The Hatch That Was Always Open: How Normalisation Killed a Skipper

A Route That Was Never Meant to Cross That Hatch

On the night of 29 April 2019, the fishing vessel Artemis was moored alongside at Kilkeel Harbour, Northern Ireland. The skipper had been ashore and had been drinking. Returning to his bunk after using the toilet, he took the route he always took — the same route he'd walked countless times before. It passed directly over the vessel's mess deck hatch, left open as it usually was, for ventilation.

He fell through it, in darkness, and sustained fatal head injuries. He was found the next morning.

What MAIB Found

Post-mortem toxicology confirmed a blood alcohol content of 215mg/100ml — nearly three times the UK drink-drive limit. But MAIB's investigation didn't stop at impairment. It found that post-build modifications to Artemis had created an access route to the toilet that passed directly over the mess deck hatch — a routing the vessel's original layout had never included. The hatch itself had no guard, no coaming, and no policy requiring it to be closed when not in active use. Leaving it open had simply become normal.

No formal risk assessment had ever been carried out on the modified layout. Nobody had connected ‘we always leave the hatch open’ with ‘the route to the toilet now crosses directly over it’ as a combination worth examining, until the night both factors were present at once, in the dark, with a severely impaired crew member walking it alone.

Recommended Actions

1. Ensure all hatches in crew movement areas are either guarded or kept closed when not in active use, particularly during hours of darkness
2. Carry out a risk assessment of crew movement routes following any vessel modification that alters internal layout
3. Install physical guards or coamings at any hatch opening in a routine crew movement area, regardless of how long the vessel has operated safely without one
4. Establish a clear alcohol policy for vessels where crew live aboard, recognising how dramatically impairment increases the risk of an otherwise-manageable hazard

Human Element Analysis