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Fatal Design Flaw
Posted: Monday, February 22, 2010 4:27 PM
Joined: 02/05/2008
Posts: 386

Dockwalk magazine's regular column, What Went Wrong by Kelly Sanford, highlights a different marine accident each month, focusing on the lessons learned. We've received feedback that some readers would like to comment on it. So we're republishing it in the forum so you can have your say.

This month's column is about a design flaw that cost an innocent bystander his/her life.

In the world of private pleasure vessel design, just about anything goes. Though certain structural and environmental safety criteria must be met, there is no law against bad design. No boat is going to be perfect, and just about every captain can walk through their boat and point to a number of items they would change.


However, some captains are expected to work with a greater handicap – some design flaws are far more than a nuisance, some design flaws are dangerous. According to an investigation by the Cayman Islands Shipping Registry, a questionably designed wing control station is largely to blame for egregious injuries to one bystander and the death of another during an otherwise unremarkable berthing of a large yacht.


In a synopsis provided by the International Mariners’ Alerting and Reporting Scheme, MARS (which provides no specific details regarding vessel length, location or the date), the yacht had nearly completed docking procedures when the accident occurred. The report states, “Wind and tidal conditions were benign and the arrival and mooring procedures followed the yacht’s normal routine. During the mooring operation, the yacht was being maneuvered from the port bridge wing control station. When not in use, this station folds into the bridge house for storage. Due to the design of the bridge wing control station, it was necessary to put the engine controls in the full-ahead position before the control station could be closed.”


Once four lines were secured and fenders were in place, “A crewmember placed the bridge wing control in the full ahead position and closed the wing control station.” The crewmember failed to realize that the engines were still running and that the controls of the port wing station were still engaged.


“With the engines engaged, the yacht…wrenched three of the mooring points from the quay. Two bystanders were struck by flying debris and/ or recoiling mooring ropes. One person was struck in the legs, fracturing them. The other person sustained serious head injuries…. The person with the injuries to the legs was…expected to make a full recovery; however, the person struck on the head…died five days later,” the report states.


Blake Stahl, an accredited marine surveyor with the Marine Survey Group, says, “I constantly see designs that may be aesthetically pleasing, but represent a major threat to the life and limb of crewmembers, passengers and, in this situation, innocent bystanders. These issues usually involve anchoring/mooring, hydraulic boarding systems, tender/ water toy launching systems, proper escape from interior spaces, etc. …


The design requiring control levers to be advanced for stowing of a wing and/or any other secondary station is unfortunately very common. Many yachts equipped with secondary control stations, whether they are wing stations or aft control stations, often have removable [or] hinged covers that also require advancing of the controls for closure. Given the general acceptance – and current widespread use by many yacht manufacturers – Fatal Design Flaw of this arrangement, I feel the [responsibility] lies on the procedural side in this situation.”


Stahl explains, “The advancement of sound-proofing technology, coupled directly with the distance separating a control station and machinery space, [means] ‘hearing’ the engines is usually impossible. Therefore, it is imperative to verify the status of the main engines [from] any control station, active or inactive, before ‘touching.’”


Stahl advocates the following protocols:

·         No crewmember, other than the designated operator, is to deploy, operate, engage, stow, etc. any of the vessel’s control stations (primary or secondary) once the main engines have been powered on, whether dockside or at anchor. This rule carries forward until the vessel’s captain has inspected the anchoring or docking arrangement and powered off the main engines at the voyage’s conclusion, regardless of the number of hours or days that have elapsed.


·         Upon abandoning a secondary control station, the designated operator must immediately engage a primary control station (usually inside and not typically “touched” by anyone), thereby de-activating all other stations prior to vacating that deck level.


·         Fabrication and use of a small placard that must be placed over the levers of any unattended control station prior to leaving it. This placard should read something like, “Are engines running...Are controls active?”


“I think adherence to a practiced procedure is the single most important part of the safe operation of a vessel,” Stahl says. “[Here], there was no reason for a member of the crew to stow the wing station until the captain inspected the docking arrangement and powered off the mains. Had either of the first two bullets been part of S.O.P., the incident would have been avoided.”


In theory, every vessel (even in the absence of design issues) should have a set of docking procedures, but far too often in the reality of pleasure yacht operations there can be numerous distractions and deviations from what might universally be considered “rigorously safe” docking procedures. Distractions compound vulnerability when a vessel has an inherent design flaw that presents a potential danger.


The MARS report concludes, “Where novel or unusual designs introduce additional risks, these should be properly assessed and appropriate control measures introduced. Removal or elimination of such risks should be considered in preference to introducing procedural controls aimed at reducing or mitigating the risks.” The report also emphasizes that, “Persons not involved in mooring operations should be kept at a safe distance until the operation is complete.”

Posted: Monday, February 22, 2010 6:47 PM
Joined: 14/01/2009
Posts: 1026

Assuming that the yacht was fitted with electronic, fly by wire controls, I'm not convinced that Blake Stahl has correctly identified the defect. . Very easy to critize modern yacht design details or state that if proper " procedure had been followed ", the accident could have been avoided. Better to observe that enlightened installation could have prevented the accident. Ive sailed with electronic controls for many years. No " Procedure " is required because the control circiut , specified by the new build project manager, will automatically " Time out " . It is a very simple circuit. As soon as a wing control station is brought into Neutral for a user predetermined time, " timeout" occurs and control is transfered back to the wheelhouse. The operator must only finger poke a momentary switch on the wing station to re activate the control and sequence. . This is user friendly, foolproof technology . It is way to easy to become preoccupied with a docking scenario then forget to manually deactivate a wing control station. If this timeout system is not practical on a particular yacht, an audible Beep... Beep alarm, indicating control activation " Stand Clear" is very simple to concieve and install.
Posted: Tuesday, February 23, 2010 10:06 PM
Joined: 24/10/2008
Posts: 6

Sounds like the incident that occured with the Hakvoort 164'  'JaMaSa " ?

Posted: Tuesday, February 23, 2010 11:30 PM
Joined: 23/02/2010
Posts: 1

Right junior! Firstly, assuming is something that should never be done, assumptions are the root cause of far too many accidents. Am I to understand the vessel should have been fitted with a system that would require no procedures to be in place? (no such system) Clearly control procedures should have been in place. An innocent bystander would still be alive had control procedures been in place and properly followed. No matter how fool proof you think your vessels controls are they should still be subjected to control procedures, electronic controls are renowned for going rogue. Perhaps if a safety case followed by appropriate risk assessments had been carried out then this accident would not have happened, i.e. the risk would have been identified and the necessary design modifications and or procedures would have been put in place. Do you guys carry a copy of The Bridge Procedure Guide or ISM Code? If this happened in the UK someone (The Captain) would be held responsible, sorry is just not good enough.
Posted: Wednesday, February 24, 2010 2:42 AM
Joined: 01/08/2008
Posts: 14

I am in total agreement with jasmcp. Too often have I seen in both the merchant and yachting industry assumptions made that lead to accidents, near misses and vessel/ machinery damage. Arrival and departure procedures are just like any other safety procedure i.e. working aloft or entering an enclosed space. They are there for a reason and I see time and time again these procedures are ignored. Unfortunately I am seeing it a lot more now I am in the yachting industry and the lack of professionalism and care taken about peoples work is appalling. I fail to understand why they are called superyachts with supercrews. As I see it there is nothing super about them. There are no details of the vessels length, however the report does say 'large yacht'. If it was CI flagged and over 24m in length it must have had an ISM system onboard covering the procedures necessary for safe operation. When will people learn that cutting corners costs lives. I really hope this incident has opened some eyes.
Posted: Wednesday, February 24, 2010 6:55 AM
Joined: 14/01/2009
Posts: 1026

" Am I to understand the vessel should have been fitted with a system that would require no procedures to be in place? " Well Jasmcp , Not so simple. We all have procedures in place to compensate for human error or equipment malfunction. These procedures are critical to safe operation. The next best defense is to ensure that the design and installation of equipment compensates for the inevitable operator error. I can tell the crew 15 million times to make sure all port holes are dogged down... but in addition I am fitted with sensors and alarms because they just might forget one. A double safety. All over your wheelhouse is modern electronic equipment that automatically Prompts you with a question....are you sure you want to do this ? YES or NO, before it will perform a non standard operation. A double safety. If you jump into my small Rib right now you must remember to shift the outboard motor into neutral before you wind up and pull the start cord. If you forget the cord will stay locked. A double safety to prevent operator error. If you accidentally trigger my engine room fire suppression system, a siren sounds, lights flash, discharge countdown comences and you must leave the engine room immediately to avoid suffocation . A double safety to prevent engineer fatalities. You can go on and on about proper procedure . I believe that proper installation, design and the knowledge of how equipment works is the ultimate safety. Or to put it bluntly....you have now been warned about the dangers presented by activated wing controls when the yacht is as rest....if you choose to ignore the retro fit of a timeout system or other measure to prevent unauthorized use...you are irresponsible.
Posted: Wednesday, February 24, 2010 1:09 PM
Joined: 01/08/2008
Posts: 14

It is good to hear you operate on a very doubly safe boat junior. I think the point being made is on the dependence people put on these safety systems or double safeties as you put it. They are not fitted to take the place of the human operator. The fact that crew members are assuming the control system has done its job and taking action without checking is the problem. How many times have main engines been started with turning gear engaged, causing serious injury or damage, even though there are interlocks fitted? A lot, thats how many. My vessel has a system that automatically switches our stabilizers from zero speed to normal stabilization at a preset speed. However if the speed log gets dirty or turbulent water upsets the transducer the speed signal is lost and the switch over will not take place. Zero speed stabilization whilst under way is very dangerous. This is why the officer on watch must check to see if the change over has taken place and not just assume the control system has done its job. Even if this yacht was fitted with the time out system you mention (Does this mean that whilst manoeuvring if you put one of the sticks to neutral it times out? Seems a little dangerous.), the short timeout period still allows for the sticks to be put to full ahead whist still in control of the engines. A better control system would be to have the addition that the control console is disabled when the station is not in its full extended and locked position. No matter what control system is in place, no matter what sensors you have, failure is always a possibility and reliance on sensors alone is foolish. Visual checking by the person in command should always be done, whether this is for your portholes, shell doors (herald of free enterprise) or even down to the level of oil in your sump. There is no doubt that some systems are better designed than others but it is the responsibility of the Master and the DPA to ensure that his crew are operating and following ISM and the procedures set in place in the safest way possible.
Posted: Wednesday, February 24, 2010 2:14 PM
The back-and-forth so far just reinforces the MARS conclusion which said, “Where novel or unusual designs introduce additional risks, these should be properly assessed and appropriate control measures introduced. REMOVAL OR ELIMINATION of such risks SHOULD BE CONSIDERED IN PREFERENCE TO INTRODUCING PROCEDURAL CONTROLS aimed at reducing or mitigating the risks.” I also think Blake Stahl is wise to point out that yachts are riddled with dangerous design flaws that are in place out of indifference from the designer, the frugality of the owner or because it suits the aesthetic of the boat. I agree that the safety of the crew is frequently compromised to suit some arbitrary desire. You see it all the time. For example, how many times have you seen deck furniture sitting on a crew area or engine room escape hatch? Complacency with an unsafe design is dangerous. There is no undoing dead – so where the risk of death can be averted, steps should be taken. Perhaps we could all walk away from this story with the realization that crew should be more proactive in encouraging (or insisting) that owners “remove or eliminate” any fixable flaw so human error is removed from the equation!
Posted: Wednesday, February 24, 2010 2:21 PM
Joined: 02/05/2008
Posts: 40

Here is a link to a report on the Marine Accident Reporting Scheme which contains photos of the design flaw discussed in this incident: http://www.nautinst.org/MARS/mars09/200952.htm . There has been some speculation that this story is about the M/Y JeMaSa, however I should point out that there is nothing in the report which can confirm the identity of the vessel, nor anyone involved in the accident. It is entirely possible that this was a different incident. In doing research for this article, I have learned that accidents similar to this one are rare, but not unique. There will be a little more on this subject next issue.
Posted: Wednesday, February 24, 2010 2:50 PM
Joined: 13/12/2009
Posts: 4

Near Fatal Design Flaw Recently I cooked on my stove top. I stepped away for a second and before I knew it my g/f put some paper towels on top of the stove, without turning it off, and it was a near disaster. These stove owners are becoming too demanding in their quests for the perfect stove and in turn these stoves are becoming very unsafe and full of design flaws. We all know that there should be a hand sized breaker switch for the safe on/off operation of stoves, as opposed to these sleek little knobs that are currently being used.
Posted: Wednesday, February 24, 2010 3:12 PM
Joined: 18/03/2009
Posts: 10

Randall, you should go back and play on the shallow end of the gene pool, the water looks to be a little too deep for you here. This is not the place for that kind of sarcasm. What are you, 12-years-old? Somebody died, you dolt - have a little respect.
Posted: Wednesday, February 24, 2010 3:25 PM
Joined: 14/01/2009
Posts: 1026

And Kelly...while your doing your, what went wrong investigations, have a close look at yacht remote controls. Too many yachts are going cheap and convenient by using keychain size, automobile style , omni direction radio signal remotes, instead of industrial IR narrow beam remotes. A crew with an omni in his pocket can unintentionally trigger a powerful hydraulic function while sitting in the saloon reading the newspaper. This cannot happen with a narrow beam IR remote. So many yachts fail to modify the standard factory delivery code on the remote that its common to see the crew on the "new guy" in town press the button and a passarelle down the dock extends. Plenty of accidents.... And Randal if your on a modern yacht, you indeed have a design flaw. Yachts should be fitted with induction cookers. Much safer. The glass top never become hot, cant start a fire and best of all they give your aircon system a break because there is no residual heat after you turn off the stove top elements.
Posted: Wednesday, February 24, 2010 4:54 PM
Joined: 13/12/2009
Posts: 4

Shad, Of course it is very unfortunate that someone died, however, because of that I'm not allowed to poke fun at the fact that human error is being called a design flaw? Yes that makes perfect sense!! Me poking fun at this being called a "design flaw" has 100% nothing to do with being disrespectful to the person who was killed. I have the utmost sympathy for them, their family, and anyone that was affected by this situation. The fact that you see it like that is very pathetic, and you for sure shouldn't be questioning anyone's gene pool. Junior, I was joking as I see my stove comparison being about as much of a "design flaw" as the "engine control" "design flaw" being talked about on this yacht. If the throttles have to be put ahead to be stored, then obviously the engines should not be on when you do this. If there was some type of unknown variable there, then of course it should be called a design flaw, but there is not! It's cut and dry, if the engines are on, don't slam the throttles full ahead to store them. If you are not sure if they are on, take 5 seconds and check them. Plain and simple....human error-1, design flaw-0, regarding this issue.
Posted: Wednesday, February 24, 2010 4:56 PM
Joined: 02/05/2008
Posts: 40

Junior, that is an interesting suggestion. I remember guests getting into battle royales with neighboring boats who had similar remotes for the SAT TV. I had not heard of this compatibility problem with controls, but I’ll admit that in the last few years I have spent far more days at a desk than I have at sea, and I believe you that control overlap is a potential problem. I would be happy to cover control overlap, but here’s the rub: before I can write a What Went Wrong on a topic, I need to have either someone with a fairly detailed first hand account of a specific incident or an official, third-party report from a source like the USCG, MCA, MARS, IMMARBE or an insurance company. You would think these reports would be easy to obtain from some master list of incident disclosure; unfortunately, no such list exists, and these reports are often VERY difficult to access – even when I already have knowledge of a specific accident. So with this in mind, if anyone has a first-hand account on this topic or any other topic which they would like to see covered in the What Went Wrong forum, you can contact me through the Assistant Editor of Dockwalk, Janine@dockwalk.com. As you can see from this current topic, names and dates can be kept in close confidence, so if someone is willing to share a “teachable moment” I will always honor any request to do so anonymously. Thanks for the interesting suggestion, Junior. I’ll put it on my radar and see what I can come up with.
Posted: Wednesday, February 24, 2010 5:15 PM
Randall, a design flaw is absolutely partially to blame for that person being killed. The controls were not accidentally knocked into forward, they were forceably and intentionally slammed into full ahead because the design of the wing station required it in order to be stowed. I suggest you look at the photos on the link. Human error played a part in the tragedy, but if the wing station had been thoughtfully designed, this accident would not have happened. Period.
Posted: Friday, March 26, 2010 12:11 PM
Joined: 16/10/2008
Posts: 5

Blake Stahl is a bit too quick on blaming the control layout design...it doesn't quite cover the issue.
Clearly, the control design on the motoryacht in question could have been improved on, but in this case simple procedures, which I'm sure were clearly formulated on the yacht, should have prevented this accident. Discipline in following procedures is the key-issue here. You just have to work with what you've got sometimes, since yachts will never be perfect. That's why you need experienced, sensible crew.  I wonder if there was a dockwatch to keep interested bystanders on a safe distance, while mooring the yacht.....
Suggestions that electronics could have minimized the risks and different controls should have been fitted simply ignore the hard fact that there are many yachts outhere which were designed and built in another technological era. How about those classics or pre-80's built yachts then? Should everybody "upgrade" to modern technology, which has proved not to be perfect either?
You analyse potential risks in operation for every individual yacht and adjust your operation procedures accordingly. If you, as a Captain, deem the risks or likelyness of potential errors too high, the equipment in question needs modification and preferably not operated  until that modification has been carried out. Or you leave the yacht.
It will minimize risk, but we'll have to accept that accidents always can occur, even/especially when high-technology  comes into play that is designed to 'prevent' such accidents, as this technology too is developed by humans. My experience has taught me never to fully rely on electronics and to keep thinking for myself. That's my double safety.

Posted: Saturday, March 27, 2010 2:31 AM
Joined: 01/06/2008
Posts: 1049

I agree that the greatest safety devices are proper training, procedure and  adherence there to, however that said, accidents happen. If a simple solution to add a margin of safety is available, one should probably enact that option even if just from a liability standpoint (after all, isn't that the masters primary duty, to guard against liability?). In that vein, since I have a portable control box for wing station duty with electronic controls, I have, since the Thailand issue brought the thought to bear, had installed a guarded switch which will deactivate the throttle and gear controls by simply putting down the guard. Lift the guard and engage the switch and I have live controls. This provides an extra safety in that if I have that control station selected and the switch down, there are no live stations in the boat, therefor any position can be accidentally manipulated with no engagement of controls. The bridge or engine room station must intentionally be engaged before any engine or gear control can be enacted.

What one has to consider when dealing with this type of stuff is what will a court finding be in case of an accident, not only civilly but criminally as well. When one is being tried in front of a group who are not trained seamen, what will they think of the comment "I shouldn't have had to do anything to make that system safer because nobody should have done that." I can tell you right now, that answer does not go a long way to mitigating liability. You're much better off when you answer, "I recognized that issue and put this guard in place. Regrettably, it wasn't enough." Showing you recognized an issue and tried to mitigate it takes you a lot further away from culpability in an accident.

Posted: Saturday, March 27, 2010 6:18 AM
Joined: 14/01/2009
Posts: 1026

What Fonz says is correct....all yachts have danger zones....its up to a smart captain to spot these danger zones, then devise strategies to avoid problems. One feature of yachting is that the typical captain and owner is simply passing by and will only spend a year or two on any particular yacht. Typically so short that they never get the opportunity to put the yacht thru a refit and work out some of the danger zone details. I'm looking at a big sailing yacht on the end of the quay. It has push button deck switchs, for its big hydraulic primaries, located for aesthetic reasons on deck in the deadly 'V" zone. Accident waiting to happen. Not so easy to move till refit time. hope the captain stays and the owner owns it long enough to fix it, rather than pass this design defect on to the next crew..
Posted: Saturday, March 27, 2010 11:40 AM
Sounds like the incident that occured with the Hakvoort 164' 'JaMaSa " ?
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