Accident Investigation Report 1/2016
Investigation report into marine accident including what happened, safety lessons and recommendations made:
This reports the MAIB’s investigation of the collapse of a mezzanine deck on the Wightlink ferry St Helen, at Fishbourne ferry terminal, Isle of Wight, on 18 July 2014. The passengers and vehicles on board the cross-Solent roll-on roll-off passenger ferry St Helen were in the process of disembarking at Fishbourne ferry terminal on the Isle of Wight when the vessel’s starboard forward mezzanine deck collapsed. The deck collapsed because one of its steel wire lifting ropes parted. The lifting rope parted because it had not been routinely lubricated and the mezzanine deck had not been properly maintained.
A crewman and 11 cars, with their seated passengers, were on the deck when it collapsed. The crewman suffered a minor head injury and was temporarily rendered unconscious; several passengers suffered minor impact related injuries. The mezzanine deck was structurally damaged and was later removed from the vessel.
Shortly after the accident, MAIB issued Wightlink a recommendation to immediately instigate a wire rope lubrication programme on the mezzanine decks of its vessels.
- The mezzanine deck collapsed because one of the steel wire lifting ropes supporting it parted.
- The steel wire lifting rope parted because it had not been properly maintained and its condition had been allowed to deteriorate to a dangerous level.
- Wightlink’s maintenance management system was found to have weaknesses in key areas.
- The lack of a robust wire rope lubricating regime was subject to a longstanding safety management system non-conformity and had been highlighted during periodic inspections and statutory equipment examinations.
Wightlink has been recommended (2016/101) to review and, as necessary, improve its safety management system to ensure the company: acts promptly in response to non-conformities affecting important and critical equipment on board its vessels; applies a proactive response to the management of observations and deficiencies identified during the thorough examination of its vessels’ lifting equipment and notifies the relevant authority in the event of damage to a vessel that requires structural repair.
A recommendation (2016/102) has been made to British Engineering Services Limited to ensure its policy on the scrutiny of its thorough examination reports:
- Identify the instances when its customers have repeatedly failed to address shortcomings identified during lifting equipment examinations, and
- Provide a mechanism for bringing shortcomings to the attention of its customers and, where appropriate, the relevant authorities.
Finally, a recommendation (2016/103) has been made to the Maritime and Coastguard Agency to ensure its audit inspections of Wightlink vessels provide specific focus on the effectiveness of the company’s maintenance procedures.