Chain of Events

1
Chain of Events An examination of the events
leading up to, and resulting from, the 67 foot
fall of a trainee from the rigging of the Lady
Washington.
Capt. Les Bolton, Executive Director, Grays
Harbor Historical Seaport Authority Co Chair of
the ASTA Technical Committee les_at_historicalseapo
rt.org
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May 20, 2006 - 1830 hrs. Weather Sunny Warm
Wind 18 kn. W. Sea State Calm Departing Port
of Ilwaco, Washington in the Columbia River for a
3-hour sail with the public. Lady Washington was
following Hawaiian Chieftain out of the marina
channel under slow motor as the crews of both
vessels went aloft to cast off gaskets.
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Contributing Factors

• A family medical emergency resulted in the
  unplanned departure of our regular Senior Master
  one week earlier than was originally planned.
• A short-term Relief Master was brought in. (Very
  competent and capable.)
• This Relief Master had worked for us in the past,
  but was not completely familiar with our
  organizational protocols, or the capabilities of
  this crew.
• It was the Relief Masters last sail before
  turning over command.
• There were 48 passengers onboard (an audience).
• A Trainee requested permission to lay aloft to
  the pole top and touch the main truck after
  casting off and coiling the topgallant gaskets.

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Contributing Factors

• Although this was out of the ordinary,
  particularly for a trainee, permission was
  granted.
• Passengers were made aware that something unusual
  was going to be happening.
• Trainee climbed aloft, cast off and coiled
  gaskets.

5
Contributing Factors

• All eyes were aloft making it more difficult for
  the trainee to change his mind, increasing
  pressure to perform.

6
Contributing Factors

• Trainee climbed to the pole top and made an
  unthinking mistake.
• He clipped into a Backstay.
• As he began easing himself down he slipped, lost
  his grip and fell . . .

7
Mechanics of the Fall

• As the trainee fell, still clipped into the
  backstay, he did attempt to catch himself.
• A crewmember on the topyard twenty feet below
  heard him as he began to fall, grabbed into the
  topyard jackstay, reached out and grabbed the
  trainees harness lanyard. Although he could not
  hold the trainee, he did slow the fall and change
  the trainees trajectory, causing him to swing in
  toward the mast at a reduced speed.
• Twenty feet lower the trainee struck the main top
  with such force that he spun full circle as he
  continued his fall. This impact again reduced
  his rate of decent.
• Twenty-four feet lower, falling inboard he struck
  the starboard rail cap and pin rail, breaking a
  belaying pin with his jaw and cheekbone before
  falling inboard striking the deck very lightly
  with his head and feet. His torso was suspended
  approximately six inches off the deck by his
  harness and lanyard, still clipped into the
  backstay.

He was alive, conscious, in extreme pain,
bleeding from his head, face and hands.
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Our Emergency Response and other factors that
improved our potential for a positive outcome

• Upon losing his grip on the harness our topman
  sounded the alarm ALL HANDS.
• Mate called Hands to emergency stations.
• We drill often.
• We were fortunate that he fell inboard. Our
  backstays run outboard to the channels. He could
  have been hanging outboard below the channels.

9
Our Emergency Response and other factors that
improved our potential for a positive outcome

• Master focused on vessel operation VHF 16 call
  Situation location
• Mate called 911 on ships cell phone Situation,
  location victim status, requested closest/best
  transfer point for 11 foot draft. Passed off
  phone to medical team.
• Senior Medical officer requested assistance from
  passengers (two nurses on board)
• First aid response team have First Aid kit,
  trauma kit, cervical collars backboard and
  blankets on deck in minutes. Set up visual
  screen, assisted as required.
• Steward informed passengers that we have had an
  accident and need their cooperation. Cleared the
  aft deck and approaches requesting passengers
  move to the port bow. Began singing to calm
  passengers and mask sounds from aft deck.
• Mate directed idle hands to prepare for receiving
  USCG first Responder on the port side and prepare
  for mooring dockside on the starboard side.
• Idle hands assist Steward with passengers,
  checking on them, join in singing.

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Our Emergency Response and other factors that
improved our potential for a positive outcome

• USCG First Responder was a shipmate, left two
  days before. Very reassuring - He knew what to
  expect, what he would and would not need to
  transfer.
• Victim was secure on our backboard before EMTs
  boarded. All hands were standing by to transport
  victim over the side on to the gurney.
• Mate gathered victims wallet, passport, address
  book, medical forms and day pack.

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Our Emergency Response and other factors that
improved our potential for a positive outcome

• Mate assigned to travel with victim carried
  victims daypack, personal documents, crew record
  and a cell phone. (Forgot charger)
• Master Apologized to passengers, explained the
  need to follow specific protocols and asked for
  their patience. He assured passengers that they
  would all receive full refunds.
• Crew Muster Aft deck

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Immediate Post Incident Response and other
factors that improved our potential for a
positive outcome

• CREW MUSTER Assessment and assignments
• Status Reports Each Crewmember and vessel
  general
• Greatest need is to stay focused, be vigilant,
  dont make mistakes. Focus on your job, do your
  job, return to the ship. NO comments, NO
  visitors, NO shore leave.
• Mate is with our shipmate, he will keep us
  posted.
• Set up ramp for disembarking passengers
• Two crew to attend to passenger refunds and check
  passenger emotional state.
• Crew member assigned to collect names and contact
  information of eyewitnesses.
• Idle hands to clean up, furl, stow and wash down.
  Save tag related equipment.
• Muster in one hour

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Immediate Post Incident Response and other
factors that improved our potential for a
positive outcome

• Executive Director Established as ONLY media
  contact for this incident.
• While driving - calls to Marine Operations
  Committee Chair and Insurance Agent Advised of
  situation will keep updated as new information is
  available.
• Met with Master for quick overview.
• Met reporters on site Confirmed that there was
  an accident. Passed out business cards with cell
  phone number written on back, collected press
  cards - Our crew did an excellent job of
  responding to a very distressing accident. They
  are very concerned about their injured shipmate
  and they just need some time to process what has
  just happened. I will keep you informed as we
  know more.
• Marine Operations Manager Making arrangements
  for testing.
• Crew Muster to review accident, and current
  status.

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Immediate Post Incident Response and other
factors that improved our potential for a
positive outcome

• Crew Muster
• Address Trauma - Terrible accident Excellent
  response Your shipmate is alive
• Full accident review by Master and crew - Marine
  Operations Manger takes notes.
• Recognized the positive actions of each
  crewmember and the cumulative positive effect
  that had on the fate of their shipmate.
• Discussed the seriousness of the accident and the
  need to follow established protocols.
• Questions and answers.
• Requested all hands to quickly write out where
  they were, and what they remembered of the
  sequence of events leading up to, and following
  the accident.
• Master to fill out organizational Incident
  Report Form, form CG2692 and ensure a complete
  log entry as well.
• Marine Operations Manager responsible to
  transport crew for testing.

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Organizational ImpactMaking Lemonade

• Lukas Watch
• We were fortunate that our schedule called for
  the ship to be in the Portland area three days
  later. Spending four hours with our injured
  shipmate at the regional trauma center was placed
  as a voluntary option on the duty roster. Crew
  were there 8 to 12 hours a day, every day, for
  the next two weeks. Good for him Great for our
  crew.

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Organizational ImpactMaking Lemonade

• Controlling the Message
• We established a written public statement, posted
  at all office phones, on both boats and e-mailed
  to all Board and Marine Operations Committee
  members.
• A trainee fell from the rigging the Tall Ship
  Lady Washington last Saturday evening as the ship
  was departing Ilwaco on a three-hour public sail.
  
• The trainee was stabilized and immediately
  transported to a regional Trauma Center in
  Portland.
• We are very thankful for the quick action of the
  ships crew and local emergency personnel in
  responding to this unfortunate accident.
• As we have more details, we will make them
  available to you.
• We were able to follow up later with factual
  details and positive spin.

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Organizational ImpactMaking Lemonade

• Internal Review Process
• Ships met with Executive Director and Marine
  Operations Manager to discuss and establish
  strict interim operating parameters for trainees
  and paid staff.
• Marine Operations Committee met with all senior
  staff, and officers of both vessels to review the
  accident and our response, what we did right, how
  we could have improved our responses.
• Evaluated other emergency scenarios and our
  readiness to react quickly and effectively.
• Evaluated our crew training protocols and our
  training documentation.
• Reviewed and reestablished appropriate written
  operational parameters for trainees.
• These meetings were the most well attended and
  productive
• Marine Operations Committee meetings that we have
  ever had.

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Organizational ImpactMaking Lemonade

• Weaknesses were identified, and plans were made
  to address those weaknesses.
• Trainees Aloft Work stations were identified.
  No unaccompanied trainees beyond work stations.
  Additional training/review required beyond work
  stations.
• Trainee Checklist Develop a new progressive
  learning checklist that documents and encourages
  Trainee advancement and becomes part of the
  Trainees permanent record.
• Crew Training - Set aside EVERY Monday after
  1530 for crew training NO Public
• Crew Training - Schedule at least one 911 Cross
  Training per year.
• Safety Gear - Immediate inventory, evaluation and
  review of harnesses and Lanyards.
• Rig modifications - Lay-up traveler on Royal
  Poles. Attach baggywrinkle where main yard
  intercepts backstay.

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Organizational ImpactOutcomes

• Rig modifications Completed
• Safety Gear After much research and discussion
  it was determined that most of our gear was
  designed for light/recreational duty, some of our
  systems were mismatched (fall arrest/fall
  protect) and none of them met industry standards
  for cut-away rescue.
• Research and negotiations resulted in the
  purchase of a new system based on the PETZL
  Navaho seat harness with double poly-dac lanyards
  and SS locking carabineers for each crewmember,
  plus four PETZL Chester (Quick converter to full
  body harness) for each vessel.
• Crew Training - EVERY Monday after 1530 is set
  aside for crew training NO Public
• Crew Training - 911 Cross Training is
  tentatively scheduled for last week in June.
• Trainee Checklist DRAFT 3 is currently in use
  aboard both of our vessels.

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Organizational ImpactOutcomes

• Trainee Checklist DRAFT 3 (currently in use) -
  Final DRAFT - 4 is near completion
• Day One
• Sign Aboard Checklist (3 Items)
• Vessel Orientation Checklist (8 Items)
• Basic Safety Orientation Checklist (6 Items)
• Week One
• Essential Tools Checklist (3 Items)
• Basic Knots Checklist (6 Items)
• Docking Protocols Checklist (4 Items)
• Dockside Tour Operations Checklist (5 Items)

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Organizational ImpactOutcomes

• Week Two
• Dock Lines Checklist (5 Items)
• Sail Theory Checklist (3 Items)
• Advanced Knots Checklist (2 Items)
• Lookout Checklist (3 Items)
• Helm Checklist (3 Items)
• Safety Checklist To be completed ASAP -
  Required for consideration as a Topman
• Harness Checklist (6 Items)
• Pre - Aloft Checklist (11 Items)
• Aloft Checklist (6 Items)
• Deck Checklist (10 Items)
• Advanced Safety Checklist (6 Items)

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Our Future ?