Marine and Safety (Courts of Inquiry) Regulations 2007

INVESTIGATION INTO PASSENGER INJURY

HIGH SPEED PASSENGER VESSEL

“WILD RIVERS JET 3

RISBY COVE, STRAHAN

Marine and Safety (Courts of Inquiry) Regulations 2007

INVESTIGATION INTO PASSENGER INJURY

GH SPEED PASSENGER VESSEL

WILD RIVERS JET 3”

RISBY COVE, STRAHAN ON THE WEST COAST OF TASMANIA

16th NOVEMBER 2011

MARINE AND SAFETY TASMANIA

Marine and Safety (Courts of Inquiry) Regulations 2007

INVESTIGATION INTO PASSENGER INJURY

GH SPEED PASSENGER VESSEL

COAST OF

CONTENTS

FOREWORD Page 3 SUMMARY Page 4 SOURCES OF INFORMATION Page 5 THE VESSEL ‘WILD RIVERS JET 3’ Page 6 & 7 NARRATIVE Page 8 COMMENT AND ANALYSIS Page 9 & 10 CONCLUSIONS AND RECOMMENDATIONS Page 11

FOREWORD Inquiries and investigations into Marine Casualties occurring within Marine and Safety Tasmania’s (MAST) jurisdiction are conducted under the provisions of the Marine and Safety Tasmania (Courts of Inquiry) Regulations 2007. Incident investigation reports must be submitted to the Board of Directors of MAST. It is MAST policy to publish such reports to increase the awareness of marine incidents so as to improve safety at sea. Copies of the reports can be obtained from: Marine and Safety Tasmania, PO Box 607, Hobart 7001 Or the MAST website: http://www.mast.tas.gov.au

3.

SUMMARY On Wednesday the 16th of November 2011 the high speed passenger vessel “Wild Rivers Jet 3” departed from the jetty at Risby Cove in Strahan, on the West coast of Tasmania. The time was approximately 1400 hrs, there were 9 passengers on board and the skipper. Just prior to the completion of the 55 minute trip, the skipper conducted a final ‘spin’ of the vessel and then proceeded to the jetty where the passengers disembarked. A short time later, a female passenger complained to her husband of pain in her right shoulder which could have been due to her falling against a handrail during the final ‘spin’ on the jet boat ride. Subsequently, x-rays revealed she had suffered a broken right collar bone.

4.

SOURCES OF INFORMATION

• Incident Report from the Skipper/Operator.

• Phone interviews with Skipper on 4th and 8th January 2012.

• Phone interview with injured passenger on 10th January 2012.

• Phone interviews with the husband of the injured passenger on 4th and 10th January 2012.

• Letter written by the injured passenger and her husband addressed to the operator of ‘Wild Rivers Jet 3’ and dated 25th November 2011.

• Telephone conversation with a representative of the company that supplied the seats on ‘Wild Rivers Jet 3’.

• Safety Management Plan for “Wild Rivers Jet 3” Certificate No: 46.

• Review of six previous incident investigations conducted in Tasmania and New Zealand.

5.

DETAILS OF HIGH SPEED PASSENGER VESSEL “WILD RIVERS JET 3” Length: 5.99m Beam: 2.34m Draft: 0.95m Engines: One inboard 200kw petrol engine coupled to a Hamilton jet unit. Hull materials: Aluminium monohull. Year built: 2000 Survey status: 2E for 12 passengers and 1 crew within smooth water limits of the port

of Strahan. Crew qualification requirements: Skipper: Coxswain Restricted with jet boat endorsement and workplace level II

first aid. The vessel layout is an open monohull with two rows of four individual seats at the centre and aft, two passenger seats and the helm position are forward. The skippers’ seat is on the port side and helming is carried out from a seated position. Controls & Instrumentation: Engine speed is controlled by a foot or ‘accelerator’ pedal and the jet unit is controlled by a lever on the side of the vessel next to the skipper, the steering wheel is similar to a car steering wheel. There is an engine speed instrument (rev counter) as well as various engine monitoring instruments and alarms. Communication is by V.H.F. radio and mobile phone, however, due to the topography of the King River, the effectiveness of this equipment is somewhat spasmodic. However, VHF relays can be carried out in an emergency and there is also a separate UHF radio directly linked to the Abt railway communications centre. Communication to the passengers is by word of mouth from the skipper. All the seats face forward and are identical. They consist of a waterproof, close mesh synthetic type of fabric which is tensioned on the frame to give comfort and a degree of cushioning, the top of the seat back frame is also padded. Each seat has a ‘grab bar’ attached behind it for the use of the passenger behind, there are also grab bars fitted to the forward console and on each side of the vessel. Lifejackets are supplied to each passenger and worn by all on board for the complete duration of the trip. Safety briefing of the passengers is carried out prior to embarkation and notice is given to passengers prior to each ‘spin’.

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Passenger was seated in back row second from right.

Passenger seat in foreground with side grab bar next to vacant seat.

7.

NARRATIVE On Wednesday the 16th of November 2011 the high speed passenger vessel “Wild Rivers Jet 3” departed from the jetty at Risby Cove in Strahan which is on the West coast of Tasmania. The time was approximately 1400 hrs. There were 9 passengers on board and the skipper. As intended, the vessel did her regular tourist run of approximately 50-55 minutes proceeding from Strahan out into Macquarie Harbour and then up into the King River and returned. The purpose of the trip is to show the passengers the scenery of the area and inform them on the history of the King River. The skipper also carries out approximately 8-9 360 degree high speed ‘spins’ to add a ‘thrill’ aspect to the trip. This type of manoeuvre can only be carried out on a vessel fitted with a water jet propulsion system. The trip went as planned and the vessel returned to Strahan just before 1500 hrs. At completion of the trip but prior to proceeding to the disembarkation jetty, the skipper carried out one final ‘spin’. On this occasion, the female passenger sitting in the aft starboard central seat (there are 4 seats in the row) moved or leaned across the outboard vacant seat and apparently struck her right shoulder on the side hand rail. Following the ‘spin’ the skipper proceeded to the jetty and the passengers disembarked. Shortly after, the female passenger informed her husband that she felt she had hurt her shoulder. At approximately 1520 hrs, she was examined by a paramedic and subsequently transferred to Burnie hospital by ambulance where a broken right collar bone was diagnosed. The husband of the injured passenger later informed the skipper/operator of the jet boat on the situation, who subsequently forwarded an incident report to Marine and Safety Tasmania.

8.

COMMENT AND ANALYSIS There are approximately 4-5 jet boats similar to ‘Wild Rivers Jet 3’ operating in sheltered and smooth waters in Tasmania. All operations are approximately the same whereby passengers are taken to view interesting areas and ‘spins’ are carried out to add a ‘thrill’ aspect to the trip. As mentioned earlier, the 360 degree ‘spins’ are only possible when the vessel is propelled by a water jet unit. In all cases the skipper has to hold a certificate of competency as required under the MAST issued ‘Manning Determination’, he/she also has to hold a ‘Jet Boat Endorsement’ for the particular vessel. This endorsement is issued following a prescribed training period on the vessel and is carried out within the area it is to operate. Marine and Safety Tasmania requires all operators of passenger carrying vessels to comply with a Safety Management Plan (SMP). These plans require the assessment of risks relating to the particular vessel, its operations and also the training and qualifications of the crew. In fact, most SMPs for vessels of this size will usually be a document of some 20 pages. (Example SMPs are available from MAST if required) With regard to the SMP requirements for “Wild Rivers Jet 3”, the crew qualifications and safety requirements for the day in question were complied with and the SMP certificate of compliance was current. In the incident report, it was stated that the weather on the day was a NW wind of 8-15 knots with calm water and good visibility. It is not considered that the weather conditions were a contributory factor to the incident. Prior to departure from the jetty in Risby Cove the passengers were issued with lifejackets and a safety briefing was conducted. It was also determined that the 7 overseas student passengers could understand English. The safety aspects of the 360 degree ‘spin’ was explained and this was followed up with the skipper warning the passengers prior to each ‘spin’ and reinforcing the need to hold on to the grab bars. Once all passengers were seated, the husband of the injured passenger asked the skipper if the seating positions were correct as there was a vacant seat outboard from his wife and was informed, by the skipper, that the positions were correct. Following the telephone interview with the injured passenger it would appear that at the conclusion of the final ‘spin’, she may not have been holding on to the grab rail as tightly as she had done during the previous ‘spins’ and this may have contributed to her moving into, or leaning across, the vacant seat next to her and her shoulder coming into contact with the outboard grab rail. In the interview with the skipper/operator, he stated he was not aware of the passenger suffering injury until her husband informed him later the same day.

9.

During the process of this investigation, previous incident reports from Tasmania and New Zealand were reviewed. While the sample was quite small, it became apparent that this type of incident has occurred on at least three occasions in the past few years, one in Tasmania and two in New Zealand. While constructive recommendations were made, methods to try and retain a passenger in their seat were not addressed by the reports. It is considered that two options are available; these being, the use of seat belts and/or the provision of armrests. The provision of either of these options should not mitigate the need for a passenger to hold tightly on to the grab bar when a ‘spin’ is in progress. However, it should assist in retaining them in their seat should they lose their grip on the grab bar. This in turn would reduce the possibility of injury to themselves or other passengers (as has happened). The provision of seat belts in the larger, high speed passenger carrying, rigid inflatable boats is now a requirement. However, this is to primarily address the high vertical accelerations which can occur on these types of vessels. It is considered that the provision of seat belts in the smaller jet boats, as used in Tasmania, would not be appropriate should, for some reason, emergency evacuation be required. While the review of previous incidents was not extensive, in all instances the vessels were not fitted with arm rests and this resulted in the passenger moving horizontally and injury occurring to themselves or others.

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CONCLUSIONS AND RECOMMENDATIONS

These conclusions identify the different factors contributing to the incident and should not be read as apportioning blame or liability to any particular organisation or individual. The high speed vessel “WILD RIVERS JET 3”, its purpose and operation. Overall, the operation of the vessel is for the entertainment of tourists in order to show the uniqueness of the environment, in this case Risby Cove and the King River, also the ‘thrill’ factor of travelling at relatively high speeds and the conducting of 360 degree ‘spins’. During these ‘spins’ there is an obligation on the passenger, for their own safety, to hold on to the grab bars as instructed by the skipper. However, it is the responsibility of the owner and skipper to ensure that the requirements of the Safety Management Plan are followed and adhered to. Furthermore, the safety and comfort of all passengers on the vessel are of paramount importance. Recommendations:

• Passenger safety briefing – The owner and/or Skippers, responsible for the vessel operation, to review the current safety briefing, given that this incident has occurred and determine if the safety instructions relating to the conduct of the ‘spin’ are considered adequate and appropriate. Furthermore, that the safety briefing be scripted to ensure no salient points are omitted irrelevant of the person responsible for giving the briefing. A copy of the script to be forwarded to MAST for attachment to the vessel’s Safety Management Plan.

• Passenger seating allocation – It is understood that not all trips will have a full complement of passengers and as a consequence there will be some vacant seats. It is recommended that when this situation occurs, then the skipper allocate the seating to try and reduce the number of passengers sitting next to a vacant seat. This is provided that the stability of the vessel is not compromised.

• Passenger seats – It is strongly recommended that MAST amend the survey

requirements for this type of vessel. This amendment to require that all future vessels, which are put forward for survey, be fitted with seats that are provided with armrests. These armrests to be sufficiently strong enough to adequately restrain any sideways movement of the seated passenger.

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