MAIB report: Fatal person overboard from Diamond Emblem 1 at Great Yarmouth Yacht Station, River Bure

Summary:

On 19 August 2020, Laura Perry, a member of a family group on board the motor cruiser Diamond Emblem 1 fell overboard from the aft deck when the boat’s stern made hard contact against the embankment wall opposite the Great Yarmouth Yacht Station. She became entangled in rope and the propeller, suffering multiple injuries that resulted in her drowning.

The key safety issues identified were:

• An adequate guardrail around Diamond Emblem 1’s stern would likely have prevented the passenger from falling into the water.
• The boat’s driver at the upper helm control position was unable to control the motor cruiser at the time. This was most likely because the helm position changeover lever had been incorrectly set to the lower helm control position.
• There was no way of identifying which helm control position had active control at the upper helm position.
• No one on board fully understood the functionality of the boat’s dual helm controls and the driver was unaware that the engine could be stopped from the upper helm control position.
• Both the handover and documentation provided to the family group were not sufficient to ensure they were competent to drive a boat with dual helm control.
• Diamond Emblem 1’s conformance with the Recreational Craft Directive’s essential safety requirements was incomplete in several respects and hazards inherent in the boat’s design were not considered.

Safety recommendations:

• In October 2020, the Chief Inspector of Marine Accidents urgently recommended the Association of Inland Navigation Authorities to amend the proposed Code for the Design, Construction and Operation of Hire Boats (the Hire Boat Code) to strengthen the requirements for person overboard prevention, handover procedures and engine control systems (recommendation 2020/129). The recommendation was partially accepted.
• A further recommendation has been made to the Association of Inland Navigation Authorities to provide guidance and oversight to its members in complying with the requirements of the Hire Boat Code when adopted as mandatory by them in 2022 (2022/113).
• The Broads Authority has been recommended to: make the British Marine and VisitEngland Quality Accredited Boatyard Scheme a requirement of its licensing provisions (2022/114); review its licensing regime with respect to required boat documentation and following up on a change in hire boat company ownership (2022/115); and retain records that demonstrate compliance with the Recreational Craft Directive’s requirements for boats operating in their waters (2022/116).
• The owner of Diamond Emblem 1 has been recommended to: align its handover procedures with the Hire Boat Code (2022/117); ensure appropriate documentation is provided to hirers (2022/118); assess and mitigate the risk of falling overboard from its boats (2022/119) and eliminate the risk on boats with dual helm controls by providing a means of identifying the active helm control position (2022/120) and control system interlocks (2022/121); and ensure that safety critical controls are easily identifiable on any boats that they operate (2022/122).
• The Boat Safety Scheme has been recommended to conduct a review of its requirements for hire boats with multiple helm positions to require a means of identifying the active helm and control system interlocks (2022/123).

Andrew Moll, Chief Inspector of Marine Accidents, said:

“Boating holidays provide an excellent way of experiencing the UK’s network of inland waterways and the vast majority of the many trips completed each year are safe and uneventful. However, this tragic accident demonstrates that boating is not without risk. A serious situation can quickly develop from benign circumstances if adequate precautions are not in place to mitigate the risks associated with controlling the boat and preventing people from falling overboard.

“Large motor cruisers with sophisticated controls are becoming increasingly common and are often driven by members of the public who have limited or no proficiency in boat handling. It is imperative that complex multi helm controls incorporate appropriate technical features and indications to minimise the likelihood of an inadvertent loss of control. Adequate protection around exposed deck areas is equally important in ensuring that no one falls into the water. Furthermore, handovers, including in-water demonstrations, and hire boat documentation need to be complete and rigorous in order to ensure that hirers have sufficient proficiency to safely handle the vessel in their charge.

“Following this investigation, I have made recommendations to enhance the governance, oversight and safety of hire boat operations. I have also recommended to the boat’s operator that they address various aspects of the safe operation of their boats. This includes enhancing its handover procedures and undertaking a thorough assessment of the risks of people falling overboard from its hire craft to ensure that the hazards are appropriately mitigated. Such an assessment is essential to ensuring that another similar accident to this does not happen again.”