HEALTH AND SAFETY EXECUTIVE HID SEMI PERMANENT CIRCULAR

Hazardous Installations Directorate SPC/Enforcement/82

Review Date: March 2007 Subject File: 261

Author Section: OSD 3.3 OG Status: Fully Open

Issue Date: March 2004 Version No: 1

STATUS: For Action by IMTs

TO: All OSD Band 1-3 Inspectors

RISK ASSOCIATED WITH VERTICAL CHUTE TYPE MARINE

EVACUATION SYSTEMS

PURPOSE

This note contains advice to Offshore Division Inspection Management Teams

(IMTs).

On 9 October 2002, a fatal accident occurred while an evacuation drill (using a

Marin-Ark vertical-chute marine evacuation system) was being conducted in Dover
harbour.

This note applies in relation to those installations which have a vertical chute type
marine evacuation (escape) system. The purpose of this note is to ensure that duty
holders for such installations are aware of the fatal accident, and have taken account
of any relevant lessons. A proforma letter is provided in Appendix C for this purpose.
Also, if considered appropriate by the IMT, this note may be given to a duty holder.

BACKGROUND

Type of system

1. The system involved in the accident comprises one or more vertical tubes and
liferafts. The tube is made up from a series of totally enclosed sections like
wind socks, to control the rate of descent. Each section is about 2 metres long
and the total system in use was 24 metres long. Persons descending the
vertical tube arrive in a liferaft at the bottom.

Accident details

2. The personnel being evacuated were untrained and they represented a typical
passenger cross section on board a ferry. The 125th person to descend was a
lady who became trapped close to the bottom of the system. She became
 unconscious before she could be released. She was taken to hospital where
she was pronounced dead.

3. The lady concerned became trapped in the chute in a position in which her
arms and legs were above her body (see Figure 1). The most likely cause of
death was that she then could not breath properly, ie she was subject to
positional asphyxia.

More details

4. More details of the accident can be found as follows:

a. The MAIB Safety Bulletin 1/2003, including interim safety

recommendations, found in Appendix A.

b. The MAIB final recommendations (from the full MAIB investigation

report), found in Appendix B.

c. The full MAIB investigation report can be found on the internet.

d. SADIE safety alert No 495, issued in September 2003. This includes

some of the interim recommendations from the MAIB. SADIE alerts can
be accessed after free registration with SADIE.

Some comments on vertical chute systems

5. An article in "Safety at Sea International" April 2003 written by Liferaft

Systems Australia (LSA) provides a view on vertical chute systems of the type
involved in the accident. LSA concludes that if evacuees can become trapped
inside a vertical chute during a harbour drill in controlled, calm conditions, the
question must be asked what would happen in a real emergency evacuation
at sea. In the event that a person does become trapped the system must be
rendered unusable, placing lives at risk.

6. Vertical chute systems of the type described are designed for very high rates
of escape, eg a person entering the tube every few seconds. Rate of entry of
persons was not a contributing factor in the fatal accident. However, it may be
advisable to apply some restraint to the rate at which persons enter the tube,
to avoid exacerbating blockage problems, and to avoid injury to persons at the
exit from the tube.

Use of vertical chute systems offshore

7. There is no indication that vertical chute systems of the particular type

involved in the accident are in use on any offshore oil and gas installation on
the UKCS. The manufacturer of the equipment has a website which includes
a list of vessels fitted with this type of equipment. None of these vessels
appears to be a UK offshore oil and gas installation.
8. Vertical escape systems, such as the Selantic Skyscape, have been fitted to
some UK offshore oil and gas installations. Skyscape is based on a vertical
net tube and can be regarded as a type of chute system, but the chute is
broken up into short inclined planes which limit the rate of descent. Thus, it's
design differs markedly from the system involved in the above accident, and
there is no indication that it would suffer from exactly the same accident
mechanism as the system concerned. However, as with any chute system,
attention needs to be paid to the possibility of the system being blocked by
persons who become snagged or otherwise jammed in the chute.
Consideration also needs to be given to:

a. Whether problems may arise from clothing, survival suit or lifejacket

riding up,

b. The possibility that persons could find themselves in a position where

they may unable to breath.

RECOMMENDATIONS (ADVICE TO THE IMTS)

9. If a Marin-Ark vertical chute evacuation system is fitted (or is to be fitted) to a

UK offshore [oil and gas] installation, OSD 3.3 should be consulted.

10. Where other vertical chute escape systems such as Skyscape are fitted, it is
recommended that the attached proforma letter (Appendix C), or similar, be
sent to the duty holder. This asks the duty holder to review their vertical
escape system in light of the above accident and the MAIB report of the
accident.

11. OSD 3.3 may be consulted for further advice.

FURTHER INFORMATION

Further information can be obtained from OSD 3.3 – 0151 951 3188 or 0151 951
3137 and from OSD 5.5 (0207 717 6921).

Information can also be obtained from the contacts listed in the MAIB Safety Bulletin
1/2003
Figure 1. Evacuee in piked position.

Taken from MAIB Report No 18/2003 "Report on the investigation of a fatal accident
during a vertical chute evacuation drill from the UK registered ro-ro ferry P&OSL
Aquitaine in Dover Harbour on 9 October 2002."
APPENDIX A

MAIB Safety Bulletin 1/2003

Fatal accident during a marine evacuation system deployment drill in Dover

Harbour on 9 October 2002.

This document, containing Interim Safety Recommendations, has been produced for
marine safety purposes only. It is issued on the basis of information available to
date.

The Merchant Shipping (Accident Report and Investigation) Regulations 1999

provide for the Chief Inspector of Marine Accidents to make recommendations at any
time during the course of an investigation if, in his opinion, it is necessary or
desirable to do so.

The Marine Accident Investigation Branch (MAIB) is carrying out an investigation into
the fatal accident of a volunteer evacuee during a deployment drill of a vertical-chute
type marine evacuation system. The MAIB will publish its report on completion of its
investigation, with final recommendations.

The volunteer evacuee became stuck in the chute and lost consciousness during the
rescue. She was released and taken to hospital where she was pronounced dead.
This case illustrates that blockages in vertical-chutes can occur, and this bulletin
makes interim recommendations on the conduct of drills, the adverse effect of
blockages in an actual emergency, and the need to remove the risk of blockages in
the chutes.

Stephen Meyer
Chief Inspector of Marine Accidents

Press Enquiries:(+44) 0207944 4691 / 3387; out of hours:(+44) 020 7944 5925
Public Enquiries:(+44) 020 7944 3000
Internet address for DfT Press Notice: http://www.dft.gov.uk/

INTERIM SAFETY RECOMMENDATIONS

Background

At about 1219 on 9 October 2002, a fatal accident occurred while an 'abandon ship'
drill, using a vertical-chute type marine evacuation system, was being conducted in
Dover harbour.

After the marine evacuation system was deployed, eight people descended the
vertical-chute into two large, fully reversible liferafts. These people were evacuee
receivers and assistants, observers and manufacturer's representatives. After some
124 people had gone down the chute and entered the liferafts, a female volunteer
began her descent. However, 9 seconds later she shouted for help; the chute
controller stationed at the top shouted to her to wriggle, but she replied that she
could not. A chute sweeper*, who was one of the ship's officers, then went down the
chute in a controlled manner and found the volunteer stuck in a piked position
(hands and feet above her head) inside one of the descent sections. Her lifejacket
and jacket had come off and were over her face and head. The sweeper tried to pull
her up, but was unsuccessful. He called out for someone to cut her out. The chute
was then cut to allow her to descend in a controlled manner into the liferaft, where
she arrived unconscious. After first-aid had been administered, she was evacuated
ashore by a fast craft, which had been standing by, and taken to hospital where,
sadly, she was pronounced dead.

*A person trained to clear blockages in chutes.

Comments

This tragic accident has highlighted a number of risks that need urgent attention. The
volunteer who died might not have been particularly fit or healthy. Until the actual
cause of death has been established, it is recommended that only fit and healthy
volunteers are selected to participate in drills.

The initiator for this accident appears to have been the riding up of the volunteer's
lifejacket over her face and head. It is recommended that all personnel using a
vertical-chute marine evacuation system should be provided with lifejackets that
cannot ride up.

It would seem that in struggling, the volunteer caught her feet, which allowed her
body to continue downward. She ended up in a piked position, thus blocking the
chute. Recommendations are made to shipping companies to take this possibility
into account in their safety case/risk assessment of evacuation procedures, and also
to manufacturers to remove all possible causes for such a blockage.

Interim Safety Recommendations

Shipping companies, which have, or are, intending to have vertical-chute marine

evacuation systems installed on their ships, are recommended to:

1. Revalidate their risk assessment for drills, with particular emphasis on

selecting fit and healthy volunteers.

2. Revalidate their safety case and/or risk assessments on the adverse effects of
possible blockages in chutes at the time of the evacuation in an actual
emergency.

3. Ensure that all personnel using a vertical-chute marine evacuation system

wear lifejackets which will not ride up during the descent of a chute.

4. Manufacturers of all vertical-chute marine evacuation systems and the

authorising bodies, are recommended to:

5. Take urgent action to remove any possible causes of blockages in chutes by

redesign and/or other means.

Published 14 February 2003

APPENDIX B

Recommendations extracted from MAIB Report No 18/2003 "Report on the

investigation of a fatal accident during a vertical chute evacuation drill from the UK
registered ro-ro ferry P&OSL Aquitaine in Dover Harbour on 9 October 2002."

Notes

a. The full MAIB report can be found on the Internet.

b. Numbers in [ ] refer to the relevant conclusions in the full report.

Recommendations

Shipping companies which have, or are intending to have, vertical-chute marine

evacuation systems installed on their ships, are recommended to:

For drills

1. Prepare or revalidate their risk assessments, with particular emphasis on:

selecting suitable personnel, inspecting the inside of the chute and ensuring
that the chute is clear before the next evacuee is allowed to enter. [3.26]

For actual emergency

2. Revalidate their safety cases and risk assessments on the adverse effects of
possible blockages in chutes at the time of the evacuation. [3.26] [3.28]

The Maritime and Coastguard Agency is recommended to:

3. Ensure that all lifejackets on board vessels equipped with MESs within MCA’s
jurisdiction, are suitable for safe descent with the specific MES installed.
[3.16]

4. Take to the European Union for action with regard to the Marine Equipment
Directive and forward to the IMO the requirement that all lifejackets on board
vessels equipped with MESs worldwide, are approved for use with the specific
MES installed. [3.16]

5. Take forward to the IMO that a reporting system should be set up, to gather
reports of all accidents involving MESs. [3.25]

Manufacturers of all vertical-chute marine evacuation systems, and the

authorising bodies, are recommended to:

6. Remove any possible causes of blockages in MES chutes by redesign and/or

other means. [3.20]

Published July 2003.

APPENDIX C

PROFORMA LETTER TO DUTY HOLDER

Dear Sirs,

Accident involving a vertical chute system

We are writing to you in the light of a fatal accident involving a marine evacuation
system based on a vertical chute.

In October 2002, a fatal accident occurred during an evacuation drill in Dover

Harbour using a Marin-Ark vertical-chute marine evacuation system. Details of the
accident can be found in the MAIB Investigation Report.

We understand that the installations for which you are responsible are fitted with a
vertical marine escape system. We appreciate that this is a different design from the
Marin-Ark system, and that your systems are primarily for escape and not for
evacuation. However, some of the recommendations arising from the MAIB report of
the accident may be relevant to your systems.

It may be that you have already reviewed your vertical escape systems in light of the
above accident and MAIB report. If not, we would be grateful if you could conduct
such a review, and advise us of the expected completion date. Issues to consider
include:

• risks assessment for any drills using the vertical escape system

• whether the current safety case takes adequate account of possible blockage
of the escape system

• whether there is any possibility of users clothing, survival suits, or lifejackets

snagging and blocking the system, or riding up.

• whether there is any need to make arrangements for a "sweeper" (a person

with training and equipment to clear the escape system if it becomes blocked
by a person).

Yours sincerely

IMT Inspector