Amadeus MOB

Operational Briefing: Lessons from the Amadeus Incident

What Happened:

On 13 December 2023, at approximately 00:09 hrs, the UK registered crab potting vessel Amadeus experienced a very serious marine casualty in the German Bight, North Sea, approximately 58 nautical miles north-west of Heligoland, Germany.

A deckhand tragically fell overboard while engaged in the routine task of manually hauling crab pots by leaning over the vessel’s side. The incident occurred when the Amadeus rolled in rough seas, causing the deckhand to lose balance and enter the water.

Critically, the deckhand was not wearing a tethered safety harness or a personal flotation device (PFD) at the time. Despite immediate actions by the crew, including cutting the back rope and an emergency manoeuvre by the skipper, and initial observations of the deckhand swimming, he became unresponsive within about two minutes due to the cold water. Subsequent attempts to recover him with a boat hook were unsuccessful, as he was struck by a large wave and disappeared.

A comprehensive 23-hour search involving numerous vessels and helicopters ultimately failed to locate him. The investigation highlighted demanding work conditions and inadequate rest as contributing factors to the exhausting and unstable task.

Immediate Operational Checks:

Fellow officers and independent mariners must conduct an immediate review of their on-board safety procedures, particularly those pertaining to deck operations and man overboard prevention and recovery. It is imperative to strictly enforce the mandatory wearing of appropriate personal flotation devices (PFDs) and, where applicable, harnesses or positioning lines for all personnel performing tasks that require leaning over the vessel’s side or in adverse weather conditions.

Verify that man overboard (MOB) recovery equipment is readily accessible, fully functional, and that all crew members are thoroughly drilled in its rapid deployment and use. Furthermore, assess work-rest patterns to mitigate fatigue, which can severely impair judgment and reaction times during critical moments. Ensure robust communication protocols are in place for all deck operations, especially for individuals working alone or in high-risk areas.

Working alone on deck should always be avoided. Minimise vessel motions where possible, and consider heaving-to. 

Lessons Learned:

• Failure to ensure and enforce the mandatory wearing of personal flotation devices (PFDs) and safety harnesses for deck crew.
• Inadequate risk assessment for routine deck operations, particularly those involving leaning over the vessel’s side in rough seas.
• Insufficient emergency preparedness and effectiveness of man overboard (MOB) recovery procedures, especially concerning an unresponsive casualty in cold water.
• The impact of demanding work schedules and inadequate rest on crew fatigue and overall safety.
• Lack of effective physical barriers or alternative safe working methods for tasks requiring proximity to the vessel’s edge.

Tags:

Fall Overboard, Fishing Vessel, PFD, Man Overboard, Fatigue

Official Report

Read the full safety report here: Amadeus report and safety flyer published