Home Associations MAIB Report: carbon monoxide poisoning of the motor cruiser Diversion, River Ouse

MAIB Report: carbon monoxide poisoning of the motor cruiser Diversion, River Ouse

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MAIB Report: carbon monoxide poisoning of the motor cruiser Diversion, River Ouse

The motor cruiser “Diversion”.

Report on the investigation of carbon monoxide poisoning onboard the motor cruiser Diversion on the River Ouse in York

Summary:

At about 20:00 on 4 December 2019, the bodies of two men were discovered in the cabin of the privately owned motor cruiser Diversion, which was moored to a quay in the centre of York, England. The bodies were those of the boat owner, Ronnie Holmes and his friend, Stephen Jewitt, who had spent the previous evening in the city centre socialising with former work colleagues and were spending the night on board.Both men had died as a result of carbon monoxide poisoning. The carbon monoxide had leaked into the cabin from the boat’s diesel-fuelled cabin heater exhaust.

Chief Inspector’s statement:

Andrew Moll, Chief Inspector of Marine Accidents said:

“The MAIB investigation into this tragic loss of lives once again highlights the importance of installing carbon monoxide alarms on boats with enclosed accommodation spaces. This is the fifth fatal marine accident investigated since 2014, where a functioning carbon monoxide alarm could have saved lives. Carbon monoxide alarms suitable for the marine environment are readily available, inexpensive and simple to fit, and I urge boat owners to invest in one as soon as possible.

“It is commonplace for marine engines, generators, cookers and heaters to produce carbon monoxide during normal operation; amateur installation and un-serviced appliances can introduce the risk of boat users inhaling lethal levels of this toxic gas. The importance of checking the installation and routine servicing of all such devices by a professional cannot be overstated.

The key safety issues identified were:

The cabin heater’s exhaust silencer was not designed for marine use. Its connection to the exhaust pipe system was not gas tight, the installation had not been checked by a professional heater installer, and it had not been serviced.

The cabin ventilation system did not meet the requirements of the Boat Safety Scheme and this might have increased the rate at which the carbon monoxide accumulated in the boat’s cabin space.

The owner and his friend were not alerted to the danger because a carbon monoxide alarm had not been fitted

Recommendations
As a result of the investigation’s initial findings the MAIB issued a safety bulletin, which has since been referenced in Boat Safety Scheme publications and has been featured in the 2020 Carbon Monoxide awareness week. As a result of these actions, no recommendations have been made in the report.

Related publications
Safety Bulletin SB2/2020: https://www.gov.uk/maib-reports/safety-warning-about-carbon-monoxide-poisoning-after-the-loss-of-2-lives-on-the-motor-cruiser-diversion

Contact InformationMaggie SheldonDepartment for Transportmaggie.sheldon@dft.gov.uk

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