A skipper survived severe pain during a deck accident which could have been alleviated if he had been able to access a knife to free his leg, according to the official investigation.

The Marine Casualty Investigation Board (MCIB) report into the incident on board An Portán Óir, a 9.9-metre fishing vessel, in Dingle Bay, Co Kerry, last October noted that lack of a personal locator beacon (PLB) was also a contributory factor.

However, having a designated person ashore to raise the alarm if the vessel was overdue proved “invaluable”, the MCIB report notes.

The report recounts how on Friday, October 14th, 2022, the boat was taken on a routine fishing trip to lift, bait and shoot lobster pots in Dingle Bay.

“The boat was operated by the owner (the Skipper), and he was a qualified and experienced boat operator with valid certification,” it says.

The Cygnus 33 GRP decked vessel with an inboard diesel engine is registered in Tralee, Co Kerry.

“The skipper was shooting the final string of 30 lobster pots, with ten pots in the water, when his leg became entangled in the pot ropes. The boat was in gear to stretch the string, and the rope tightened around the skipper’s leg, and he was pulled aft,” it says.

“ The skipper grabbed the rope between the pots, and tied it to the handrail to avoid being pulled overboard. He was unable to free himself as the rope around his leg was under tension, and he remained stuck in this position until he was rescued around four hours later,”it says.

It notes that the skipper normally had a knife tied to the rails aft, but this had been removed during painting and had not been replaced.

This was “a major factor in the skipper being unable to free himself”,it says.

It also notes that he was not wearing an approved personal flotation device/lifejacket and PLB on deck and if he had he would have been able to activate the PLB and get assistance as soon as the incident occurred.

Under Section 9.2.4 of the Code of Practice for the Design, Construction, Equipment and Operation of Small Fishing Vessels of less than 15 metres length, “an approved PLB capable of transmitting a distress alert on 406 MHz band, shall be provided for each person on board and shall be carried by each person on deck at all times”.

“Each PLB should be ready to be manually activated”, the code states.

“ This lack of PLB is considered a contributing factor in the extent of the injuries sustained,” it says.

The alarm was raised when the boat failed to return, and a search was initiated with the Dingle lifeboat, local vessels and Coast Guard rescue helicopters.

The skipper was treated in hospital for “severe” muscle and nerve injuries which prevented him from returning to work for some time.

“The skipper always had a designated person ashore who was aware of his voyage and his expected return time. This proved to be invaluable,” the report says.

“When the alarm was raised, and the rescue services were tasked, there was also an excellent response from the local community, and even though the skipper suffered serious injuries, without the rapid response, the outcome may have been far more serious,” it says.

Read the full report here

Minister for Transport Eamon Ryan has today (Thursday 25 May) announced the appointments of John Carlton, Deirdre Lane and Captain Phil Murphy as board members of the Marine Casualty Investigation Board (MCIB).

The appointees are additions to the board and provide a replacement to Frank Cronin, who ended his second term with the board on 31 March 2023.

John Carlton is the port services manager at Shannon Foynes Port Company. He is responsible for managing all port services, port operations, marine operations, engineering and asset management, project management and the environmental health and safety (EHS) function of the company. He is a qualified marine engineer and has a broad range of marine engineering, general engineering, port operations, EHS management and senior executive management/corporate governance experience.

Deirdre Lane is the Harbour Master for Dunmore East. She is responsible for the safe and efficient operation of the harbour, including the day-to-day management and maintenance of the harbour and its installations. She is a Master Mariner and holds a first class honours degree in Nautical Science and an MSc in Shipping Operations with a specialist strand in Safety Management. She has also completed training in internal auditing and marine incident investigation and analysis.

Phil Murphy is the senior marine officer at Wexford County Council. He is responsible for oversight and management responsibilities of all the piers, harbours and marinas in the County, including New Ross Port. He is a Master Mariner and also holds a diploma in Nautical Studies and Port Management.

The three appointments were made pursuant to a Public Appointments Service process.

Commenting on the appointments and Frank Cronin’s departure, Minister Ryan said: “The appointees bring a wealth of knowledge and experience in several areas that are important to the continued operation of the Marine Casualty Investigation Board.

“I want to thank them for giving their time and expertise to the important work the board undertakes. I also wish to thank Frank for his dedication and commitment to the MCIB since his appointment in 2017. I wish him the best of luck in his future endeavours.”

The Marine Casualty Investigation Board (MCIB) has criticised the “general safety environment around paddlesports in Ireland” which it has identified as a “systemic factor” in a serious incident involving kayakers in Donegal’s Mulroy Bay last year.

A group of six kayakers were rescued in the tidal sea lough on March 19th, 2022, but the MCIB has classified the event as one that “posed a threat of death or serious injury”.

It has identified a combination of “causal and contributory factors”, including unsuitable weather conditions; inadequate training and qualifications; inadequate trip and contingency planning; inadequate safety equipment; inadequate protective clothing; and an inadequate safety environment.

This incident occurred during a commercial, guided trip, involving a trip organiser and five clients, which was intended to be about three kilometres and involved crossing the sea lough.

The clients were adults who typically had little or no kayaking experience. Only one client wore a wetsuit as thermal protection against the effects of cold water immersion, while the others wore clothing such as jeans and winter coats, the report says.

It says the group got into difficulty when the wind speed increased and the sea state deteriorated. The double kayak capsized but its two clients were able to right the kayak and make their way to one side of the lough.

Another two clients, in single kayaks, separately made their own way to the other side of the lough, after one of them capsized and swam for about 20 minutes to reach the shore.

The remaining client and the organiser both capsized and lost contact with their kayaks. They drifted in the water for approximately one hour, isolated about mid-way across the lough, until they were rescued by the Irish Coast Guard.

The report says they required hospital treatment before being released later that day.

“This rescue only became possible because of the diligent actions of a member of the public, who saw people in the water and notified the emergency service,”it says.

The report says the trip organiser’s training was primarily in seamanship skills for the crew of a ship, which he undertook about seven years ago, followed then by about one year working offshore as a crewmember on a commercial fishing boat.

It says he had attended a three day first aid course about nine months before this incident. He had the Level 2 Kayak Skills Award from Canoeing Ireland (CI), which he had received about nine months before this incident.

It quotes the organiser’s website, which stated that “we are an experienced team and we are all certified kayaking instructors that will take you on an amazing kayaking trip in any of the locations we operate in”.

“However, the MCIB’s investigation identified how the trip organiser is not the holder of a kayaking instructor qualification from either CI or any other national governing body,”the report says.

It also says the organiser had no formal training in the planning or navigation of kayaking trips, such as the Essential Coastal Navigation award from CI, and no formal training in the methods of rescuing kayaks or capsized kayakers, or the management of kayaking incidents.

A participant who booked the trip told the organiser that they had all kayaked before and that they could all swim.

The report says that “when the trip commenced he found out that most of them had little or no kayaking experience, and that one of them could not swim”.

It said the organiser did not operate a process of a written questionnaire or forms to be completed by participants in advance of a booking, such as those describing their swimming ability, kayaking experience or details of health or medical conditions.

On the day of the trip, a small craft warning was in effect for all Irish coastal areas, meaning that winds of at least force 6 were expected.

All of the group were provided with correct personal flotation devices, it says.

It says the trip organiser had a mobile phone placed within the pocket of his raincoat, which became inoperable when exposed to water after he capsized and entered the water.

He had a first aid kit stowed in his kayak but did not have a phone in a waterproof pouch, and did not have recommended safety equipment, as outlined in the Code of Practice for the Safe Operation of Recreational Craft, such as a VHF radio; Personal Locator Beacon (PLB); signalling flares; spray deck; tow rope; or emergency shelter.

The report says the alarm was raised by a member of the public who has lived in the area for many years and had kayaked on this sea lough many times before.

“She had considered going out kayaking on the day of this incident but had dismissed this idea because it was too windy. Her experience is that the lough is generally safe for kayaking, but it has a noticeable tide, and the weather needs to be calm for kayaking to take place safely,”it states.

The MCIB report makes a number of recommendations, and notes that it has investigated a number of kayaking and canoeing incidents at sea and on inland waters since 2007, as a result of which eight fatalities occurred.

It lists the kayaking/canoeing incidents are as follows:

1. MCIB 155 – Gaddagh River, 2007.
2. MCIB 180 – Clodagh River, 2010.
3. MCIB 241 – Inchavore River, 2014.
4. MCIB 275 – River Suir, 2017.
5. MCIB 283 – Roughty River, 2018.
6. MCIB 285 – Lough Gill, 2019.
7. MCIB 296 – Caragh River, 2019.

It says that the circumstances of the above kayaking incidents have some common features in that incidents occurred in winter or spring months, which has implications for cold water shock and the onset of hypothermia.

It also found common features such as:

• skills levels of the kayaker/instructor not being sufficient for the type of water conditions;
• mixed ability groups do not have sufficiently qualified leaders/instructors;
• incidents occurred during the latter half of the excursion.

The MCIB says its annual reports for 2020 and 2021 strongly encouraged all organisations (especially clubs and commercial entities) associated with water sports and water recreational activities to audit their safety systems, and to have regard to the Code of Practice for the Safe Operation of Recreational Craft and all guidelines or recommendations issued by any governing sports bodies.

It says it made recommendations in 2021, including :

• The establishment of a directory of commercial providers of coastal sea and river paddle facilities;
• How best to enhance safety sHow best to enhance safety standards within the commercial paddlesports provider sector;
• A mandatory registration or licensing scheme of instructors and their qualifications.

The report says it is” disappointing to note that the MCIB continues to be advised of situations where little or no regard was paid to governing body safety guidelines”.

“The MCIB has observed a continuing increase in the number of very serious incidents involving paddlesports, some of which could very easily have led to fatalities,” it says.

The full MCIB report is here

Vessel owners and operators, masters, skippers, fishers and seafarers are reminded of their responsibilities in relation to carrying out routine tasks and maintenance on board their vessels.

The advice from the Department of Transport comes on the foot of two incident reports from the Marine Casualty Investigation Board (MCIB) published in November last year, which cover marine casualties that resulted in serious injury.

As previously reported on Afloat.ie, the MCIB has warned of the dangers of working on ships at height after a 29-year-old Polish national fell from the Arklow Clan while it was berthed in Aberdeen, Scotland in August 2021.

The casualty sustained injuries both legs that required extensive hospitalisation, multiple surgeries and rehab.

Also for Afloat.ie, Lorna Siggins wrote about the MCIB’s report into an incident on the trawler FV Marliona in Co Donegal in February 2021, whereby the skipper’s arm was trapped by a trawl door and it was only by the quick action of a crew member that he did not sustain more serious injury or even lose his life.

Marine Notice No 27 of 2023 draws attention to the International Labour Office publication titled Accident prevention on board ship at sea and in port, highlighting its sections on risk assessment and hazard identification, use of PPE, working at height, operating heavy equipment, the dangers associated with particular fishing methods such as trawling and dredging, and adherence to applicable work hours and rest legislation.

For more, see the Marine Notice attached below.

Modifying vessels, including making changes to a vessel’s engine, without proper evaluation of the consequences, is very dangerous, the Marine Casualty Investigation Board has warned. It has urged the Minister for Transport to introduce rules for open commercial fishing boats, assign a minimum freeboard based on the boat size, and ensure that open boats have sufficient reserve buoyancy to stay afloat if swamped with sea water.

The MCIB Report is into the sinking of the 5.35 metre open fishing boat, Anna Louise, which was “on a routine fishing” trip to lift lobster pots in Bantry Bay. It says this was “a very serious marine casualty.”

The report says the fibreglass boat was operated by the owner’s brother (the Skipper), a qualified and experienced boat operator with valid certification. The Skipper had lifted two strings of lobster pots onboard with a total of ten pots and was retrieving the marker buoy when a wave came over the stern, flooding the boat. The Skipper tried to reach the bailing bucket, but a further wave swamped the boat, and the boat sank quickly. The Emergency Position Indicating Radio Beacon (EPIRB) floated free and was activated. The distress signal was received by Valentia Marine Rescue Sub-Centre (MRSC) who initiated rescue operations. Bantry inshore lifeboat was tasked as well as Castletownbere lifeboat and Rescue Helicopter R115. The Skipper swam ashore and made his way through fields to a house from where he called to advise he was safe and well. The rescue operations were terminated. The boat was later salvaged from 12 metres of water. There were no injuries and no pollution.

MCIB Report photo of Anna Louise

The weather on the date of the incident was a maximum of Force 4-5 on the Beaufort Scale.

Waves were of 1.5 metres to 2.5 metres,which is at the top of the allowable range for this type of boat, according to the report.

Modifications had been carried out to the boat, the MCIB report says, which had reduced the freeboard. “These modifications should have been presented, for approval, to the Surveyor who had issued the Code of Practice Certificate in accordance with CoP requirement. The original freeboard was considered small but there is no minimum freeboard specified in the CoP for open boats of this size.

“The boat was swamped by waves coming over the stern and filling the boat with sea water. The boat sank quickly as there was no reserve buoyancy when it was full of water. The boat freeboard had been reduced due to additional weights onboard making it more vulnerable to swamping.”

The Board makes a number of safety recommendations including that the Minister for Transport should issue a Marine Notice reminding owners of fishing vessels of the dangers associated with modifying vessels, including changes to a vessel’s engine, without proper evaluation of the consequences.

“The Minister for Transport should introduce rules for open commercial fishing boats < 15 m to assign a minimum freeboard based on the boat size and to ensure open boats have sufficient reserve buoyancy to allow the boat to stay afloat if swamped with sea water.

“The Minister for Transport should issue instructions to panel surveyors when inspecting open commercial fishing boats that do not have a Declaration of Conformity or CE plate showing the CE category and maximum design load, to require a full load test to ensure boat skippers know the maximum safe loads allowed onboard and the minimum freeboard allowed.

The full report is available on the MCIB website

The Marine Casualty Investigation Board has recommended that the Minister for Transport should amend or update the Code of Practice for the Safe Operation of Recreational Craft to advise owners to ensure that auxiliary engines fitted to racing yachts provide the necessary power to allow safe inshore or coastal passage, particularly when adverse weather or sea conditions prevail.

This recommendation is included in the MCIB report into the fire which burnt and sank the yacht Black Magic in Ringabella Bay off Cork Harbour in December 2021.

The MCIB also says the Minister for Transport should publish a Marine Notice highlighting the risks associated with refuelling operations or decanting volatile flammable liquids at sea or alongside, to or from open containers in the vicinity of hot and exposed surfaces.

The smoke plume clearly visible from the shore

The yacht Black Magic with one person onboard, sailed from Crosshaven, Co Cork, for Kinsale Harbour at about 10.30 a.m. on December 13, 2021, but an hour-and-a-quarter later off Cork Harbour the outboard engine on the transom of the yacht, caught fire which spread rapidly. The Skipper called for help in a ‘Mayday’ message on VHF. A fishing boat in the vicinity relayed this to the Coast Guard at Valentia. Another fishing vessel rescued the Skipper at approximately 12.00 hrs, and a Port of Cork RIB that responded to the ‘Mayday’ took him ashore. He was not injured. The yacht sank at 12.48 pm at Ringabella Bay.

The MCIB report makes three findings, concluding that “the continuous operation of the outboard engine onboard yacht Black Magic as it made the passage from Crosshaven marina to the vicinity off Ringabella Bay at the engine’s maximum design capacity caused the engine to suffer a significant mechanical failure such that hot engine components were exposed to petrol fuel and oil lubricants which spontaneously ignited and caused a fire onboard. This consumed the vessel which subsequently sank off Ringabella Bay. 

“The lack of wind and the sub-optimal capacity of the yacht’s outboard engine to power the yacht at the required speed as it motor sailed out of Cork Harbour was a contributory factor in the loss of yacht Black Magic.

Black Magic on fire. Photo: courtesy Cian O'Connor

“Refuelling the outboard engine by topping up the engine’s fuel tank likely resulted in a fuel spillage in the vicinity of the engine and transom. The spilt fuel was likely to have been a contributory factor in the subsequent fire, which started at the outboard engine and resulted in the loss of the yacht.”

The Skipper, who is not named, having read the report, commented to the MCIB that the yacht was “extremely light” and the outboard, which the MCIB identified as a PARSUN 3 horsepower, single cylinder 4-stroke, mounted on a transom bracket was sufficient to push her in the flat calm waters on the day. He said  that he was “hugging the coast in flat calm and zero wind” and had raised the mainsail at the RCYC marina. He said that it took him “a long time to get over this, and was having nightmares for a long time.”

The full investigation report is available on the MCIB website here and see a vid of the burning yacht on youtube here

The Marine Casualty Investigation Board (MCIB) report into the death of a Donegal student during a kayaking trip in Co Kerry has said the outing was not properly assessed for risk.

Aisling O’Connor, 21, from Ballyshannon, Co Donegal, drowned after she became trapped under a tree branch in the Upper Caragh river near Glencar, Co Kerry, on November 2nd, 2019.

She was among a party of 27 on a trip organised by the University of Limerick (UL) Kayak Club.

The UL biochemistry student was resuscitated and transferred by helicopter to University Hospital Kerry, but she died two days later.

Another kayaker required medical resuscitation and hospitalisation, and the MCIB described his situation as “a near fatality”.

The 202-page MCIB report called on the UL Kayak Club to “immediately review its procedures and assessments prior to embarking on group river activities” and to examine its procedures in relation to Canoeing Ireland (CI) standards.

It has also recommended the kayak club should “suspend its activities until its safety regime is audited to a standard acceptable to Canoeing Ireland”.

The report says the prevailing conditions, including the features of the river, were “not suitable for all the members of the trip to manage safely”.

It says the trip was” not properly assessed for the risks attached to the prevailing conditions and having regard to the skills and experience of the group taking part in what is a high-risk sport”.

It says those in charge of identifying and assessing the risks in advance, and on the day, were “insufficiently trained and experienced themselves to be able to assess the risks given the combined factors of river conditions and the nature of the group”.

It says this arose as there was “a lack of adherence to the ULKC Safety Statement 2014 and the Trips Policy and Procedure which set out control measures, which led to a lack of accredited training, which in turn led to poor decision making”.

It says that had there being CI- qualified instructors available (or persons with recognisable equivalent training and experience) they “would have identified that the group was too large and its makeup too inexperienced and would not have approved a trip that involved a group of beginners in those conditions, and/or, having embarked would have realised that the conditions being experienced were not suitable and would have terminated the trip”.

It says the gaps in the club safety environment were “contributed to by the lack of any supervision/audit, or capacity to effectively supervise or audit, of the safety of university students engaged in high risk activities by the UL Students’ Union, and by the absence of any overarching, agreed, and communicated, spheres of responsibility between the ULSU and UL, leading to an environment at club level where there was a serious disregard of the ULKC Safety Statement 2014 and Trips Policy and Procedure, and CI recommended standards”.

The report notes that the Upper Caragh River was” a Grade 4 river on the day and a Grade 3 with parts at Grade 4 normally”.

“The river trip planners and leaders did not correctly gauge the river as a Grade 4 river despite the elevated river levels,” it says.

“The recent heavy rains in the locality resulted in the river level being higher, current flows being considerably faster and more powerful to the degree that the intermediate paddlers had difficulties in controlling their boats,”it says, noting that two casualties – one of whom died - were intermediates at Level 2 and Level 3 Skills competency.

The MCIB report says that “river trip planners and leaders made no risk assessment for the river trip on the Upper Caragh River”.

“Had they done so, the assessment of the corrected river grade that day (Grade 4) would have significantly affected the planning of the river trip process and either altered the composition of the river trip groups and/or the conduct of the river trip or may have re-directed the trip to a more suitable venue,” it says.

“ The absence of a comprehensive risk assessment was a causative factor in the capsize incidents,”it says and the kayak club’s 2014 safety statement was not adhered to.

The report says the absence of a contingency plan in the event of the leaders and seconds requiring closer supervision of an increased number of inexperienced kayakers due to the prevailing river conditions was a “contributory factor” in this incident.

The MCIB report makes a number of recommendations for UL Kayak Club, UL Students’ Union and UL, along with the Minister for Transport and Canoeing Ireland.

In its comment on the draft report, the UL Kayak Club defended planning for the trip.

In a joint statement, UL Student Life and University of Limerick said they were “extremely conscious of the heart-breaking loss of life at the centre of this tragic accident”.

“We remain absolutely committed to the health, well-being and safety of our student community of over 18,000 students,” they said.

“The MCIB report into the incident which occurred during a planned outing of the UL Kayaking Club in November 2019 contains recommendations that are relevant to UL Student Life, the UL Kayaking Club, University of Limerick, Canoeing Ireland and the Minister for Transport,” they said.

“UL Student Life and UL have and will continue to work together to consider the findings of the final MCIB Report and to implement the recommendations so that the highest possible safety standards are in place within all clubs to which our students are affiliated,” they said.

“While this was a most tragic accident, it is acknowledged that lessons can and will be learned as well as improvements made to ensure the safety of our student community,” they said.

A link to the full report is here

The Marine Casualty Investigation Board (MCIB) has initiated an inquiry into a recent incident on the river Corrib where up to ten people were rescued after their rowing craft were swept towards the Galway city salmon weir.

The incident was one of two which occurred on the river on January 14th when the river was in full flow and three rowing boats attached to the University of Galway and to Coláiste Iognáid secondary school capsized.

No one was injured, but Labour councillor and chairman of Claddagh Watch river safety group Niall McNelis said the situation involving the university students who were caught on the top of the weir was potentially very serious.

The sport of rowing is exempt from mandatory lifejacket use.

The MCIB confirmed early this week that it decided to carry out an investigation into this incident.

“A full report will be published in due course”, an MCIB spokeswoman confirmed, adding that the board “will not be making any further comment”.

As Afloat reported earlier, both incidents occurred between 11 am and 12 noon on January 14th, with the first being the capsize of an octuple or “eight” rowing craft with students from Coláiste Iognáid or “ Jez” secondary school.

The capsize occurred up river from the weir and across from their clubhouse. All students were rescued by their club safety launches within minutes and taken ashore.

A more serious incident occurred shortly after that when two rowing craft with University of Galway students were swept towards the salmon weir, where they were caught by pontoons and capsized due to the strength of the river flow.

Ten rowers - none of whom are obliged to wear lifejackets due to the sport’s exemption - had to be taken from the top of the weir by club safety launches in very challenging conditions.

The Irish Coast Guard confirmed that its Valentia Rescue Coordination Centre was alerted through the national 112/999 call answering service at 12:08hrs on January 14. It said it was reported that ten rowers were “possibly in difficulty at the weir”.

The Galway Fire Service, An Garda Siochana, Coast Guard Helicopter R118 from Sligo, Galway RNLIlLifeboat and Costelloe Bay Coast Guard unit were tasked, it said.

“During the 112/999 call the caller confirmed all boat occupants had been recovered to the club safety boats responding locally,”the Irish Coast Guard said, and rescue units were stood down.

The University of Galway is compiling an internal report. It said support boats were on the water at the time the two boats capsized and no-one was injured.

“ All rowers were brought safely from the water to the river bank within minutes,” a spokesman said.

“The university is deeply grateful to other rowing clubs for their support and prompt response. We also thank the emergency services for their rapid response,”he said.

He confirmed the university has engaged with Rowing Ireland, the national representative body, and is reviewing all safety measures and precautions which are in place for our rowing club and other river users”.

It said it would cooperate fully with any MCIB inquiry, and would support any initiatives to improve water safety and rescue services on the Corrib.

A spokesman for Coláiste Iognáid said that it was satisfied that all safety procedures were followed when its boat capsized, and said all students were fine and parents were informed.

Speaking on behalf of the Galway water users’ multi-agency group, RNLI Galway operations manager Mike Swan said that a dedicated rescue craft above the weir which was on call “24/7” was essential.

Corrib Rowing and Yachting Club said it supported calls for a dedicated rescue boat, as the nearest service up river is the Corrib-Mask Rescue Service in Lisloughrey, Co Mayo.

A fuel leak is believed to have caused a fire on board a passenger ferry linking Ballyhack, Co Wexford with Passage East in Waterford, last year.

A Marine Casualty Investigation Board (MCIB) report says the crew of the Frazer Tintern reacted immediately after the master of the vessel detected a strong smell of diesel fuel while en route to Passage East in early August 2021.

A crew member had also called the master to say he could also detect a strong smell of the fuel and was going to investigate. The incident occurred at around 18.05 hours on August 5th, 2021.

The MCIB report says that when the crew member got to the mesh door at the number one (No.1) engine compartment, he was met with black smoke and flames.

“The crewmember notified the master straight away that they had a fire onboard. The master immediately shut down the No.1 engine and turned off the engine room fans,” it says.

“Two crewmembers then activated two portable fire extinguishers and rigged fire hoses to provide boundary cooling,”it says.

The vessel continued to the Passage East slipway to get passengers off as quickly and safely as possible, it says, although the fire was brought under control.

It says that on arrival, all passengers and vehicles were “disembarked in a safe manner”.

“The vessel was then secured, and the remaining engines shut down. When the smoke dispersed fully, the crew investigated the engine room to confirm the fire had been extinguished,”it says.

The two-deck crewmembers used portable fire extinguishers, the fire was knocked back, and fire hoses were run out to provide boundary cooling while the master continued to navigate the vessel towards Passage East slipway, it says.

The report says that the machinery space fire suppression system was not operated. The vessel was moored up, and the remaining engines were shut down.

“The three crewmembers then carried out a visual inspection of the engine compartment after the remaining smoke had dispersed and confirmed that the fire was fully extinguished,” it says.

The MCIB report says the fire was “most likely caused by a return line fuel leak on No.1 main engine providing fuel to the area”.

It says that the volume and pressure of the fuel was greatly increased by the fuel return line being blocked or shut off, while the ambient high temperature and swirling airflow in the vicinity assisted in the atomisation of the fuel.

It says the fuel may have been ignited by arcing of the No.1 main engine alternator, but it was more likely to have been from fuel spraying onto hot surfaces such as the engine exhaust manifold or turbocharger casing.

It says that shutting down the engine removed the source of fuel from the fire and would have had a far greater effect in extinguishing it than the use of portable extinguishers.

It says that due to the extent of the fire and subsequent damage to No.1 engine, “the exact location and cause of the fuel leak has been impossible to determine”.

It recommends that the owners/operators should ensure that all return line flexible fuel hoses are fixed as per the engine manufacturer’s recommendations.

It also says the owners/operators should arrange to have the airflow from the machinery space ducted away from the main car deck and clear of any public areas. This is to ensure that a fire in the machinery space will not impinge on public areas.

It says the owners/operators should arrange to have the shut-off valves removed from the fuel system return lines to prevent the potential of over-pressurisation of the system. It also recommends that they need to ensure that the firefighting procedures and domestic safety management systems put in place post the incident are “followed and practiced and logged regularly”.

The MCIB reports recommends that the Minister for Transport should issue a marine notice to owners/masters of passenger vessels to remind them that “in the case of a fire or other potentially serious incident a distress/Pan Pan call as appropriate should be made at the earliest opportunity”.

It also says the minister should request a review of manning and crew qualification requirements for Class IV passenger vessels operating in restricted waters as per action 25 of the Maritime Safety Strategy of 2015.

It notes that the owners initiated an internal enquiry into the incident immediately before any repairs were undertaken.

“ This enquiry yielded some useful information on the history of the event”, the MCIB says, but it "did not clearly identify the root cause of the fire".

It says it did lead to the operators adopting a safety management system to improve processes onboard.

It says that since the incident, the door leading to No.1 engine compartment on the ferry was fitted with a weight and magnetic lock so that it closes automatically when the fire alarm is activated.

The board of the Marine Casualty Investigation Board (MCIB) says it welcomes the publication of the General Scheme of Merchant Shipping (Investigation of Marine Accidents) Bill 2022 and the Government’s decision to establish a new independent Marine Accident Investigation Unit (MAIU) within the Department of Transport.

“The board believes that the new proposed structure and the potential for greater synergy with other investigation units within the department’s remit will enhance future investigations of marine casualties and thereby contribute to greater marine safety,” it said in a statement on Tuesday (13 December).

Restrictions on the membership of the board which arose following a European Court of Justice decision in 2020 were resolved by the Merchant Shipping (Investigation of Marine Accidents) Act 2022, the board adds.

In February this year, the board completed a recruitment drive for additional investigators to the investigator panel “which comprises independent persons with a high level of technical expertise”.

In September, this was followed by a recruitment process for a full-time expert marine consultant for the MCIB, which is ongoing.

The board says this is in line with recommendations in the review of the organisational structures underpinning marine accident investigations commissioned by the Department of Transport.

It adds that it has “assured the minister and the department of its full support and cooperation to ensure continuity for ongoing and new investigations and to enable a smooth transition of the function of investigating marine casualties from the board to the new unit which will be established by the current bill.”

This story was updated on Wednesday 14 December with a link to the bill.