Source · Prevention of Future Deaths

Michael Hanlon

Ref: 2015-0294 Date: 23 Jul 2015 Coroner: Philip Sharp Area: Cumbria Responses identified: 1 / 1 View PDF

An inefficient boat entry system, potential crew tiredness from additional shifts, and inadequate monitoring of working hours raised safety concerns for crewmembers.

Date 23 Jul 2015
56-day deadline 17 Sep 2015 est.
Responses identified 1 of 1
Accident at Work and Health and Safety related deaths

Coroner's concerns

AI summary
An inefficient boat entry system, potential crew tiredness from additional shifts, and inadequate monitoring of working hours raised safety concerns for crewmembers.
View full coroner's concerns
During the Inquest it became apparent that members of the crew had failed to gain entry to the boat on returning from on shore. One crewmember had slept on deck. I also concluded one crewmember had attempted to climb through a doorway on the upper deck near to the position where the deceased had fallen. There was a possibility, but no finding was made, that the deceased may have been endeavouring to enter the boat by this route when he fell.

I also concluded crewmembers and in this case the deceased were likely to have been asked to work additional shifts when the boat came in to port, potentially causing tiredness amongst crewmembers. Further the deceased’s work pattern did not match the shift rota and his time sheet was not made up to the time of his last shift.

The system for entering the boat after 10.00p.m involved certain members of the crew having a key, but otherwise requiring knowledge of a key code to obtain a key from a box situated at the front of the boat. The key could then be taken to the entry door at the rear of the boat, a door opened and then the key returned to the front of the boat in to the key box before the crewmember would then enter the open door. (i) The efficacy of the entry system for certain crewmembers who were returning to the boat after 10.00pm.

(ii) The recording of and monitoring of crew working hours by the officers to ensure crewmembers are not required to work additional hours unless the safety of the boat, crew and passengers was in danger.

Responses

1 respondent
Pluteus Limited
PDF
Action Taken

A keyless entry system has been installed to address concerns around access, and a 24-hour watch system is in place when owners/guests are onboard. A Captain's Standing Order is to be issued to ensure procedures are in place to monitor working hours and rest periods. (AI summary)

View full response
Dear Sir; RE: Rule 28 Report - Michael Robert Hanlon We refer to your letter of 23rd 2015 addressed to Patrick Bond of Marine Response, and in particular the section "Regulation 28: Report to prevent future deaths" (PFD) We do not propose to repeat the contents of email of [Sth June 2015 &nd the attachment thereto ("the Owners Submissions), but your findings and conclusions, for the record we hereby restate the Owners Submissions We are keen to co-operate and address the concerns you have identified &s & result of the inquest However; please note that in so, no acknowledgement or admission of failings or liability is intended or to be inferted At paragraph 7 ofthe PFD, you have identified two areas of " Action Required" , 9s follows: To provide all crew members with & key to enter the boat save when the owners Iguests were on board when & 24 hour watch should be implemented (the First Action); and To ensure that all officers properly record tbe crews shift rota and that working hours are recorded daily &nd the captain should check periodically that this policy is maintained and overtime work justified to him when needed (the Second Action) (together; the Action Points) We understand from the terms of the Chief Coroner's Guide to the Coroners and Justice Act 2009 (paragraph
173) and the specific guidance on PFDs issued in the Chief Coroner's Guide No5 (dated 4 September 2013) (paragraphs 24 and 30}, that specific remedial actions should not usually be recommended in & PFD Nevertheless, given the views you have expressed as to the action you would recommend if you were empowered to do 50, we have referred the Action Points to both the captain of Faith, and Wright Maritime LLC (Wright Maritime) who are retained to advise on safety and security matters in relation to te vessel: In connection with the First Action; Wright Maritime and the Captain have both commented that providing keys tO seafarers for access outside of hours has proven to be unreliable; unsatisfactory and impossible t9 control, particularly because can be lost or forgotten This can potentially lead to problems with access_ Pluteus Llmited Is Incorporated in the British Virgin islands, Registered Number 1712376 Reglstered Office: Woodboume Hall , PO Box 3162, RoadTown; Tortola; British Virgin Islands. Rogistered Agent In Cayman Islands Campbells Corporale Services Limited, Floor 4, Willow Hause, Cricket Square, Grand Cayman;, KY1 -1103, Cayman [slands ILd July noting doing being Group keys

72 and also to potential security breaches if the lost is found by persons who are unauthorized to access the vessel: As part of & refit programme; commencing in 2014, & new; "keyless" , entry system has now been installed (after some delays, in summer 2015) on board Faith whereby each crew member on arrival is issued with & personal access code (rather like a cash withdrawal PIN code), which they can choose themselves (thus making it more memorable), which is and personal to them &nd which should be kept confidential This has removed the need for keys; which is the common form of access in yachts of Faith'$ age_ Since inception, the keyless entry system has proved to be a reliable means of access ad, in all the circumstances, is felt to be & better and more reliable means of access thn providing each crew member with key. At the time of the incident & system was in place such that if a crew man returned and could not access the interior of the vessel (for example; if the code which at that time was @ standing general code, rather than a unique code issued to each crew member had been forgotten) the crew member could either the ship's doorbell or telephone in to the boat In such circumstances the appointed watch keepers would respond to any incoming calls, including the door phone till 22.00 after which they retire: The telephone system is programmed such that ay incoming calls which unanswered for more than 3 rings; will sound in the Captain'$ cabin. Under the new system, with the unique personally chosen codes, it is considered far less likely that & code will be forgotten Nevertheless; the back-up system of calling in will remain Please also note that & 24 hour watch system is implemented in place of the keyless entry when the owner or are on board The new keyless system that has been installed addresses the concerns you have set out in the PFD. However; we of course remain open t0 any further thoughts you have on this subject In connection with the Second Action; & system of recording working hours and hours of rest is &nd has alweys been in place a8 per Interational Maritime Organisation and Intemational Labour Organisation requirements Given the concems you have identified in the PFD; steps will be taken by the Captain by means of & Captain'$ Standing Order to ensure appropriate procedures are put in place to monitor those working hours and to ensure that crew members &re not working additional hours without the requisite rest periods; in particular between shifts, unless the safety of the boat, crew ad passengers is in danger: The Captain' $ Standing order is to be issued in the week beginning 3 " August 2015. We have concems with to the wider circulation publication of this letter in particular in relation to Faith's security arrangements, particularly when the owner and are on board. In the circumstances information should be regarded as private &nd confidential, not for wider circulation / publication If we can be of any further assistance Or provide any further information; please let us know-

Report sections

Investigation and inquest
On the 23rd April 2013 I commenced an investigation into the death of Michael Robert Hanlon who was born on the 8th December 1990. The investigation concluded at the end of the inquest on 27th May 2015. The conclusion of the inquest was that Michael died from 1(a) Drowning. His death was an accident.
Circumstances of the death
On the 6th April 2013 Michal Robert Hanlon as a deckhand on a luxury boat M.Y.FAITH owned by you. It came in to Antibes Harbour. He had worked a night watch and then worked for the whole of the 6th April 2013 without rest or sleep. He with other members of the crew went out in to Antibes to meet friends. He returned to the boat at approximately 11.30p.m but did not enter it. He was seen walking on the boat until 00.11 on the 7th April 2013. At some point later before 00.22 he fell from the upper deck of the boat hitting the quay before drowning in the harbour.

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Report details

Reference
2015-0294
Date of report
23 July 2015
Coroner
Philip Sharp
Coroner area
Cumbria

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 Sep 2015 (estimated).

Sent to

Plateus Ltd

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