Jacobs, Dudley Gordon
Deceased
Dudley Gordon Jacobs
Demographics
male
Date of death
2011-06-11
Finding date
2015-10-23
Cause of death
Drowning
AI-generated summary
Captain Dudley Gordon Jacobs, an experienced maritime check pilot, died by drowning when the tug Adonis capsized in Gladstone Harbour while participating in a two-tug towing operation. The primary cause was the departure from the approved Marine Execution Plan (MEP). The tug masters, led by the master of the Aphros, implemented an over-the-stern tow configuration contrary to the pre-approved in-harbour towing procedure that required a shorter bowline arrangement. Critical contributing factors included: excessive speed (8.3 knots versus recommended 6 knots) leaving no safety margin for the Adonis to manoeuvre; a dangerously short towline (37 metres versus recommended 60-100 metres) placing the tug too close to the barge; and speed too high for the master of the Adonis to react adequately. The girding manoeuvre (towline moving from stern to side) was rapidly fatal. Emergency release mechanisms failed or were not effectively deployed. The coroner found the incident entirely preventable had the approved MEP been followed.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Departure from approved Marine Execution Plan by tug masters
- Implementation of over-the-stern towing configuration contrary to approved procedure
- Excessive vessel speed (8.3 knots versus recommended 6 knots)
- Inadequate towline length (37 metres versus recommended 60-100 metres)
- Towline too short placing tug dangerously close to barge bow
- Use of mooring lines instead of appropriate towline with insufficient breaking strength
- Master's inability to react due to speed and lack of manoeuvring margin
- Girding manoeuvre causing rapid capsizing
- Emergency release mechanism failed or not effectively deployed
- Obscured emergency wheelhouse release by bookshelf
- Locking pin not in armed position on tow hook release
- Crew member difficulty reaching release mechanism from opposite side
- Master Phipps' directive to depart from MEP not effectively questioned
- Lack of appreciation of emergency tow hook release purpose
- Crew members not empowered to challenge master's decisions
Coroner's recommendations
- The wheelhouse emergency tow hook release mechanism should be relocated to a position readily accessible to the master while remaining at the helm, such as on the ceiling immediately above or slightly forward of the helm, to enable operation in emergency situations without leaving the helm
- The relevant authorities should investigate and implement the practicable solution of re-plumbing emergency tow hook release cables to position the release in an overhead position accessible from the helm
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