Lifeboat Accidental Release During Maintenance – Investigation Report

The Turkish registered, ISM accredited bulk carrier Gulser Ana entered Stormont Wharf, Belfast on 16 October 2001. On arrival, she underwent a Port State Control inspection by MCA surveyors. Thirty-seven deficiencies were found and the vessel was detained. On the morning of 17 October 2001, two seamen were tasked with freeing up and greasing the releasing hooks on the starboard lifeboat while it was in the water. These had been found seized the day before, during the inspection.

2013.06.24 - Lifeboat Accidental Release During Maintenance - Investigation Report Figure 1

At 0800 on 17 October 2001, Gulser Ana’s bosun instructed two seamen to free up and grease the releasing hooks on her starboard lifeboat. These had been found seized the day before during the Port State Control inspection.

Standing by and operating the lifeboat winch, the bosun lowered the lifeboat into the water with two seamen on board. Both seamen were wearing lifejackets and hard hats. They freed and greased the forward hook, but found the aft hook operating rod sheared. Therefore, after the latter had been freed up and greased, the seamen used lashing to secure the hook in the closed position, ready to hoist.

At about 0910, the bosun called the chief engineer and chief officer to inspect the operation of the hooks. The two seamen then attached the fall lifting blocks to the lifeboat hooks, and the bosun raised the lifeboat to the embarkation level. During the ascent, the seamen sat down and held on to safety lines.

At the embarkation level, the boat was left suspended by the falls and, at about 0920, the chief officer boarded it to inspect the work. He was wearing working gear and a hard hat, but no lifejacket.

About 30 seconds to 1 minute after he boarded the boat, the forward hook released itself suddenly and without warning. The forward end of the boat dropped, leaving it suspended vertically from the aft fall. The two seamen and the chief officer were thrown into the water.

The two seamen were able to pull the chief officer to the surface and keep him afloat. About 5 minutes later, all three were picked up by the pilot launch, then met ashore by the dock police and an ambulance.

2013.06.24 - Lifeboat Accidental Release During Maintenance - Investigation Report Figure 2

A seaman who witnessed the accident from the main deck, collapsed with a suspected heart attack and was taken to hospital by ambulance. The two seamen who had been thrown into the water were released later that day, having suffered bruising to their legs. The seaman who collapsed on board was also released that day, apparently having suffered an anxiety attack. The chief officer was kept in hospital, suffering from a broken vertebra, lacerations above the left ear, and severe bruising to the left eye.

The inspector found three defects in the hook release mechanism which probably existed before the accident. These were:

  • The safety pin was missing from the releasing lever, as shown in the figure below, taken on the day of the accident by an MCA surveyor.
  • The operating rod to the aft hook cam C was sheared, and cam C had been lashed in the secure position. However, the loose end of this operating rod was not secured in any way.
  • There was free play in the mechanism and bearings because of wear of the rod bearings.

2013.06.24 - Lifeboat Accidental Release During Maintenance - Investigation Report Figure 3

SOLAS Chapter III, regulation 36, requires that instructions for maintenance and repair of onboard lifesaving appliances shall be available and easily understood. The vessel’s own instructions were written in English and gave basic instructions on how to lower and hoist a lifeboat. These instructions contained no information on how to reset the hook release mechanism before hoisting the lifeboat.

The manufacturer’s manual for the releasing gear was available on board, but was written in very poor English. The posted “Operating Instruction for Lifeboat” (Figure below) had been translated into Turkish, and this text placed on “Dymo” strips. The instructions describe the basic steps to be taken when launching the boat.

2013.06.24 - Lifeboat Accidental Release During Maintenance - Investigation Report Figure 4

MAIB’s accident investigation report concluded in the following contributing factors that resulted to the accident:

The aft hook was lashed in the closed position, so that operation of the on-load release hook would have released only the forward hook.

The release mechanism was not fitted with an interlock to prevent inadvertent operation of the release mechanism when on load, that is, out of the water.

The cause of the inadvertent release of the forward hook from the fall block lifting ring has not been established with certainty, but the following factors probably contributed to this release:

  • The release mechanism was poorly maintained and in an unsafe condition.
  • The safety pin designed to secure the release lever was not fitted to the lever. Consequently, the lever might have been operated unintentionally, thus releasing the forward hook.
  • There was free play in the mechanism because of wear of the rod bearings; this could have allowed the forward hook to appear reset when it was not.
  • The seamen in the lifeboat might have released the mechanism by disturbing one of its exposed cranks, levers, or the loose end of the sheared aft hook operating rod.
  • None of the crew had received any training specific to the maintenance of the lifeboat hook release mechanism.
  • The manufacturer’s maintenance manual does not describe how to maintain the release mechanism, other than to state that moving parts should be greased.
  • The maintenance instructions for the release mechanism were not written in the working language of the crew and were of little value to them.
  • No written procedures were made, or formal risk assessments carried out, to ensure that the repairs and testing of the hooks were carried out safely and effectively.
  • The repair to the release mechanism was not carried out safely or effectively.
  • The managers of the vessel did not achieve the objective of the safety management system of ensuring that the lifeboat hook release mechanism was operated safely.
  • Bureau Veritas, the recognised organisation authorised to audit and confirm the compliance of the vessel’s safety management system, did not ensure that the instructions for the onboard maintenance of the lifeboat hook release mechanism were appropriate, comprehensive and easily understood by the crew.

Finally MAIB made the following recommendations:

  • Through appropriate procedures in the company’s safety management system, all the essential documentation on board should be in the working language of the crew.
  • A formal risk assessment procedure on board all vessels should be introduced.
  • Procedures should be introduced, through inclusion in the company and vessel safety management systems, ensuring that individuals working on any job have sufficient knowledge, experience, and training to complete the work safely.
  • Guidance in IACS Recommendation 71 “Guide for Development of Shipboard Technical Manuals” should be followed.

Source: MAIB

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