The Toggle and the Becket: How a Loose Lifejacket Fitting Killed a Deckhand on Kingfisher
Vessel: Kingfisher (DH 110), 18.35m steel potting vessel
Date & location: 12 July 2024, 30nm east-north-east of Wick, Orkney Islands
Outcome: Deckhand Richard Fiati (40) fatally dragged overboard, entangled via his own PFD's loose rescue becket
Human factors: Silent Workaround · Unassessed Equipment Change · Challenge Culture Gap
Source: MAIB Report 12/2025
30nm East-North-East of Wick — 12 July 2024
Kingfisher was shooting her fourth string of creels when deckhand Richard Fiati, toggling the third creel onto a leg rope at the shooting table, inadvertently threaded a newly-introduced blue creel toggle through both the leg rope eye and the loose becket hanging from his own 275N PFD — its Velcro housing had degraded and let it hang free. The deployed back rope dragged him across the table and overboard. His PFD inflated automatically, but 275N of buoyancy could not overcome the weight of the sinking creel string. The skipper reversed to full astern and the crew recovered him in about seven minutes using the hauling winch, but despite CPR, a defibrillator from a nearby guard vessel, and a rescue helicopter, he was declared deceased. The cause of death was drowning.
Three Small Changes Nobody Flagged
Several crew members had already experienced their own PFD beckets snagging on gear and had simply cut them off — without telling the skipper or owner, invalidating the PFD's certification and removing a rescue aid in the process. A newer, longer, more pointed blue creel toggle had recently been introduced for ease of threading; its introduction was never treated as a change requiring a risk assessment review. And the onboard risk assessment required PFD wear as mitigation against drowning but never identified the specific snagging hazard the beckets themselves posed on the shooting deck. Each change was small. None was escalated. Together, they created the failure that killed Richard Fiati.
Recommended Actions
- Review MGN 588(F) Amendment 2 to ensure PFDs supplied are compatible with the vessel's working areas, mitigating snagging risk (MAIB 2025/132)
- Review risk assessment methodology to identify actual on-deck risks and reduce them as low as reasonably practicable (2025/133)
- Ensure all crew complete mandatory training courses (2025/134)
- Treat any change to deck equipment, however minor, as a trigger for risk assessment review before operational use
Human Element Analysis
Silent Workaround
Crew who found their PFD beckets snagging solved the problem themselves by cutting them off — a workaround that felt reasonable in the moment but removed a certified safety feature and told no one it had happened.
Unassessed Equipment Change
A new toggle design, chosen for convenience, changed the entanglement risk profile at the shooting table. No one connected ‘new tool’ to ‘needs a risk review’.
Challenge Culture Gap
The information needed to prevent this accident — loose beckets, the new toggle's snag risk — existed within the crew the whole time. It was never escalated to the skipper.
How This Pattern Repeats
| Industry | Incident | The parallel |
|---|---|---|
| Aviation | Kegworth air disaster, 1988 | An unreported operational change (engine vibration symptoms) combined with a novel technical detail crew hadn't been fully briefed on, contributing to a fatal misdiagnosis under pressure. |
| Manufacturing | Bhopal disaster, 1984 | Small, individually rational maintenance workarounds accumulating, unreported, until they combined into a catastrophic failure. |
| Healthcare | Various ‘workaround culture’ surgical never-events | Frontline staff independently modifying safety equipment or procedures to solve an immediate nuisance, without escalating the underlying design flaw. |
See How You'd Handle It
The scenario opens with a PFD becket that's started hanging loose from its Velcro housing. What you do about it is the first decision point.
What Every Skipper and Deckhand Should Take From This
- A PFD becket that hangs loose is a snagging hazard — inspect, repair, or replace it; never cut it off
- Report any equipment workaround to the skipper, even one that felt like a sensible personal fix
- Any change to deck equipment, however small, should trigger a fresh look at the risk assessment
- Fast recovery (Kingfisher's crew managed about seven minutes) is necessary but not sufficient if entanglement holds someone underwater the whole time
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Related Reading
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