Positional asphyxia during a vertical chute evacuation drill from ro-ro passenger ferry P&OSL Aquitaine with loss of 1 life

Location: Berthed at Port of Dover, England.

Accident Investigation Report 18/2003

Read our marine accident investigation report, which includes what happened, actions taken, and recommendations:

aquitaine-chute.pdf (1,292.27 kb)


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 a Marin-Ark marine evacuation system.

Safety issues

  • 18% of evacuees had their lifejackets displaced during descent. This could have caused added resistance and instability to the evacuees’ path down the chute

  • there is a need for the approval, both in the UK and internationally, of suitable lifejackets, which provide a safe descent for MESs

  • sweepers need more effective means to clear blockages, especially during an emergency, when it is essential to keep the chute operational at all times

  • there is a conflict between administrations wanting as close to a realistic drill as possible, and shipping companies’ duty of care to their evacuees

  • if the risk assessment’s recommendation for of all evacuees to wear lifejackets fitted with leg straps had been adhered to, it is unlikely the deceased passenger’s lifejacket would have ridden up


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.

  • 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

This report was published in July 2003.

Published 23 January 2015