The Marine Accident Investigation Branch (MAIB) has published its report into the collapse of the mezzanine deck on Wightlink’s St Helen car ferry that took place in July 2014 and made worldwide news.
The report lays out long-running maintenance failures that led to the incident, which resulted in injuries to passengers and staff – a crewman was knocked unconscious – as well as damage to vehicles.
In the synopsis of the report, the investigator stated (our emphasis),
Wightlink was aware of many of the safety issues and contributing factors highlighted in this investigation report.
Of note: the absence of a formal mezzanine deck greasing routine had been subject to an internal safety management system non-conformity for over 2 years; the failure to address the non-conformity was highlighted by the Maritime and Coastguard Agency 9 months prior to the accident; and the failure to lubricate the steel wire lifting ropes was identified during 6-monthly examinations.
Given this knowledge, and the potential consequences of a rope parting, Wightlink demonstrated little or no appetite to allocate the resources necessary to resolve this long-standing issue.
This apparent lack of impetus was probably influenced by an over reliance on its 4-yearly wire rope replacement program and the Royal & Sun Alliance Engineering Inspection & Consultancy and the Maritime and Coastguard Agency’s reluctance to escalate the issue.
Deck allowed to “deteriorate to a dangerously unsafe condition”
The summary of the findings:
- St Helen’s mezzanine decks had not been maintained in accordance with the equipment manufacturer’s instructions. This allowed the material condition of the collapsed deck to deteriorate to a dangerously unsafe condition.
- Wightlink’s mezzanine deck greasing routines had fallen into abeyance and their steel wire lifting ropes had not been routinely dressed and lubricated over many years.
- Wightlink’s maintenance management system had weaknesses in key areas. In particular: maintenance roles and responsibilities were confused, record keeping was inconsistent and time was not allocated for the conduct of some essential maintenance.
- One of the collapsed mezzanine deck’s main structural beams failed on impact with the main deck. The beam failure occurred at the site of a previous fracture that had been repaired to a poor standard.
- The previous weld repair to the mezzanine deck’s failed beam had not been subject to formal approval and had left the deck in a structurally weakened condition.
- Wightlink was aware that its mezzanine deck greasing routines had fallen into abeyance; the maintenance shortfall had been subject to an internal safety management system non-conformity for over 2 years.
- Wightlink’s appointed lifting equipment surveyor repeatedly observed that the lifting wires for Saint Class mezzanine decks had not been dressed and lubricated. Given the previously identified potential catastrophic consequences of a lifting rope failure, the surveyor and/or his employers, Royal & Sun Alliance Engineering Inspection & Consultancy, should have elevated the recurrent report observations to a safety critical deficiency.
Wightlink’s response
Wightlink, who say they cooperated fully with the MAIB investigation and entirely accepts the recommendations of its report, also say they have has already implemented all of the MAIB’s recommendations.
Interim Chief Executive John Burrows says:
“We apologise for the injuries caused to customers and staff that night at Fishbourne and for the damage to customers’ vehicles. Immediately after the incident we took all necessary measures to check and confirm that the mezzanine decks on our other vessels were safe for use. The mezzanine decks on St Helen were not used again and the ferry was sold to another operator in March 2015.
“MAIB reports are crucial to ensuring that the entire maritime industry learns the lessons from incidents at sea. We have improved our maintenance schedules after a comprehensive review of our systems and have now introduced a new electronic Planned Maintenance System to ensure nothing like this happens again.”
The following images (© Crown copyright) are from the MAIB Report on the investigation of the collapse of a mezzanine deck on board the roll-on roll-off passenger ferry St Helen Fishbourne Ferry Terminal, Isle of Wight on 18 July 2014 (embedded below).
Click on images to see larger versions
The report
OnTheWight has given you a summary of the finding above. To get the full picture please see the report embedded below. Click on the full screen icon to see larger version.
Images: © Crown copyright, 2016 Report on the investigation of the collapse of a mezzanine deck on board
the roll-on roll-off passenger ferry St Helen Fishbourne Ferry Terminal, Isle of Wight on 18 July 2014
Top Image: © Matt Jones
