UPDATED: A damning report into the mezzanine deck collapse on Wightlink’s ‘St Helen’, compiled by the Maritime Accident Investigation Branch (MAIB) following an 18-month investigation, has today (Thursday) been published revealing the full details surrounding the incident, as first reported by Island Echo.
A crew member was thrown to the floor and knocked unconscious when the mezzanine deck on the 32-year-old vessel collapsed and fell around 2 metres as vehicles prepared to disembark at the company’s Fishbourne terminal on 18th July 2014. The injured crewman was found slumped face-down at the outer edge of the mezzanine deck; he was unconscious and bleeding from a cut close to his left temple.
Emergency services raced to the scene including the Isle of Wight Fire and Rescue Service, HM Coastguard, Police and ambulance crews, who treated several of the passengers seated in their cars who had suffered whiplash and other impact-related injuries. Others were suffering from shock.
The investigation has found weaknesses in the way that Wightlink managed the day-to-day maintenance of its vessels and, in particular, their mezzanine decks. The report has highlighted how a 28mm inboard steel wire ramping rope – used to raise and lower the mezzanine deck – failed resulting in the forward edge of the mezzanine deck coming to rest at an angle of approximately 30° to the horizontal, with its outboard corner remaining in its suspended position.
A detailed examination conducted by the MAIB has concluded that the dominant factor at the break site appeared to be overload due to excessive mechanical wear as a result of lack of service lubrication. Corrosion and fatigue are reported to be secondary contributing factors, which are also attributed to the lack of lubrication.
The report has also identified that the wire rope sheave grooves had suffered wear. The ramping wire’s vertical sheave was deformed, and off centred and wear was found on its horizontal sheave, which was indicative of an incorrect fleet angle. Both sheaves showed material wastage through corrosion and the absence of lubrication.
Detailed in the report is that the deterioration of the decks’ lifting ropes and their sheaves had occurred over a prolonged period of time and could easily have been avoided by the simple application of grease.
During an inspection of the vessel after the collapse, it was apparent to the inspectors that the material state of St Helen’s collapsed mezzanine deck had been allowed to deteriorate to a dangerous condition because it had not been maintained in accordance with the equipment manufacturer’s instructions. Furthermore, the extent of the deterioration was not identified during the periodic inspections and 6-monthly examinations conducted by the ship’s crew and the Royal & Sun Alliance Insurance Group Plc (RSA) surveyor.
Investigations throughout the course of the report have determined that Wightlink had no record of St Helen’s mezzanine deck lifting ropes ever being oiled or greased during the 4-year maintenance cycle prior to the collapse of the mezzanine deck. However, the MAIB say it is understood that the shore-based fleet technicians lubricated the ropes during May 2014. The oil used, Exxon Mobil MOBILARMA LT, was a general purpose rust preventative and was not suitable for use as a wire rope lubricant.
At the time of the accident, the starboard forward mezzanine deck’s lifting ropes had been in service for a total of 4 years and 3 months, with the replacement overhaul having been postponed from April 2014 until September 2014 when time for the refit ran out. The report says that if the lifting ropes had been replaced in April, the accident would not have occurred.
Back in June 2012 the master of St Helen recorded a non-conformance report stating that maintenance systems did not include requirement for greasing mezzanine decks, with one record showing that the starboard aft mezzanine deck has not been greased since June 2011 (one year). The master stated at the time that it was a long term oversight that applied to all Portsmouh to Fishbourne car ferries and suggested a corrective action of implementing a robust greasing programme that was recordable and auditable – but the proposed corrective action was not implemented.
In October 2012 a Document of Compliance inspection by the Maritime and Coastguard Agency (MCA) noted that mezzanine deck greasing non-conformaty was ongoing from June 2012.
In the same month – October 2012 – a fleet management meeting was held where it was stated in the minutes:
“There is no time to do greasing whilst a St Class vessel is on the run, and it needs to be done properly [suggested possible use of fleet technicians]. The programme would need to be documented on a practical form, and be fully auditable”.
A year later, in October 2013, another fleet management meeting was held and it was said:
“A Mezz Deck Greasing Programme is required for the St Class vessels. This will be carried out by the Fleet Technicians, but I will need to produce a formal procedure. Work in progress”.
A similar update was provided at the meeting held on 23rd April 2014, just 3 months before the deck collapse. All in all the non-conformance report was re-issued six times prior to the wire rope failure.
Maintenance instructions from MacGregor’s – the manufacture of the mezzanine system – recommended a 4-weekly lubrication routine for its mezzanine deck lifting ropes and lifting rope sheaves.
In addition to the failure of the wire rope, the main inboard longitudinal deck beam fractured and failed in the July 2014 incident at a previous fracture point, which had been weld repaired to a ‘poor standard’. No records could be found by the MAIB of either the earlier mezzanine deck beam failure on St Helen, nor of the weld repair carried out on the beam. The MAIB say such a structural failure should have been reported to the MCA, and the repair subjected to a formal approval process.
Dating back over 2 years prior to the deck collapse, in May 2012, a daily mezzanine deck inspection on board St Helen identified that the port forward deck’s outboard ramping rope had suffered chafing and fraying damage, with several strands broken. The repair request raised by the crew stated that the rope needed to be replaced and as such the lifting rope was subsequently inspected by the company’s route superintendent, who concluded that the damage had probably occurred when the rope was installed in 2010.
The superintendent decided to keep the rope in service and instructed the crew to monitor its condition closely. Subsequent inspections on 23 May 2012, 17 July 2012 and 17 October 2012 found no further apparent deterioration.
On 7 November 2012, a Royal & Sun Alliance Insurance Group (RSA) surveyor attended the vessel and immediately condemned the damaged rope. During the same visit the RSA surveyor condemned a lifting rope on St Helen’s starboard aft mezzanine deck. New ropes were fitted the following week.
The RSA surveyor who had conducted the most recent examination of St Helen’s mezzanine decks (2½ months before the collapse) was well qualified. He had 5 years’ experience with the vessel and its equipment, and had been an RSA surveyor for 16 years and was considered fully competent to conduct the 6-monthly thorough examinations. However, the number of defects found during the post-accident inspections, and the condition of the wire ropes in particular, is of serious concern to the MAIB, who say it indicates a fundamental failing in the assurance process provided by RSA.
The root cause of the wire rope failure (lack of lubrication) was repeatedly identified and highlighted in the RSA surveyor’s examination reports. Despite this, Wightlink took no steps to address the observations made in those examination reports. Of further concern to the MAIB, RSA did not rate the severity of the wire rope corrosion and took no steps to intervene; this was despite its generic inspection procedure and risk analysis documents identifying that the failure of a lifting rope presented a catastrophic risk.
Given the length of time the RSA surveyor had worked with Wightlink and its crew members, the MAIB say he should have gained a good understanding of the company’s approach to its lifting rope maintenance. Today’s report says that having seen his inspection report observations being ignored repeatedly, the inspector did not take the opportunity to escalate his concerns and raise a Section 6 dangerous deficiency. Had he done so, Wightlink would have been forced to take appropriate action to resolve its long-standing SMS non-conformity.
Royal & Sun Alliance Insurance Group Plc has since disposed of its engineering division, RSA Engineering Inspection & Consultancy, and no longer provides any engineering inspection services or inspections. All employees, contracts and intellectual property have been acquired by the privately owned company British Engineering Services Ltd.
In conclusion, the Maritime Accident Investigation Branch states in its report:
“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.
“It was evident that lubrication of the mezzanine deck steel wire lifting ropes on board Wightlink’s vessels had fallen into abeyance over many years since the introduction of St Clare in 2002, and they had not been routinely dressed and lubricated.
“The outer strands of the collapsed deck’s ramping ropes were dry and there was little penetration of lubrication to their inner strands.
“Wightlink’s management team was well aware of the maintenance shortcoming as it had been raised in communications from their masters on several occasions as a company SMS non-conformity 2 years earlier. The remedy was simple to implement but the non-conformity remained extant up until the rope failure. It was clearly apparent that there was no appetite within the company to implement a greasing routine as this would have required either manning the vessels during the night-time layup, or taking decks out of use while the vessels were in service.
“To mitigate the risk of wire rope failure, Wightlink had a policy of discarding the lifting ropes after 4 years in service. However, the rope that parted had been in service for 4 years and 3 months. If the starboard forward mezzanine deck had been overhauled and its lifting ropes replaced as originally intended during St Helen’s refit in April 2014, the accident would not have happened. Nevertheless, the decision to delay the wire rope replacement should not mask the real issue. Steel wire ropes must always be properly maintained in accordance with best practice”.
As a result of the incident, Wightlink has:
• Conducted immediate inspections on board all its vessels operating with MacGregor equipment to confirm the safe condition of the equipment, and replaced a number of wire ropes.
• Retired St Helen from service; prior to this its mezzanine decks had been permanently taken out of service.
• Written a formal monthly greasing schedule into an electronic planned maintenance system.
• Introduced a 30-month maximum wire rope replacement schedule.
• Developed a risk assessment to enable crew members to conduct mezzanine deck inspections while the decks are suspended only on the lifting wire ropes.
• Implemented a new centralised electronic Planned Maintenance System for all Saint Class vessels, and commenced roll out of the system across its other ships.
• Contracted the mezzanine deck manufacturers to carry out annual maintenance inspections.
• Contracted the mezzanine deck manufacturers to carry out annual maintenance inspections.
Wightlink has been recommended to:
• Review and, as necessary, improve its safety management system to ensure the company:
• Acts promptly in response to non-conformities affecting important and critical equipment on board its vessels
• Applies a proactive response to the management of observations and deficiencies identified during the thorough examination of its vessels’ lifting equipment
• Notifies the relevant authority in the event of damage to a vessel that requires structural repair
British Engineering Services Limited is recommended to:
• Ensure its policy on the scrutiny of its thorough examination reports:
• Identify the instances when its customers have repeatedly failed to address shortcomings identified during lifting equipment examinations, and
• Provide a mechanism for bringing shortcomings to the attention of its customers and, where appropriate, the relevant authorities.
The Maritime and Coastguard Agency is recommended to:
• Ensure its audit inspections of Wightlink vessels provide specific focus on the effectiveness of the company’s maintenance procedures.
Safety recommendations shall in no case create a presumption of blame or liability.
You can read the full report at https://www.gov.uk/maib-reports/collapse-of-a-mezzanine-deck-on-board-ro-ro-passenger-ferry-st-helen.
In a statement, Wightlink have today said:
“The Marine Accident Investigation Branch (MAIB) has today published its report into the mezzanine deck incident on St Helen in July 2014.
“Wightlink Ferries operated St Helen on its Portsmouth to Fishbourne route. The company cooperated fully with the MAIB investigation and entirely accepts the recommendations of its report.
“Wightlink has already implemented all of the MAIB’s recommendations for the company (the report also has recommendations for the Maritime and Coastguard Agency and Royal Sun Alliance Engineering & Inspecting Consultancy)”.
Wightlink’s 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.”
At the beginning of December it was confirmed that Wightlink’s CEO, Russell Kew, had stepped down from his position by mutual agreement, although Wightlink have told Island Echo that this was not related to the MAIB report, which entered a consultation stage towards the end of 2015.
UPDATE @ 10:00 – Andrew Turner, the Island’s MP, has issued a statement in response to the MAIB report, saying that Wightlink were ‘reckless with people’s lives’. He is now calling for a full response from Wightlink to reassure that they will never again put the lives of passengers and staff at risk.
Mr Turner has today said:
“This is a damning report. Wightlink were reckless with people’s lives and took no notice of numerous warnings of the danger, either from external inspectors or their own staff. As any public transport operator will say, the Health and Safety of staff, passengers and members of the public comes before anything else. Had, God forbid, anyone been killed, it is clear that senior directors of the Company would now be facing corporate manslaughter charges.
“What is so disturbing about is the exposure of a culture so devoid of responsibility for Wightlink’s legal obligations that it makes one wonder whether they are capable of fundamentally changing the company’s approach to safety.
“Examination of the accounts for Wightlink show very high profits. The highest paid director received £714,000 plus pension contributions in 2015 (up from £382,000 the previous year), and bonuses worth well over £1m were paid to senior directors for their performance. At the same time as paying senior staff such enormous salaries and bonuses Wightlink were simply ignoring basic safety procedures. One wonders what kind of due diligence Balfour Beatty could have possibly undertaken before purchasing the business and entrusting its reputation to the old Wightlink management?
“I am calling for a full response from the Company to explain what radical and well-funded measures they have already taken, and will now take to ensure that they will never again put at risk the lives of their staff and passengers. It seems to me that all regular independent safety inspections should be published along with internal documents that raise safety concerns. We need detailed commitments from Wightlink and their owners to put right any faults immediately without regard to cost. We need to know that they are fit to run this lifeline service. I will also be talking to Transport Ministers to examine what further actions may need to be taken”.
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