A report about flooding that could have had a tragic outcome.
What the reporter told us:
A large yacht (100m+) weighed anchor and got under way with the intention of completing a 2-hour passage to another anchorage. The weather was good and the sea calm. Approximately 10 minutes after getting under way, an alarm for the elevator was received in the engine control room (ECR). The Chief Engineer dispatched the ETO to investigate. A minute later the ETO called the ECR to report that a vast amount of water was coming down the stairwell and out of the elevator shaft doors. It was quickly ascertained that the port side, lower deck, shell door was not closed. The bridge was called and requested to stop the ship. The shell door was closed.
Water had flooded down two decks via the stairwell and the elevator shaft. On the bottom deck the water collected on the tank top and was contained between the closed watertight doors. The incident was responded to and dealt with quickly, but this could have ended very differently.
Cause: The vessel has several shell doors on the lower deck (at the waterline) and the main deck (normal freeboard deck). Some of these had been open at anchor and all should have been closed prior to departure. The bridge pre-departure checklist requires that all shell doors are checked as closed. The checklist was completed, but the task was not. The shell doors can be visibly sighted from the port and starboard bridge wings. They are also monitored by CCTV and by a mimic monitoring panel on the bridge that displays the status of the openings. None of these were checked by the bridge team prior to departure.
Conclusion: Various methods were available for checking the status of the shell doors however the bridge team appeared to be unfamiliar with them or complacent about their use. The SMS pre-departure checklist is a wipe-clean laminate with a series of boxes to be ticked, but it had not been signed as completed. The checklist was completed by ‘box ticking’ without verification that the tasks were actually done.
CHIRP engaged with the reporter who confirmed that a new pre-departure checklist, which requires the ECR staff to check the hull doors are closed, had been drafted and submitted for approval before he left the vessel. He also asserted that in his 20-year sea going career he had never seen an incident like it. Apparently, most of the crew on board had never heard of the Herald of Free Enterprise disaster.
With the amount of money this vessel cost to build it is hard to understand why the mimic monitoring system which was installed on the bridge was not duplicated in the ECR. However, the consensus of our Maritime Advisory Board members was that individuals have to be responsible and accountable for their actions or lack of them. On this vessel the bridge officers had a clear duty to carry out the pre departure checks diligently; there was a checklist to follow, there were multiple methods to monitor and confirm that the shell doors were indeed closed and yet they failed to do so. Was the failure incompetence, a lack of safety culture, complacency or negligence? There was certainly a lack of oversight.