WILL IT take another Drum Major incident to make Canal & River Trust ensure that volunteer lock keepers are properly trained to deal with 'cilling' and hang-up emergencies? asks Allan Richards.
The narrowboat, Drum Major, sank with the loss of four lives after ‘hanging-up' at Stegneck Lock (pictured) on the 19th August 1998 on the Leeds & Liverpool Canal near Gargrave.
The investigation report
The Marine Accident Investigation Branch report into the incident found that the boat sank due to an uncontrolled ingress of water whilst locking down after the boat had hung up on the bottom gate. Two of the several contributory factors were:
The boat being positioned too far forwards in the lock (contrary to advice provided in The Waterways Code for Boaters.
Slowness in closing a bottom paddle when the boat was seen to be hanging up.
The following is taken from The Boaters Handbook (Summer 2014 revision, page 22) which has replaced the older code:
Floating freely? As the water level rises or falls, keep a constant eye on your boat to check that it's floating freely. If it does get caught or jammed, immediately close all the paddles and work out what needs to be done to get it level again.
No mention of bottom gate.
Whilst the handbook mentions the possibility of the boat catching on the cill, the lock wall or hanging via ropes when going down, no mention is made of the similar danger of hanging up on the bottom gate.
Perhaps this is because the handbook also gives the advice Keep your boat well away from the gates and cills, perhaps not realising that, for longer boats, this may not be an option. Indeed, many longer boats, when locking downhill have to keep the bow on the bottom gate to avoid cilling. Some historic boats even have to remove fenders to do so.
The Flamingo incident
In late August, this year, Alan, Cath and David Fincher recounted a hanging up incident with their historic boat Flamingo, in CanalWorld Discussion Forum. The incident took place whilst descending the bottom offside lock of the paired Hillmorton Flight on the Northern Oxford Canal near Rugby.
A volunteer lock keeper had drawn one of the bottom paddles when Cath, who was on the other side of the lock and yet to raise her paddle, called across to him: The boat is hung—drop the paddle! However, instead of doing what it says in The Boaters Handbook (i.e. immediately closing the open paddle), the volunteer replied: No it is all-right.
A repeat of the request received a similar reply: No it is all-right, it will sort itself out.
Saved by David
By now Flamingo's counter was in danger of being submerged. The situation was saved by the Fincher's son, David, who appeared from the cabin, shouting very forcibly for the volunteer to drop the paddle but also sprinting to the top of the locks to raise the paddles in an attempt to stop the water level falling further. He managed to do this before the volunteer had fully lowered his paddle.
Unfortunately, drawing the two upper paddles caused turbulence which, in turn, caused the front of the boat to fall setting up massive wave action resulting in the boats rudder being constantly cilled.
It is worth noting the similarity with the Drum Major incident where it was the front of the boat dropping and subsequent wave action that caused it to sink with the loss of four lives.
Never seen it before
The volunteer lock keepers comment at the time of the incident was that, over several years, he had never seen this happen before.
More worrying is that he appeared to not have been trained regarding what to do if a boat was not floating freely. That, or he had simply forgotten his training...
Hazard not identified
Investigation of the Flamingo incident has found that South East Region's risk assessment for volunteers operating locks at Hillmorton does not not identify cilling/hang-ups as a hazard. Furthermore, some other regions are using similar risk assessments.
In contrast, CaRT's General Risk Assessment for Lock Operation—Narrow and Broad Locks (which was reviewed in March this year as part of CaRT's ‘Pawl Project') does identify cilling and hang-ups as hazards.
Method statement
A method statement documents how to carry out a task safely bearing in mind the associated risk assessment. Perhaps it is unsurprising that the method statement for Hillmorton (and other South East Region sites where volunteers are used) provided under the Freedom of Information Act does not identify cilling/hang-ups in its summary of hazards.
Bizarrely, in responding to a request for information, CaRT claim that the method statement provided was produced in March 2015. However, the method statement itself is dated 23/10/2015 just to the left of the authorising manager, the unfortunately named, Lee King.
This date is some seven months after that claimed by CaRT, two months after the Flamingo incident and one month after the Freedom of information request was made.
Check repeatedly
Even more bizarre is the method statement, step 11, under 'Safe Method: LOCK OPERATION by Volunteer Lock Keepers (SE Waterway)'. It reads: ‘Check repeatedly that boats will not become hung up on ropes, lock gates or stage boards whilst water levels change'.
It totally fails to document what action should be taken by the volunteer in the event that a hang-up occurs!
.... and from CaRT's response to the Freedom of Information request, it appears that other regions are using similar method statements which fail to tell tell volunteer lock keepers what to do in the case of a hang-up/cilling emergency.
Totally unacceptable
Together, the risk assessment and method statement form the basis for pre-job and on the job training and assessment for lock operations undertaken by volunteer lock keepers. To find that the risk assessments used by some regions fail to identify cilling/hang-ups as hazards is totally unacceptable.
To find that method statements fail to state what volunteer lock keepers should do when faced with cilling/hangup emergencies is also totally unacceptable.
No statement
Whilst the incident was reported two months ago, CaRT has still made no official statement on the matter. Would it not be better for it to accept that it needs risk assessments and method statements that address the known hazards of cilling/hang-ups and provide existing and new volunteer lock keepers with training for these emergencies?
.... or will it take another Drum Major incident to it act?