MAIB Report Diamond Emblem 1

[Naughty Cal]

https://assets.publishing.service.gov.uk/media/62710e0be90e0746ca7e55da/2022-5-DiamondEmblem1-Report.pdf

 

A tragic chain of events on a family Broads boating holiday.

[booke23]

I'm not very familiar with broads cruisers, but it seems to me the design of the rear of the boat in this incident is a man over board waiting to happen, especially with those stairs. It also highlights the potential perils of dual helm positions. 

 

The report is a very sad read. 

 

 

 

 

 

[Guest]

34 minutes ago, booke23 said:

I'm not very familiar with broads cruisers, but it seems to me the design of the rear of the boat in this incident is a man over board waiting to happen, especially with those stairs. It also highlights the potential perils of dual helm positions. 

 

The report is a very sad read. Ì

 

 

 

 

 

 

Its a common design.

 

But not many if any have stern guards as lots of Broads boats moor stern on at various locations.

 

The comment made in the coroners report will only result in a social media campaign to have all boats so fitted.

 

Then what?

 

 

[booke23]

20 minutes ago, The Happy Nomad said:

 

Its a common design.

 

But not many if any have stern guards as lots of Broads boats moor stern on at various locations.

 

The comment made in the coroners report will only result in a social media campaign to have all boats so fitted.

 

Then what?

 

 

 

I don't think a stern rail would make much difference. It doesn't stop people going over the back of cruiser sterns on narrowboats.

I think the comment in the report of applying international standards to dual helm positions is probably a more sensible suggestion.

[Guest]

27 minutes ago, booke23 said:

 

I don't think a stern rail would make much difference. It doesn't stop people going over the back of cruiser sterns on narrowboats.

I think the comment in the report of applying international standards to dual helm positions is probably a more sensible suggestion.

 

You've done better than me extracting that comment, what did it say?

[booke23]

5 minutes ago, The Happy Nomad said:

 

You've done better than me extracting that comment, what did it say?

 

It's in Section 4.1, a couple of paragraphs down....here's the quote:

 

 "A requirement for hire boat companies operating vessels with multiple 
helm positions to comply, where possible, with international standards 
for a positive visual indication of the active helm position and 
interlocks to prevent inadvertent engine operation from an inactive 
helm position (3.2.2)"

Edited May 6, 2022 by booke23

[Naughty Cal]

8 hours ago, booke23 said:

I'm not very familiar with broads cruisers, but it seems to me the design of the rear of the boat in this incident is a man over board waiting to happen, especially with those stairs. It also highlights the potential perils of dual helm positions. 

 

The report is a very sad read. 

 

 

 

 

 

That is fairly typical of the stern of more modern Broads based hire boats. A lot of the moorings are stern on.

 

 

[David Mack]

Having skim read the report I still don't really understand how the dual helm control worked in this case and how it actually should work. Which suggests that there is plenty of scope for confusion in the hands of inexperienced hirers.

10 hours ago, booke23 said:

I'm not very familiar with broads cruisers, but it seems to me the design of the rear of the boat in this incident is a man over board waiting to happen, especially with those stairs.

 

The 250mm wide landing at the bottom of the stairs looks frightening to me - providing winder stairs at the bottom together with a banister rail parallel to the stern would not reduce internal space too much, but would make the stairs significantly safer.

But in this case the woman who died was entering the cabin from the 850mm long rear deck - not a great deal different from the back deck of a trad stern narrowboat.

[Guest]

1 hour ago, David Mack said:

Having skim read the report I still don't really understand how the dual helm control worked in this case and how it actually should work. Which suggests that there is plenty of scope for confusion in the hands of inexperienced hirers.

 

I've read that bit of the report a couple of times and I agree its pretty unclear.

 

Somebody with a dual helmed boat may be able to clarify.

 

Paging @MartynG

 

 

 

Edited May 6, 2022 by The Happy Nomad

[Naughty Cal]

The dual steer boat we hired was very straight forward.

 

To switch helms both had to be in neutral and then at the lower helm there was a manual changeover lever. The lever would only engage and disengage the helm controls if both the upper and lower stations were in neutral. 

 

It wasn't possible on that particular boat to have a situation like this where it was unclear which helm was in control of the boat.

[Alan de Enfield]

27 minutes ago, The Happy Nomad said:

 

I've read that bit of the report a couple of times and I agree its pretty unclear.

 

Somebody with a dual helmed boat may be able to clarify.

 

Paging @MartynG

 

 

 

 

We have dual helmed boats.

The old system used to be that you had to 'switch over' the steering from the 'inside helm' to the 'flybridge helm'and vice versa but now it doesnt matter.

 

The steering works off either helm BUT the throttles need to be centered (in neutral) on (say) the lower helm then you can just use the other helm as normal.

 

We hired a boat on the Caledonian and it was a 'switch / button' system to disengage one throttle and engage the other one.

On all 'private' boats I have owned it is simply a case of puttingthe throttle in neutral and them going up and using the upper helm (or vice versa) No buttons or knobs to press.

 

I cannot see anyway that you could have (say) the lower helm at (say) half-throttle and be able to reduce that to 'tick-over' on the upper helm as those controls would already be in the tick over position.

 

It would be like having two gear sticks in a car - once it is in gear then only that gear stick could disengage the gears.

 

 

 

 

The boat’s driver at the upper helm control position was unable to control the motor cruiser at the time, most likely because the helm position changeover lever had been incorrectly set to the lower helm control position

 

 

 

 

 

 

Edited May 6, 2022 by Alan de Enfield

[booke23]

In this particular boat both throttles must be in neutral to switch the helm position, just as @Naughty Cal and @Alan de Enfield have described.

Either the helm switch wasn't activated when they switched helms or it was switched back to the lower helm at some point in the 5 minutes between the upper helm taking over and approaching the mooring. The helm position switch only switches the gear selector valve (hydraulic drive on this boat) and locks the valve in the inactive position. I guess the fact that this boat has hydraulic drive means it has to have a change over valve for helms......in an ideal world you wouldn't have a switch. 
 

As I understand it from the report, when they approached the mooring, the upper helm was able to reduce the throttle normally (this always works irrespective of the helm position switch as does the steering), but found the lever wouldn't go into the neutral or astern detent....it was jammed in the ahead position (which is normal if the other helm is selected on the selector switch). In their panic they managed to pull the throttle lever out to the neutral throttle control position, where they were then able to pull the lever rearwards 'astern'. But of course all this did was increase the engine revs with the boat still in ahead gear and accelerate the boat into the moored boat where it stopped suddenly. The upper helm, realising she had lost engine control put the lever back to idle and was about to press the engine stop button when someone pulled the lower helm throttle full astern, which did actually put the boat full astern where it then crashed into the opposite wall which caused the lady to go overboard. 

It's a sobering read. 

Edited May 6, 2022 by booke23

[David Mack]

1 hour ago, Naughty Cal said:

To switch helms both had to be in neutral and then at the lower helm there was a manual changeover lever. The lever would only engage and disengage the helm controls if both the upper and lower stations were in neutral. 

That seemed to be the case with the accident boat, but it appears that if you pushed the non-active control lever sideways to disengage the gearbox operation you could then push the lever forward and the engine speed would respond and could run faster than the speed selected by the active control lever.

The report also says both helms remained active, so moving either steering wheel would move the rudder (although it doesn't say what happens if the two steering wheels are simultaneously turned in opposite directions).

So there was only partial separation of the control functions. A recipe for confusion, and the occasional disaster as happened here.

[Naughty Cal]

31 minutes ago, David Mack said:

That seemed to be the case with the accident boat, but it appears that if you pushed the non-active control lever sideways to disengage the gearbox operation you could then push the lever forward and the engine speed would respond and could run faster than the speed selected by the active control lever.

The report also says both helms remained active, so moving either steering wheel would move the rudder (although it doesn't say what happens if the two steering wheels are simultaneously turned in opposite directions).

So there was only partial separation of the control functions. A recipe for confusion, and the occasional disaster as happened here.

The steering worked from either helm on the boat we were on. I do believe that is common on most dual steer boats.

 

The boat we hired the throttles were completely separated as part of the switching of the controls. Once one station was selected the other was inoperative, apart from the steering. There was no way that both could work at the same time.

 

I don't think the report here is suggesting that both helms were operative either. More that the crew had not realised that the lower helm was in control of the boat rather than the upper helm.

 

Either way it is a very sad chain of events and a reminder to make sure that you and all crew on the boat are fully aware of how the boats systems work.

[David Mack]

30 minutes ago, Naughty Cal said:

 

I don't think the report here is suggesting that both helms were operative either.

Not intentionally, but the report does say that when the lower console had control the upper console could unwittingly increase engine speed:

 

"When the lower helm control position was active and the lower helm 
propulsion control lever set to the half ahead position, the upper helm 
propulsion control lever could be disengaged (pulled out) and set to reverse; 
pulling the upper helm propulsion control lever to the full reverse position 
caused the engine speed to increase."

 

So the driver at the upper console thought she had control, and when the first collision was imminent she applied full reverse to try and stop the boat, and instead it accelerated forward and hit the moored boat in front.

Edited May 6, 2022 by David Mack

[Guest]

When I first heard about this accident I (wrongly) assumed the lady had fallen in after a single collision with a boat moored at the yacht station and on that side.

 

I hadn't appreciated there was this additional complication of the dual helm issue and then a second collision with the opposite bank.

 

It has reinforced to me the importance of 100% understanding how any dual helm boat that we may hire works.

 

 

Edited May 6, 2022 by The Happy Nomad

[booke23]

4 hours ago, David Mack said:

The 250mm wide landing at the bottom of the stairs looks frightening to me - providing winder stairs at the bottom together with a banister rail parallel to the stern would not reduce internal space too much, but would make the stairs significantly safer.

But in this case the woman who died was entering the cabin from the 850mm long rear deck - not a great deal different from the back deck of a trad stern narrowboat.

Indeed, not a great deal of difference to the stern of a trad narrowboat at all. I suppose the big difference is in the potential performance of this broads cruiser. At 42ft and of lightweight GRP construction with 60hp, at full astern I imagine it would quickly build significant speed on the way to the scene of the collision on the opposite bank, therefore creating a much greater potential to throw someone overboard, whereas a narrowboat would be going much slower in the same scenario. 

[Guest]

Although wearing a lifejacket would probably not made much of a difference in this particular incident it is noteworthy the lady wasnt wearing one.

 

Its very common on the Broads for boaters on the broads not to wear one. There really isnt an excuse for not doing so as the yards to provide them (though we have our own). We noticed on our last trip again just how many hire boaters just dont bother. I think they think its a bit 'cissy'.

 

I suspect she wasnt expecting to be on deck, though that said when transiting Yarmouth we personally would wear them regardless in case of encountering a problem. Also only being two up it saves us having to quickly don them if you make a spontaneous decision to moor up at a nice spot so we tend to wear them anyway.

 

The BA and the Yacht Station staff constantly bang on about it on Social Media.

[Naughty Cal]

17 minutes ago, The Happy Nomad said:

Although wearing a lifejacket would probably not made much of a difference in this particular incident it is noteworthy the lady wasnt wearing one.

 

Its very common on the Broads for boaters on the broads not to wear one. There really isnt an excuse for not doing so as the yards to provide them (though we have our own). We noticed on our last trip again just how many hire boaters just dont bother. I think they think its a bit 'cissy'.

 

I suspect she wasnt expecting to be on deck, though that said when transiting Yarmouth we personally would wear them regardless in case of encountering a problem. Also only being two up it saves us having to quickly don them if you make a spontaneous decision to moor up at a nice spot so we tend to wear them anyway.

 

The BA and the Yacht Station staff constantly bang on about it on Social Media.

We are as guilty as anyone on the Broads for not wearing our lifejackets. 

 

Though we did/do always wear them for mooring up at Great Yarmouth and in the more tidal sections of the lower reaches around Breydon Water on the southern side, we very rarely wore/wear them elsewhere.

[AndrewIC]

I see the report is recommending that the Boat Safety Scheme get involved in areas beyond its stated remit to “help minimise the risk of boat fires, explosions, or pollution”.

[cuthound]

18 hours ago, booke23 said:

 

I don't think a stern rail would make much difference. It doesn't stop people going over the back of cruiser sterns on narrowboats.

I think the comment in the report of applying international standards to dual helm positions is probably a more sensible suggestion.

 

Indeed, on one of my early hire holidays I witnessed a man step backwards on a cruiser stern and trip over the stern rail.

 

I remember thinking that I would rather fall in feet first off the back of a trad stern rather than enter the canal head first after tripping over a stern rail 

[Guest]

16 minutes ago, cuthound said:

 

Indeed, on one of my early hire holidays I witnessed a man step backwards on a cruiser stern and trip over the stern rail.

 

I remember thinking that I would rather fall in feet first off the back of a trad stern rather than enter the canal head first after tripping over a stern rail 

 

A guy was killed at Alrewas in that exact fashion. From memory the boat reversed hit the bank he went over the rail and came into contact with the prop.

 

 

Edited May 6, 2022 by The Happy Nomad

[cuthound]

6 minutes ago, The Happy Nomad said:

 

I guy was killed at Alrewas in that exact fashion. From memory the boat reversed hit the bank he went over the rail and came into contact with the prop.

 

Yes I remember reading about that in the waterways press. I think he was swept off the deck by the tiller when the rudder was forced sideways when it hit the bank.

 

One of my pet hates is people standing alongside the tiller when steering, rather than standing in front of it.

[Alan de Enfield]

Just to add to the story - a little bit of information about a similar 'problem' on my boat today.

 

We have been on the boat for 10 days now but been unable to start the engines due to lack of water and being stuck in about 3 feet of mud, leaves and detritus. Starting the engines would have resulted in all the rubbish being sucked into the inlet filters, and no water getting to the impellors, engine overheating...........

 

The last couple of days the tides have started to increase in size, the basin is filling and the lock is holding water. We are now floating in about 6 feet of water (we draw almost 5 feet)

 

Checked engines all over, tightened up anything loose, loosened anything tight, opened the sea-cock and started the 1st engine.

Boat surged forward pulling the stern lines very tight. Checked I had 'pulled the lever' outwards and disconnected the gears - Yes.

Into reverse and the prop stopped rotating.

Back into neutral prop started rotating, back into reverse, prop stopped rotating.

 

Did the same with engine 2 with exactly the same results.

 

Worried now that over Winter the gear boxes had 'siezed' in gear - but - why both of them ?

 

Switched engines off and started to think.

 

Checked on the 'upstairs helm' and both throttles were slightly in the forward (in gear) position.

Pulled them back into neutral.

 

With all four throttles in neutral started like a dream and prop not turning - gears engage/disengage on both engines and at both helm positions.

 

How did it happen ?

The marina staff do 2 or 3 times daily boat checks, I can only imagine that over Winter the cover had become loose and they pushed the Kayacks under the sheet to give it better shape, and in doing so had kocked the throttles into forward.

 

 

There is no engage / disengage switch between the two helm positions it simply relies on both helms being in neutral when starting. I knew this but didn't check the boat was "as I had left it"

 

What have I learnt ?

 

Add "all 4 throttles in neutral" to my pre-start checks.