Report on the investigation of a fatal accident during a vertical chute evacuation drill from the UK registered ro-ro ferry P&OSL Aquitaine in Dover Harbour on 9 October 2002 Marine Accident Investigation Branch First Floor Carlton House Carlton Place Southampton United Kingdom SO15 2DZ Report No 18/2003 July 2003 Extract from The Merchant Shipping (Accident Reporting and Investigation) Regulations 1999 The fundamental purpose of investigating an accident under the Merchant Shipping (Accident Reporting and Investigation) Regulations 1999 is to determine its circumstances and the causes with the aim of improving the safety of life at sea and the avoidance of accidents in the future. It is not the purpose to apportion liability, nor, except so far as is necessary to achieve the fundamental purpose, to apportion blame. NOTE This report is not written with liability in mind and is not intended to be used in court for the purpose of litigation. It endeavours to identify and analyse the relevant safety issues pertaining to the specific accident, and to make recommendations aimed at preventing similar accidents in the future. CONTENTS Page GLOSSARY OF ABBREVIATIONS AND ACRONYMS SYNOPSIS 1 SECTION 1 - FACTUAL INFORMATION 3 1.1 Particulars of P&OSL Aquitaine, the chute and the accident 3 1.2 Background - The Marin-Ark MES 5 1.2.1 RFD 5 1.2.2 Inception, development and approval of the Marin-Ark MES 5 1.2.3 Description and operation of the Marin-Ark MES 7 1.2.4 Risk assessment for Marin-Ark MES drills 9 1.2.5 History and description of the chute used in the drill 12 1.3 Narrative 13 1.4 Mrs McCabe-Jones 19 1.5 Reason for drill on P&OSL Aquitaine 19 1.6 The evacuees 21 1.7 Training of sweepers 22 1.8 Summary of the inspection of the chute 22 1.9 Summary of the reconstruction of the accident 23 1.10 Study of video recordings of the drill 26 1.11 Results of questionnaires from drills 28 1.12 International questionnaires 29 1.13 Post-accident research 30 1.13.1 Medical opinion 30 1.13.2 Positional asphyxia 31 1.13.3 Audio analysis 31 SECTION 2 - ANALYSIS 32 2.1 Aim 32 2.2 The accident 32 2.2.1 The evidence 32 2.2.2 The descent 33 2.2.3 Traffic light system 36 2.3 Likely cause of death 36 2.4 Lifejackets 37 2.5 Issues arising from the chute inspection 39 2.6 Descending in the Marin-Ark MES 39 2.7 Live drills 40 2.8 Risk assessment 42 2.9 Fitting of the vertical chute MES 44 2.9.1 Reasons for the introduction of vertical chute MESs 44 2.9.2 Move towards MESs 45 SECTION 3 - CONCLUSIONS 46 SECTION 4 - ACTION TAKEN 49 4.1 P&O Stena Line (Now P&O Ferries) 49 4.2 RFD 50 4.3 MAIB 50 SECTION 5 - RECOMMENDATIONS 51 ANNEXES Annex 1 Report of the examination of the Marin-Ark escape chute 53 Annex 2 Report of reconstruction of accident 71 Annex 3 SOLAS requirements 81 Annex 4 Spreadsheet on results from video recordings taken at 85 top and bottom of chute Annex 5 Spreadsheet on the responses from ship owners and 89 operators Annex 6 MAIB Safety Bulletin 01/2003 93 Annex 7 P&O Stena Line’s risk assessment at the time of the 99 accident Annex 8 P&O Ferries’ risk assessment following review on 8/4/03 103 Annex 9 P&O Ferries’ Marin-Ark safety case 109 GLOSSARY OF ABBREVIATIONS AND ACRONYMS EU - European Union FRB - Fast rescue boat IACS - International Association of Classification Societies IMO - International Maritime Organization IT - Information technology kg - kilogram LSA - Life saving appliances m - metre mm - millimetre MAIIF - Marine Accident Investigators’ International Forum MCA - Maritime and Coastguard Agency MES - Marine evacuation system MOR - Means of rescue N - Newton P&OSL - Prefix to ships’ names of the company P&O Stena Line Ltd. ro-ro - Roll-on roll-off (ferries) SOLAS - Safety of Life at Sea Convention sweeper - A person designated to clear blockages in vertical chutes UTC - Universal Co-ordinated Time Wheel Mark - Mark of approval under European Marine Equipment Directive SYNOPSIS At 1319 UTC on 9 October 2002, a fatal accident occurred during an evacuation drill from the UK registered ferry P&OSL Aquitaine. The drill was being held in Dover harbour, using an RFD manufactured Marin-Ark marine evacuation system. P&O Stena Line’s marine safety manager informed the MAIB of the accident that day. The marine evacuation system, consisting of two vertical chutes leading into two large, fully reversible liferafts, was deployed at 1233. Once the evacuee receivers, assistants, observers and manufacturer’s representatives were in place, the evacuation began. After 124 people had gone down the chute and entered the liferafts, a female volunteer, Mrs McCabe-Jones, began her descent. Nine seconds later she shouted for help; the chute controller, stationed at the top, shouted to her to wriggle, but she replied that she could not. A chute sweeper, who was one of the ship’s officers, then went down the chute in a controlled manner and found the volunteer stuck in a back down piked position (hands and feet above her head) inside one of the elasticated socks in the descent sections. Her lifejacket and jacket had come off and were near by. The sweeper tried to pull her up, but was unsuccessful. However, she slipped through the sock but retained the same piked position in the next sock down. The sweeper tried again to pull her up, but then realised she was no longer talking to him. He called out to the chute controller and to the receivers that she was not responding, and asked for someone to cut her out. She slipped through the sock and, yet again, retained the same position. The chute was then cut to allow her to descend in a controlled manner into the liferaft, where she arrived, unconscious, some 10 minutes after the start of her descent. First- aid was administered and was continued while she was evacuated ashore by a fast rescue boat, which had been standing by. She was then airlifted to hospital where she was pronounced dead. As there were no witnesses to Mrs McCabe-Jones’s descent, and she was unable to tell the sweeper what had happened, it is impossible to determine exactly how she assumed the position in which the sweeper found her. However, it is probable that the initial mechanism which caused Mrs McCabe-Jones to become stuck, was her lifejacket riding up and her legs being raised in such a way that she assumed a piked position in the sock below. Safety recommendations have been made to: • Shipping companies, to revalidate their risk assessments for drills, with regard to selecting suitable personnel and limiting the number of people in a chute to one at a time. They should also revalidate their risk assessments and safety cases, with regard to the adverse effects of blockages during an actual emergency. 1 • The Maritime and Coastguard Agency (MCA), to ensure that only lifejackets suitable for safe descent with the specific MES installed are used. It should also take forward to the IMO, recommendations on the approval of lifejackets for specific MESs and that a reporting method should be set up for accidents involving MESs. • The MES manufacturers, to remove any possible causes of blockages in chutes. 1 h p a r g o S t o E h M P k r A - n rie) a d M si or d far nto oirb pa n st r o( e ati ov k D ar n mb d i E e h t r e b e n ai t ui q A L S O & P 2 SECTION 1 - FACTUAL INFORMATION 1.1 PARTICULARS OF P&OSL AQUITAINE, THE CHUTE AND THE ACCIDENT All times are UTC. Vessel details Registered owner : Stena Ferries Ltd Chartered by : P&O Stena Line Ltd Port of registry : Dover Flag : UK Type : Ro-ro car ferry Built : Temse, Belgium in 1992 Classification society : Lloyd’s Register of Shipping Length overall : 163.4m Gross tonnage : 28,833 Passenger capacity : 1850 Chute details Type : Marin-Ark Marine Evacuation System Approval : By MCA in December 1997 Manufacture : Chute number 106 by RFD in August 2000 First installation : October 2000 on board P&OSL Provence Material : Woven nylon and warp knitted polyamide fabric with a polyurethane coating Height of chute : About 14m Number of cells : 15 Number and capacity of : 2 x 106 (deployed on 9 October 2002) liferafts System deployment time : In less than 3 minutes Accident details Time and date : 1319 on 9 October 2002 Location of accident : Alongside Cruise Terminal, Western Docks, Dover 3 Weather and wind force : Cloudy, fine and clear, wind east-north-east force 4 to 5 Injuries/fatalities : One fatality Diagram 1 Evacuation station Canopy 15 13 Bowsing in lines 11 9 Left-hand chute 7 5 Liferafts 3 1 Waterline The Marin-Ark MES deployed from a high sided ferry 4 1.2 BACKGROUND - THE MARIN-ARK MES 1.2.1 RFD Manufactured by RFD, the Marin-Ark MES provided a dry-shod, totally enclosed method of evacuating passengers and crew from a ship in distress into launched inflatable liferafts (see diagram 1). RFD Ltd was founded by Reginald Foster Dagnall in 1920. During its existence, the company has traded in the field of marine and aerospace safety and survival equipment. The factory is situated in Dunmurry (near Belfast) in Northern Ireland and manufactures survival systems with design and quality standards in accordance with ISO 9001. In 1932, RFD invented the first inflatable liferaft, and in 1979 the company invented the first MES. RFD produces a number of types of liferafts including the Marin-Ark MES, and is part of the Survitec group of companies. 1.2.2 Inception, development and approval of the Marin-Ark MES RFD developed the Marin-Ark MES to meet the IMO SOLAS requirements to provide a “dry shod evacuation” system for ro-ro ferries. This requirement arose from recommendations made after the sinking of the Baltic ferry Estonia in 1994 (see Section 2.9.1). The system was developed over a 2½ year period up to 1997, and was brought on to the market the following year. To date, about 120 systems have been installed on more than 50 vessels, over a range of about 23 ferry and cruise ship operators. Previously, RFD had manufactured and installed a limited range of marine evacuation systems using inflatable slides of different lengths, to evacuate passengers to a platform and into a series of 50-person liferafts. This type of MES was difficult to operate, needing large numbers of trained crew; it was also prone to slide and platform distortion and movement in rough seas and strong winds. The Marin-Ark MES was designed to: • Be less complex to install. • Be simpler to operate by fewer crew. • Be easier to use, by removing any exposure of passengers to the weather during the evacuation process. • Incorporate a fully reversible liferaft capable of immediate use upon inflation - whether as part of the evacuation system or as a float-free alternative. (In practice it has been found that the Marin-Ark system is easier to operate when the vessel is heeling and trimming.) 5