often self imposed, and there is always an opportunity to stop and reassess an operation when conditions are not as expected.

The SOP in place did not sufficiently address the risks associated with underway launches and was not rigorously applied at the point of execution. The use of a lifting hook without a positive quick-release mechanism introduced additional risk in a dynamic environment and became a critical weakness when the tender engine failed to start. The crew took corrective actions to self-recover, which transferred excessive forces into the boom and rigging, leading to preventable failures and creating a serious snapback hazard that narrowly missed personnel on deck.

The incident also highlights the importance of maintaining effective supervision and challenge during routine operations, particularly where informal workarounds or deviations from procedure have become accepted practice. Professional, deliberate execution of operations should be encouraged, as taking the time to perform tasks safely is often viewed positively and should not be seen as
detrimental to guest service.

The presence of two crew members inside the tender during this high-energy phase significantly increased the severity of the outcome, and both were injured during the capsize and subsequent recovery attempts. Where personnel remain in a tender during launching or recovery operations, this should occur only when the lifting arrangement is specifically certified, tested, and approved for man-riding operations.

The incident also serves as a reminder to review the suitability of lifting hooks and release arrangements used on tenders and rescue craft. Operators should ensure that equipment complies with current industry guidance and applicable regulatory requirements.

Overall, the event demonstrates how assumptions, weak procedural enforcement, equipment limitations and time pressure combined to erode safety margins. It reinforces the need for robust barrier thinking, formalised dynamic risk assessment for underway operations, confirmed vessel speed reduction, proven engine readiness, reliable release systems, effective supervision, and clear authority for any crew member to stop the operation when critical conditions are not met.

Key Issues relating to this report

Factors related to this report

Communication – The lack of communication led to assumption that the vessel would slow without an explicit final confirmation loop. No closed confirmation immediately before launch.

Pressure – Acceptance of “no bow line” due to time pressure. Normalisation of deviation from optimal rigging practice. Once readiness was declared, there was an expectation to proceed with the launch without any checks.

Capability – Underestimation of dynamic loading risks when launching underway at 6 knots. Potential gap in understanding the consequences of non-quick-release systems during partial immersion.

Teamwork – Weak or no challenge function between the launch team and the command decision point. No effective “stop call” escalation at the final stage.

Alerting – No strong intervention when the ideal safety configuration was bypassed.

Local practices – Acceptance that tender launches can be conducted with reduced rigging controls.

Distraction – Multiple concurrent system states (engine start, release, vessel movement) competing for attention.

Key Takeaways

Regulators – If people are inside the load, the system must assume something will go wrong and ensure the people still survive it. There is a clear signal here for tighter expectations around lifting arrangements for crewed transfers, stronger limits on launching while making way, and clearer equipment standards aligned with commercial safety practices, even in superyacht operations. The punchline for regulators is simple: if people are inside the load, the system must assume that something will go wrong and ensure those people still survive.

Managers – When the procedure is shaped by convenience, the sea will eventually expose the shortcomings. The key learning is how normalised efficiency can quietly override risk controls. The decision pathway shows a system in which “saving time” replaced engineered safety margins, ranging from omitting a bow line to accepting a non-quick-release hook and proceeding while underway at excessive speed. The critical weakness is not a single decision, but the accumulation of small design and procedural choices. This is exactly the type of scenario that requires conservative operating rules, clear stop conditions, and an empowered culture of challenge.

Seafarers – If you lose control of one link in a live transfer chain, you do not have time to negotiate the rest. The key takeaway is the importance of recognising when conditions no longer align with the assumptions underlying a plan and stopping the operation. Once the vessel was making way and the tender was partially afloat, the operation had entered a high-energy, low-control state in which timing,

communication, and release mechanisms became critical. In these moments, escalation and stopping the operation are not procedural hesitation; they are hazard control.