200280 Fatality During Evacuation Drill

Fatality During Evacuation Drill
MAIB Official Report Report

The following Safety Bulletin (1/2003) has recently been issued by the UK MAIB. It concerns the death of a volunteer evacuee when she became stuck in the chute.
Background

At about 1219 on 9 October 2002, a fatal accident occurred while an 'abandon ship' drill, using a vertical-chute type marine evacuation system, was being conducted in Dover harbour.

After the marine evacuation system was deployed, eight people descended the vertical-chute into two large, fully reversible liferafts. These people were evacuee receivers and assistants, observers and manufacturer's representatives. After some 124 people had gone down the chute and entered the liferafts, a female volunteer began her descent. However, 9 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 piked position (hands and feet above her head) inside one of the descent sections. Her lifejacket and jacket had come off and were over her face and head. The sweeper tried to pull her up, but was unsuccessful. He called out for someone to cut her out. The chute was then cut to allow her to descend in a controlled manner into the liferaft, where she arrived unconscious.

After first-aid had been administered, she was evacuated ashore by a fast craft, which had been standing by, and taken to hospital where, sadly, she was pronounced dead.

* A person trained to clear blockages in chutes.

Comments

This tragic accident has highlighted a number of risks that need urgent attention. The volunteer who died might not have been particularly fit or healthy. Until the actual cause of death has been established, it is recommended that only fit and healthy volunteers are selected to participate in drills.

The initiator for this accident appears to have been the riding up of the volunteer's lifejacket over her face and head. It is recommended that all personnel using a vertical-chute marine evacuation system should be provided with lifejackets that cannot ride up.

It would seem that in struggling, the volunteer caught her feet, which allowed her body to continue downward. She ended up in a piked position, thus blocking the chute. Recommendations are made to shipping companies to take this possibility into account in their safety case/risk assessment of evacuation procedures, and also to manufacturers to remove all possible causes for such a blockage.

Interim Safety Recommendations

Shipping companies, which have, or are, intending to have vertical-chute marine evacuation systems installed on their ships, are recommended to:

Revalidate their risk assessment for drills, with particular emphasis on selecting fit and healthy volunteers.
Revalidate their safety case and/or risk assessments on the adverse effects of possible blockages in chutes at the time of the evacuation in an actual emergency.
Ensure that all personnel using a vertical-chute marine evacuation system wear lifejackets which will not ride up during the descent of a chute.
Manufacturers of all vertical-chute marine evacuation systems, and the authorising bodies, are recommended to:

Take urgent action to remove any possible causes of blockages in chutes by redesign and/or other means.