Summary:
On 23 September 2017, a Filipino crewman from the fishing boat Constant Friend fell into the water at Kilkeel Harbour while attempting to board the boat from the fishing boat Silver Harvester. Silver Harvester was moored inboard of Constant Friend and alongside the quay adjacent to the fish market buildings in the harbour (Figure 1).
Figure 1: Constant Friend alongside Silver Harvester
The crewman was recovered from the water by his crewmates, then who commenced CPR. He was later transferred to hospital but died in intensive care on 28 September.
To gain access to Constant Friend, the crewman was required to climb over the guardrails, of both vessels. This was inherently hazardous. The risk of slip or fall was high because it was dark, the surfaces were wet, and the vessels were moving significantly. Additionally, the crewman’s consumption of alcohol had might have adversly affected his reaction time, co-ordination and perception of risk.
Figure 2: Quayside to Silver Harvester access
Cause of death:
No postmortem examination was carried out. The death certificate issued at Craigavon Area Hospital recorded the cause of death as ‘1(a) Hypoxic Ischaemic Brain Injury’ and ‘1(b) Drowning’.
Typical causes of hypoxic-ischaemic brain injury include cardiac arrest, respiratory arrest, near-drowning, and other forms of incomplete suffocation. These expose the entire brain to potentially injurious reductions of oxygen (i.e. hypoxia) and/or diminished blood supply (ischaemia).
A blood test taken shortly after Jory had been admitted to hospital showed that he had a blood alcohol concentration (BAC) of 291 milligrams per 100 millilitres of blood.
Figure 3: Constant Friend berthed alongside Silver Harvester
Action Taken:
The MAIB has:
Issued a Safety Flyer to the fishing industry to highlight the lessons to be learned from this accident.
Conclusions:
- Jory slipped and/or lost his grip when climbing over guardrails or stepping between Silver Harvester and Constant Friend, at night, when the moored vessels were moving significantly. Without any means of fall prevention in place, he passed between the vessels and entered the water.
- An immediate rescue attempt would not have been initiated had Jory’s crewmates not taken the initiative of monitoring his return to the boat.
- Had the risk assessment focused more thoroughly on the need to prevent crew falling in when boarding or leaving the boat, it might have recognised that the existing boarding arrangements were inherently dangerous and, therefore, might have prompted more appropriate controls to be developed. Such controls include the provision of guardrail gates and a formal arrangement for a nominated crewman to monitor and assist individuals boarding the boat.
- Although Jory had used the same method to board Constant Friend on many previous occasions, adverse environmental conditions combined with the level of alcohol in his system are likely to have affected his risk perception, reaction time and co-ordination, which caused him to fall.
- Clarification of any requirement to seek authorisation by Border Force and the procedure to be followed to meet that requirement would enable a more informed determination of the risk control options available to fishing boat owners in terms of granting crew shore leave and ensuring that safe access to and from the boat is maintained.
- The interruption to CPR and the delay in the arrival of the emergency services could have been prevented. However, it is uncertain what effect they had on the eventual outcome of the accident.
Recommendations:
A recommendation has been made to the Maritime and Coastguard Agency to revise its guidance on the safe means of access to fishing vessels.
Recommendations have also been made to Constant Friend’s owner to take account of the increased risk of a crew member falling as a result of adverse environmental conditions when returning to the boat from shore leave, and to develop a contact card and procedure for crew use in dealing with emergency situations in port.
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Source: MAIB
