The crew member was lost whilst trying to board MV ‘Zilvermeeuw’ Z 15 at Milford Docks, Wales

The report into a fatal accident at Milford Docks, Wales has been released by the Federal Bureau of Investigation of Maritime Accidents in Belgium.

The casualty lost his life whilst trying to board the ‘Zilvermeeuw’ Z15, a Belgium beam trawler that was moored at the K Wall in the Milford Docks on 11 November 2019.

On Sunday, November 10th 2019, around 15:30, the 34.8m ‘Zilvermeeuw’ arrived at Milford Docks. An additional crew member was to embark and the catch was to be landed. The crew also wanted to take advantage of the time in port to carry out some repairs to the fishing gear.

The vessel had planned to go to sea again the next day, but due to problems with the VMS, the vessel had an unplanned prolonged stay in port.

The vessel was moored with two lines fore and two lines aft. All mooring lines were attached to steel bollards on board. To keep the vessel aligned with the quay, the mooring lines needed to be adjusted by hand time and again. Reportedly, this was only done during daytime when the crew was working on deck. 

Fatal accident milford docks

During the nighttime, sufficient slack was kept in the lines so that no adjustments were to be made. This gave the vessel the possibility to drift slightly away from the quay (depending upon the length of the mooring line and the tide). After arrival of the vessel on November 10th 2019, the crew landed the catch and loaded it into a lorry and continued working till around midnight. 

On Monday November 11th 2019, maintenance on board was performed until around 17:00. Around 20:00, five crew members went ashore using the quay side ladder and visited a local pub. 

fatal accident milford docks

After having some beers, the crew returned to the vessel. All crew members were back on board around 21:30. They got back on board using the quay side ladder. Around 22:00 three crew members left the vessel again, using the quay side ladder, to visit another pub where they had consumed some alcoholic beverages. One crew member returned to the vessel at 23:15 and boarded using the quay side ladder. At 23:49, the other two remaining crewmembers arrived at the vessel. The forecastle was touching the quay, the aft was blown off. The water level had dropped since they boarded the previous time (around 21:30). The forecastle deck was approximately at the same level as the jetty. Due to the tide and the position of the vessel , the two crew members considered that boarding by the forecastle was easier and safer than by the quay side ladder. 

The first crewmember went onto the forecastle and climbed over the vessel’s guard rail. The second crewmember boarded via the forecastle immediately thereafter. The first one assisted him to get on board by lending him a hand. Once on board further assistance from the first crewmember was refused. The second crew member was holding onto one of the wires of the mast when he was on board. He started stepping sideways on the small strip of the deck between the ship’s side and the guardrail, subsequently slipped and fell into the water. 

fatal accident milford docks

The crew member that had fallen into the water tried to swim towards the quay side ladder while the crewmember remaining on board rushed to the mess room and alarmed the other crew members. 

The crew member that arrived back on board earlier, at 23:15, who was sitting in the mess room subsequently immediately came onto the deck. He found the victim face down in the water, appearing unconscious. 

He descended into the water via the quay side ladder and grabbed the victim by the clothing in order to pull him towards the quay side ladder thereby keeping the victim’s head above the water. 

faltal accident milford docks

In the meantime the other crew members arrived on deck. They wanted to pull the victim out of the water. 

They used boat hooks to bring the victim alongside the vessel. The crewmember that rescued the victim in the water climbed back on board. It was not possible to pull the unconscious victim on board by hand. 

Meanwhile, at 00:07, the emergency services were called by phone, using emergency number 112, which worked well. The crew decided to use the winch wire to lift the victim out of the water. 

The crew member who had already been in the water jumped back into it to fit a strop under the victim’s arms and subsequently returned back on board by using the quay side ladder. At 00:15 the victim was lifted on deck and CPR was commenced. 

The defibrillator (AED) was taken from the bridge onto deck. Reportedly the crew had some difficulties attaching the electrode pad due to the stress and panic this emergency situation caused. 

When attaching the first pad to the victim’s chest, the AED gave a signal that there was no contact. At the moment they were changing the pad, a Docks and Marina operative who had arrived took over the vessel AED machine and used it correctly. 

This was at 00:27. Manual CPR was given all the time. At 00:28, the emergency services arrived. 

The victim needed to be transferred from the vessel by means of a launch. The victim was transferred into the launch at 00:57. At 01:02, the victim was transferred from the launch into the ambulance. 

The ambulance arrived at the hospital at 01:19 , where it was confirmed that the victim was deceased. 

The cause of death was later confirmed to be drowning. 

The  FBIMA concluded the absence of a safe access point to the vessel caused the fall into the water. 

Boarding at the forecastle was considered safer/more comfortable than boarding by the quay side ladder at low tide and considering the distance between jetty and vessel. 

The amount of alcohol consumed by the victim adversely affected his performance (risk perception, reaction time, coordination) and so contributed to the accident. 

As the water temperature was low and no floating safety devices were available, the victim could not reach the quay side ladder before he lost consciousness due to hypothermia. CPR was only administered when casualty recovered on board, and could have started earlier if and when the emergency preparedness and response time on board were better. 

Generally, it could be concluded that the access to the vessel had not been properly assessed by the crew. No mitigating measures had been taken to make access to the vessel as safe as possible within the given conditions. 

The nearest lifebuoys were located at the wheelhouse. Safety instruction cards, as part of the safety handbook for the fishing industry, issued by PREVIS/ZVF/LIANTIS (formerly PROVIKMO), were available on board (in Dutch, see appendices). 

Safety instruction card A102 (dated 01/08/2010) described the dangers involving boarding/leaving a fishing vessel and stated that a pilot project regarding boarding/leaving a fishing vessel was ongoing. The project was stopped without an available outcome. 

The report’s conclusion were, Safety Issues No or little efforts had been made to make the access to the vessel as safe as practically possible. 

Different access points were used depending on the tide and the distance between the vessel and the jetty. 

These access points could not be considered safe as access was hindered by chains, guardrails and fishing gear. The quay side ladder was used as an access point to the vessel, as the vessel had no means of access available. 

This ladder was not considered user friendly and awkward to use. No handles were in place at the top of the ladder. Crawling on your knees was necessary to get on the ladder. 

The safety instruction cards on board described that a pilot project concerning safe access was running in 2010, but no outcome was made available. 

No results improving safe access to the vessel were visible on board. The card did not mention practical guidelines to assess/improve the access to the vessel. Emergency procedures in case of a MOB were described in the safety instruction cards on board. 

The effective implementation of these procedures on board were never tested. 

The victim was lifted out of the water by means of a strop connected to the winch wire. Effective, but not comfortable. Both the access to the vessel as the emergency response indicate that there is a higher need for vessel specific safety assessment, training and follow-up of implementation of procedures and instructions. No ship specific risk assessment was in place. 

The consumption of alcohol when off-duty in port is a common phenomenon, but the tragic consequences of this accident demonstrate that drinking to excess significantly worsen the risk of life for crew that live on board ships when in port. 

The full report can be read here.

Report into fatal accident at Milford Docks, Wales released by FBIMA

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