CHIRP Superyacht FEEDBACK 2 (Spring 2023)

An independent and confidential

MARITIME FEEDBACK reporting system for the Maritime industry

Issue 02 SUPERYACHTS Spring 2023

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Challenging the Cultural Status Quo

Adam Parnell paramount and saying ‘no’ is difficult because of Director (Maritime) implicit ‘authority gradients’, how do we ensure that safety is not compromised? This question appears in most of the reports in

W elcome to the second edition of Superyacht FEEDBACK. Judging by your comments and reaction to the first edition, you share our passion for this edition, and the answer is to empower the team to constructively challenge – and more importantly, to be listened to – when safety is at risk. Whether it’s addressing safety issues and promoting a proactive challenging the master about speed of entry towards learning culture amongst your crewmates. a crowded anchorage, or challenging your own And did you spot the safety issue apparent in assumptions about the safety of taking a ‘short cut’ to the main photo on the front page? Well done if you get the task done more quickly, developing a culture spotted that only one of the crew members working of ‘constructive challenge’ without fear of reprisal is ‘at height’ cleaning the superstructure was wearing not just essential – it’s a life-saver. a safety harness. We will cover working at height in a future issue, because in this edition we want Saying ‘no’ is difficult because of to talk about challenging the cultural status quo – implicit ‘authority gradients’, how specifically, challenging the safety culture. In a sector that focuses on meeting the needs do we ensure that safety is not and wants of its guests, where reputation is compromised?

Please note all reports received by CHIRP are accepted in good faith. Whilst every effort is made to ensure the accuracy of any editorials, analyses and comments that are published in FEEDBACK, please remember that CHIRP does not possess any executive authority.

M2090 Although the reporter does not say which side of the vessel the chef fell in from, unless they had slid the entire

A shortcut they’ll breadth of the vessel, they likely fell between the yacht and the quayside, where they could have suffered severe impact

remember for a long time injuries or even crushing. The superyacht industry is very focused on image and dislikes having areas of the yachts roped off while the teak Initial Report decks are treated; as the stanchions are removed while the The yacht was moored alongside. There was a very high tide, decks are treated, it is anyway often not possible to rope and the swimming platform was at the level of the quay. On areas off. The gangway should always be the only safe deck, a cleaning crew were scrubbing the teak swimming means of access to and from a yacht. platform with a 2-part acid solution. The chef was unaware that the work was taking place. The chef went ashore for some provisions but realised This should have been briefed to all the officers and crew at he had forgotten something, so returned to the yacht. As the daily work planning meeting. he jumped from the quayside to the swimming platform, he slipped on the wet deck and twisted his ankle before falling Factors identified in this report into the water. The chef quickly recovered but had to take Time pressure: It is easy to put yourself under time ten days off to allow his ankle to heal. pressure to meet an artificial target, but this also increases your risk of an accident. CHIRP Comment Psychologically the chef would have felt inconvenienced in Local practices: Jumping from the quayside is a bad habit returning to the ship, so took a short-cut by stepping from and is fraught with risks due to the movement of the yacht, the quayside to the swimming platform instead of using which can be unexpected. Don’t do it! the gangway, which was longer, causing the injury. The chef’s haste and focus on collecting the forgotten item were Alerting: A morning meeting where the work activities are both distractions, and he either did not notice that the deck communicated to all officers and crew would have alerted was wet or did not pause to consider that this could make it the chef that the swimming platform area was not to be slippery to walk on. used. A warning sign should also be considered.

Distraction/Situational awareness: Be aware of your surroundings – even when in a hurry!

3 LOOK

2 THINK 4 ASSESS P STO 5 LOOK AGAIN

1 STOP Take 5 before you start - Practice scanning the enviornment and identifying things that may hurt you. - Look for and recognise trip hazards, obstacles and other hazards. - Now that the hazard has been registered in your mind, it is easy to control and avoid it. - Continue scanning while performing a task; be aware of anything changing around you. - If you find yourself drifting into “autopilot” STOP and take a look around you, refocus and continue to work.

M2091 berth or rendezvous point, is to annotate the passage plan with desired speeds so that the speed of the vessel

Near miss is commensurate to the risks and allows the vessel to be stopped in a controlled manner.

approaching port Factors identified in this report Communication: The actual or perceived ‘gap’ between Initial report the reporter and the captain could have led to a severe Our reporter said, “I was woken up by my second officer, incident – collisions at 14 knots are likely to result in who had just anchored and finished his watch. He was serious personal injury and significant hull, equipment or distressed. He had the last navigation watch for arrival at pollution damage. around 0200, so as usual, the captain came to the bridge before arrival and then took over while the 2/O and lookout Distractions: the master should make it clear to guests that went to drop the anchor. during any port approaches or high-risk navigational areas, In this case, a guest and a bodyguard arrived on the no guests should be on the bridge to maintain focus on safe bridge just after the captain, who became distracted during navigation. This is in everyone’s interest. the handover due to the presence of the guest who stood at the helm. Culture: The 2/O distress suggests that the safety The captain did not realise how close they were to culture on board needed improvement. The master should the bay. The second officer realised that the boat was set an example and highlight this incident as a start to entering the bay too quickly but didn’t feel he could warn change the safety culture on board and in the company. the captain who was talking to the guest. He eventually The company needs to be proactive here and support warned him as the boat entered the bay at 14 knots, the master. narrowly missed several anchored sailing boats and going aground.” M2093 CHIRP Comment No matter how confident they might ordinarily be, many seafarers can find it challenging to speak up about an issue to someone senior. This is called the ‘authority gradient’ – Near miss due to the real or perceived difference in rank, experience, or social or cultural hierarchy. Pointing out an error is especially distractions difficult in front of an ‘audience’, particularly if they are also Initial Report perceived as ‘senior’ to ourselves. Three deck crew on a superyacht tender were engaged in Masters and senior officers can reduce the authority taking guests for a swim at sunset off some Caribbean islands. gradient by encouraging their team members to speak up – The average depth was 2-5 metres, and you get a lot of and praising them for doing so, even when the concerns are shifting sands. The helmsperson was looking back, talking to unfounded. The 2/O’s distress suggests that the captain and guests whilst drifting, with one guest standing on the stern the company had not fostered a culture of challenge and looking into the water. response on board. Developing a ‘constructive challenge’ One crew member noticed the echo sounder at a mindset within the team has additional benefits, too: crew shallow depth, almost touching and immediately told the members become more confident, teams work more helmsperson, who reacted quickly by accelerating away. cohesively, problems identified earlier, and solutions are The guest fell backwards into the water with a near miss to developed more creatively. the props! Fortunately, no one was hurt, but it could have CHIRP and the advisory board members recommend ended badly. It is unclear if prop guards were fitted. that when guests board the vessel, they are informed during their safety briefing and familiarisation tour that CHIRP Comment during high-risk navigational phases of any passage, In taking immediate action to avoid grounding the vessel, they should refrain from coming to the bridge or engine the helmsperson did not assess (forgot?) to warn the room. The master, who had arrived on the bridge with a guests that the tender would manoeuvre violently. guest, was distracted and not engaged with the navigation, The reporter did not state whether the helm checked including traffic and other hazards. that no one was in the water before coming astern, but Clear communications are required concerning taking this is an essential ‘must do’ every time – even in over the conn, and this was not evident. This indecision an emergency. left nobody taking responsibility for the vessel’s navigation, The helmsperson was distracted because they were which fortuitously narrowly avoided collision and grounding. talking to guests (a topic raised at the previous SYAB in For the 2nd officer to be asked to leave the bridge to prepare report M1969). There is a natural tension between needing the anchor long before it was required was bad practice. to concentrate on navigational safety and ‘keeping your Another crew member could assist the lookout in preparing head out of the boat’ and simultaneously being friendly and the anchor, and the officer attends to the anchor when the attentive to passengers and guests who do not appreciate vessel has reached the anchorage position. the consequences of distracting the helm from their primary A very effective navigation risk control measure task. Good people skills are required to make the safety case which would have reduced the vessels speed as the with the passengers who may not always appreciate what vessel approaches the entrance to a port, anchorage, you are trying to do.

Factors identified in this report Safety culture: A proactive safety culture would have empowered the helmsperson to remind the guests that they needed to focus on safety. Is this the case on your vessel?

Distraction: Guests and passengers should be reminded as they embark not to distract the crew; this should be part of the safety culture on board.

Local practices: In general, vessels should go to anchor and turn off their means of propulsion before allowing anyone to enter the water. If this is not possible, then a prop guard should be fitted.

M2092

Near miss during lifting of a tender Initial Report While lifting a 9m tender into the garage, the forward lifting point gave way. Luckily, at this point, the tender was over the chocks and dropped about 30cm into position, causing only minor damage. A crew member was inside the tender but was not injured. Lifting points were tested annually and visually inspected regularly, but due to the design, the underside of the lifting point was inaccessible, and any corrosion was not visible. The lifting point was rebuilt and strengthened, and an inspection hatch was made. The vessel’s SOPs were amended, so that crew members attach the crane hooks to the lifting points, exit the tender before it is lifted, and only enter the tender once in the water.

CHIRP Comment The report is positive: many safety improvements were made, and the vessel is to be commended for its positive safety culture. The equipment’s design hampered the inspection of the underside of the lifting equipment. Often, we dissuade ourselves from raising safety reports on poorly designed or installed equipment in the belief that they are ‘too big to change’ or ‘it must be right – it was built that way’. But even naval architects sometimes get it wrong, and if it had been reported, it could have been rectified when next in refit. Do not be afraid to report and record concerns about design deficiencies. Organisational safety management systems operate on a cycle of continuous improvements, and ship designers will be only Factors identified in this report too glad to receive feedback so that improvements can Safety Culture: The swift rectification of these defects be made. indicates a positive safety culture on board. On this vessel, Useful references that detail the examination and the crew can be confident that their safety concerns will be inspection regimes for lifting equipment include the UK listened to. MCA’s MGN 332(M+F) Amendment 1 and the Cayman Island’s Shipping Notice 04/2021. Additionally, UK Alerting: If you see something wrong – speak up. Just MGN 560(M) sets out the SOLAS III/36 requirements because it was built that way does not mean it is correct! for launching appliances; these must be adhered to if the tender is also classified as a lifeboat or rescue Design: Readers are encouraged to be constantly boat. Accompanying an inspector during a thorough vigilant to poor design and to feed this back to designers examination is a good learning opportunity: watch what and architects who often do not have to work with the they check for and ask questions. equipment they develop.

M2089 CHIRP strongly recommends that guests wear a buoyancy aid. Despite some resistance to doing so, if a proper

Tender capsize when explanation that they are essential safety aids is provided to the guests, then it will be more likely that they will be worn –

towing inflatable places including with the crotch straps properly in place. Once the boat had turned over, diving under the hull was also questionable because of the risk of becoming 4 in lethal danger snagged on equipment and drowning. Most engines are gravity fed, and just left alone, the engine would have run Initial report out of fuel and stopped very quickly. A superyacht tender crewed by a driver and a spotter was All fuel lost in an incident has an impact on the towing two guests on an inflatable tow. environment. The amount lost will be relatively small and As a ferry passed close by the tender, its wake will evaporate. However, the loss must be reported. caused both guests to be thrown off the inflatable. The spotter informed the driver, who turned the tender, but a Factors identified in this report combination of the fast turn and the ferry’s wake caused Overconfidence/Complacency: Not using a kill cord the tender to flip over. Neither the driver nor the spotter was or wearing a lifejacket demonstrates overconfidence – wearing lifejackets, and the driver was not using a kill cord. expect the unexpected. CHIRP believes that this should Both crew members were thrown clear of the tender. be a mandated requirement within your Safety The driver noticed that the outboard engines were still Management System! running and dived under the upturned hull to turn them off. Fuel had leaked, and the area under the hull contained Communication: When operating at range out of sight of strong petrol fumes, which nearly caused the driver to lose the superyacht, it is helpful to have a pre-arranged check- consciousness. The driver also considered the situation a in periodicity, e.g., every 20-30 minutes. That way, if you fire risk, isolated the batteries and turned off the engines cannot be reached, the parent vessel is alerted to a potential before escaping from the upturned hull. However, the problem. Carrying a means of attracting attention must be a spotter, who had since gathered the guests onto the part of every tenders emergency response kit. inflatable, had to assist the driver, who was struggling due to inhalation of toxic fumes. Situational awareness: Know where other vessels operate The crew members then tried to right the tender and how their movement or wake will affect your vessel but could not do so. They were not carrying any or any towed inflatable. Be ready to move violently when communications equipment, so they could not raise the encountering the wake or anticipate that riders might fall parent vessel’s attention until another vessel passed by off the inflatable. (about fifteen minutes after the accident) and radioed the parent vessel. Yacht crew can contact the International Seafarers’ Unfamiliarity with the equipment onboard meant that Welfare and Assistance Network (ISWAN) via it took a further fifteen minutes for the parent vessel to WhatsApp (+44 (0)7514 500153) for 24-hour help and launch a second tender to come to their aid, by which time support for issues such as bullying and harassment, the guests and crew members had been in the water for unpaid wages, and mental health support. thirty minutes. See www.seafarerswelfare.org The guests, crew and tender were recovered to the vessel, where the guests were treated for shock. No further medical assistance was required. M2110 CHIRP Comment This troubling report raises several ‘red flags’ about the poor safety culture on board this superyacht. Guests may not Lithium-ion Battery Fire be aware of or appreciate the potential dangers of towed inflatables – but the crew should have been, and they Initial Report should have led by example and worn their lifejackets, used During recreational activities for the passengers, one E-foil the kill cord, and carried an emergency means of attracting jet ski stopped due to the battery running low while in use. attention. Some kill cords are designed to act as an