The Toggle and the Becket: How a Loose Lifejacket Fitting Killed a Deckhand on Kingfisher

30nm East-North-East of Wick — 12 July 2024

Kingfisher was shooting her fourth string of creels when the deckhand, 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 him.

Recommended Actions

1. Review MGN 588(F) Amendment 2 to ensure PFDs supplied are compatible with the vessel's working areas, mitigating snagging risk (MAIB 2025/132)
2. Review risk assessment methodology to identify actual on-deck risks and reduce them as low as reasonably practicable (2025/133)
3. Ensure all crew complete mandatory training courses (2025/134)
4. Treat any change to deck equipment, however minor, as a trigger for risk assessment review before operational use

Human Element Analysis