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March 7, 2011

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Safety deficiencies exposed by cadet’s death

A teenage sea cadet’s fatal fall from height has highlighted a number of weaknesses in safety procedures on board the sail-training tall ship from which he fell.
 
Fourteen-year-old Jonathan Martin fell from a yard on the fore mast of the anchored vessel, TS Royalist, on 2 May last year. He was helping other cadets to stow the fore course sail when he fell backwards and hit the starboard gunwale 8m below, before falling into the sea. His lanyard was not clipped on to the wire jackstay.
 
Although he was recovered quickly from the water and flown to hospital, his injuries were too severe and he subsequently died.
 
The Marine Accident Investigation Branch (MAIB) conducted an investigation into Jonathan’s death but could not ascertain what prompted him to disregard the vessel’s rules to maintain at least three points of contact, and to be ‘clipped on’ at all times when on the yards. Nonethless, the MAIB speculated that the routine occurrence of unclipping in some specified activities could have encouraged Jonathan to feel able to be unclipped in other situations.
 
Investigators concluded: “In a sail-training environment populated by adolescents, a degree of risk-taking is predictable, and must be taken into account when determining the safety training, level of supervision, and safety equipment that needs to be provided.”
 
Sea cadets are not covered by the Merchant Shipping and Fishing Vessels (Health and Safety at Work) (Work at Height) Regulations 2010. The exemption of trainees resulted from discussions between the Maritime and Coastguard Agency (MCA) and the sail-training industry, which acknowledged that the Regulations would make sail-training activities unworkable and that self-regulation is the best means of ensuring the safety of trainees.
 
Individuals attending training courses on sail-training vessels are also excluded from the Merchant Shipping and Fishing Vessels (Health and Safety at Work) Regulations 1997, and the Merchant Shipping and Fishing Vessels (Provision and Use of Work Equipment) Regulations 2006 – although the General Duties Regulations place a general obligation on employers to ensure the health and safety of all persons on board.
 
The MAIB described as “compelling” the need to review the vessel’s arrangements for the supervision of cadets when at height, and defined the “under-utilisation of health and safety advisors” from the oversight of the Marine Society & Sea Cadets’ (MSSC) offshore activities as “detrimental to the safety management of TS Royalist”.
 
The Branch also found that the use of belt harnesses on board the vessel by the crew did not comply with the Work at Height Regulations. The harnesses used on board were deemed unsuitable for fall arrest, and were neither tested nor manufactured to current standards.
 
Recommending that the MSSC review and revise the precautions taken to reduce the work-at-height risks on board TS Royalist, the MAIB highlighted several issues to be considered, including: the need to provide a safety harness that is fit for purpose; the need for cadets to be ‘clipped on’ when moving about the rigging; and the ratio of supervisors to cadets, and where supervisors are positioned.
 
The Royal Navy has also been told to review its processes for assuring the MSSC’s safety management arrangements for activities undertaken by cadets.
 
In a statement, the MSSC expressed its deep sadness over Jonathan’s death and welcomed the MAIB’s recommendations. It said: “The safety of our staff, volunteers and cadets, in equal measure, is paramount to the charity as evidenced by the 30,000 cadets who have sailed on TS Royalist over the last 39 years without similar incident.”
 
“We fully recognise the importance of never resting in seeking continual improvement in the safety regimes across all our operations, as we seek to help young people develop valuable life skills through a range of adventurous activities, including on board TS Royalist.”

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