MAIB: Crushing Fatality Shows Need for Safety Management Systems

Boarding ladder at the Ardintoul feed barge (MAIB)

Published May 31, 2021 7:04 PM by The Maritime Executive

The UK's Marine Accident Investigation Branch (MAIB) has released a report into the death of a fish farm manager who was crushed during a transfer under way. 

On February 18, 2020, the assistant manager of the Ardintoul fish farm in northwest Scotland drowned after sustaining a crushing injury and falling into the water. That morning, assistant manager Clive Hendry was on site at the fish farm to oversee a chemical anti-lice treatment for one of the salmon pens. In the mid-afternoon, after the treatment was completed, he asked the skipper of the workboat Beinn Na Caillich to take him over to the farm's feed barge, a cylindrical moored platform used for storing and distributing feed for the pens. A few of the farm's technicians had taken Hendry's lunch aboard the barge earlier in the day, and he wanted to retrieve it.

As Beinn Na Caillich approached the barge, Hendry went to the starboard side and stood by an open bulwark gate. Beinn Na Caillich’s skipper engaged astern propulsion to slow the vessel as it approached the barge, intending to align the forward bulwark gate with the barge access ladder and come to a halt before giving Hendry the all-clear to step to the barge's ladder. 

At about 1510, with Beinn Na Caillich still moving slowly ahead, the assistant manager stepped through the open gate and onto the barge access ladder. A supernumerary on the bridge of the Beinn Na Caillich saw Hendry step out and shouted out in surprise. At that moment, Beinn Na Caillich’s bulwark gate post caught the assistant manager and crushed him against the barge ladder’s fender.

Image courtesy MAIB

Despite his severe injuries, Hendry managed to hang on to the ladder. A fish farm technician reached him and attempted to keep him from falling into the water by holding onto the back of his lifejacket and raincoat. However, the lifejacket crotch straps were not fastened, and Hendry slipped out and fell about 10 feet into the water. He floated to the surface face down and was not responsive. 

The crew of the Beinn Na Caillich managed to bring him alongside and called for help. Several of the fish farm's workboats responded and helped get Hendry out of the water. Despite their determined efforts and the early use of a defibrillator, he could not be revived, and he was pronounced dead at the hospital. 

A postmortem exam determined that Hendry's death was caused by drowning after a crush injury to his pelvis. He had no known medical conditions, and drug and alcohol tests came back negative. 

In its investigative report, MAIB noted that the workboat skipper had not conducted a safety discussion prior to the casualty, as recommended by UK regulations. The UK's Code of Safe Working Practices for Merchant Seafarers requires that "all personnel transfers should only take place after a thorough risk assessment has been completed and a toolbox talk carried out with all personnel involved."

Based on its review, MAIB determined that the fish farm's operator - international salmon conglomerate Mowi - had not instituted a thorough safety management system for its marine operations. "Mowi had a large feet of workboats and routinely used them to transfer staff to and from its offshore fish farm installations. However, it had not conducted risk assessments or provided safe systems of work, nor written procedures for personnel transfers by boat," MAIB concluded.

The safety agency recommended that Mowi should set up a thorough SMS and engage "appropriate marine expertise" to advise its senior management team on safe operations.