Lifeboat Incident Survey

Results from a Joint Industry Survey carried outby

OCIMF, INTERTANKO AND SIGTTO

Lifeboat Incident Survey 2000 INTERTANKO/OCIMF/SIGTTO

Page 1\\Srv01\Documents\PROJECTS\Lifeboats\Web Download Document - Lifeboat Safety.doc

IntroductionIn 1994, OCIMF in conjunction with ICS, produced a report entitled“Results of a Survey into Lifeboat Safety”. This report highlightedsome major concerns over equipment and the availability on board ofappropriate technical information and documentation; similarconcerns evidently remain. During recent years there has beencontinued concern among the Membership of our organisations overthe number of incidents that involve lifeboats. One possible benefitfrom the earlier survey may well have been to make seafarers moreaware of the inherent dangers of lifeboat launching and recoveryprocedures.

To ascertain current understanding of lifeboat issues, a questionnairewas developed and issued to all Members of INTERTANKO, OCIMFand SIGTTO. This questionnaire was not targeted at any specifictype(s) of lifeboat, but it was anticipated that the majority of incidentsinvolved totally enclosed boats and their associated hook releasesystems due to the comparative complexity of the design. In addition,the views of serving seafarers were sought on the practicality andsuitability of designated, specialist rescue craft. Concensus andresponse on this latter were inconclusive and are not included in thisreport.

The 89 completed questionnaires returned varied in standard of detail,so some minor inconsistencies exist with incident numbers. However,the relative proportions of data shown in the charts are unaffected.



T yp es o f life b o a ts in vo lve d in In c id en ts

56

3

75

F re e fa ll

O pen w ithO nboa rd R e lease

O pen w ithou tO nboa rd R e lease

To ta lly En c lo sedw ith O nboa rdR e le ase

Reason for Activity that led to Incident0

35

32

8

Emergency

Emergency Drill /ExerciseMaintenance

Survey

Activities During Operation1

36

13

14

5

6

4

91

Clearing Vessel

Embarkation/Maintenance

Launching

Lowering Boat Below Embarkation Deck

Other

Recovery of Boat Below EmbarkationDeck

Release at Sea Level

Stowing Boat above Embarkation Deck

Whilst Clear of Vessel

FindingsThe charts below show the proportions of different lifeboat typesinvolved in the reported incidents.

All reported incidents were associated with either testing ormaintaining the boats, training exercises/drills or Surveys.

The majority of incidents involved personnel being within the boats.



Primary Causes of Incidents

12

439

1

17

3 2 2

Design fault

Equipment Failure

Failure to Follow CorrectProcedure

Lack of propercommunications duringoperation

Lack of properMaintenance inAccordance withInstructionsLack of Proper Training

Primary Causes of Serious Incidents

2

11

3

5

1 1

Breakdown of Incidents caused by Equipment Failure

5

10

1

113

13

Boat ActivatedReleaseBrake

Fall wire

Gripe Release

Hook/Hook QuickRelease MechanismOther

Primary Causes of IncidentsIn the charts below, an attempt has been made to classify theincidents into three categories; Serious, Non-Serious and Minor.

Equipment failure is the greatest cause of incidents in all categories,followed by lack of proper maintenance, design faults and a relativelysmall number of Procedural faults.

Incidents directly caused by poor training and communication errorsare minimal.

Equipment FailureHook/Hook QuickRelease Mechanismfailure is the largestgroup, relating toinability to engage orrelease hooks correctlydue to cable failure ormislocated safetymechanisms.

Other major types offailure are winch brake

related, caused by internal mechanism or remote controls for brakereleases.

Primary Causes of Not Serious Incidents

7

166

1

6

2 1

Primary Causes of Minor Incidents

3

16

6

2



Breakdown of Incidents Caused by a Lack of Proper Maintenance in Accordance with

Instructions

6

21

2

6

Hook/Hook QuickRelease MechanismBoat ActivatedReleaseDavit

Brake

Other

Breakdown of Incidents Caused by Design Fault

3

1

1

1

4

2 Boat ActivatedReleaseDavit

Fall wire

Gripe Release


Breakdown of Incidents Caused by Failure to Follow Correct Procedure

5

1

4

2

Injury to Personnel

Fall wire


“Others” includes retrieval of free-fall lifeboats.

Lack of Proper MaintenanceProblems withHook/Hook QuickRelease Mechanismtop this grouping.Usually attributable towastage of criticalparts within safetymechanisms.

Design FaultsAgain, the majority ofincidents haveoccurred withHook/Hook QuickRelease Mechanismsfollowed closely byBoat ActivatedRelease. TheLifesaving Role of thelifeboat may becompromised by aninability to launch it

safely and efficiently.

The design faults reported may not have become apparent withoutregular training exercises.

Failure to Follow the Correct ProcedureA number of incidentsfrom failure to followthe correct procedureresulted in injury topersonnel. Othersresulted mainly indamage to boat orlaunching apparatus.Again, the Hook/HookRelease Mechanism is asubstantial contributorto this type of incident.



Breakdown of Incidents Caused by a Lack of Proper Training

1

1

1 Hook/Hook QuickRelease MechanismInjury to PersonnelDuring OperationOther

Total Injuries to Seamen

6

14

Lost Time Injury(Serious)Minor Injury

Lack of Proper TrainingFew incidents can be attributed to lack of proper training and no validconclusion can be drawn.

Lack of proper communication /Physical Condition AffectingOperation/OthersThese 3 categories have so few incidents that no valid conclusion canbe drawn from them.

Primary Causes of Injuries

Fortunately there were no fatalities reported in this survey. However,that potential existed where boats were seriously damaged or lost.

The number of injuries in comparison with the number of incidents islow. It can be assumed that a deep mistrust of lifeboats has developedon board vessels, resulting in operation of the boats in a manner thatlimits as much as possible any exposure to potential injury, such as aminimum number of persons in the boats when being lowered andlifted.



Breakdown of Equipment Failure

Hook/Hook ReleaseEquipment Failure

Causes of Serious Injuries

33

Equipment Failure

Human Error

20 injuries were reported, 6 being serious, requiring at least severaldays off work and 14 were minor, requiring first aid or medicaltreatment before continuing work.

These 20 injuries occurred in 13 separate incidents, 4 of whichaccounted for the serious injuries.

Serious Injuries

• A major incident was a lifeboat releasing itself and falling to thewater from the embarkation deck level. The height above the waterwas relatively small at 12 metres and three members of the lifeboatcrew incurred leg and/or back injuries. Had the freeboard beengreater, fatalities would have been likely.

• The other incidents were all caused by human error - failure tofollow correct procedure or lack of proper training. These includeda thumb crushed by a closing lifeboat door and wrist fracturewhilst starting a lifeboat engine.

Minor Injuries

9 incidents involved minor injury. Two had potential for seriousinjury: -• During a boat launch, the forward quick release hook released

itself with the boat five metres above the waterline. This resulted inminor injuries to 4 seamen. The nature was not reported but thepotential for more serious injury existed.

• A lifeboat was lowered to sea level but the launch aborted whenone hook did not release. The other released but was reconnectedand the boat recovered above embarkation deck with the crewonboard. When the boat reached the davit head the hook thatfailed released itself, resulting in the boat swinging from one fall.The three crew received cuts and bruises. Great potential existedfor serious or fatal injuries. The one fall and davit provedsufficiently strong to hold the total weight of the boat on thisoccasion.



• Some incidents include injuries incurred whilst attempting to“hook on” to the falls for boat recovery. In one incident a seamanwas struck by the swivel block and in the other a seaman incurredpinch cuts to his hands whilst holding the hook in place as therelease system was engaged. The connection of waterbornelifeboats to falls has always proven a hazardous operation, but isexacerbated by release mechanisms which are difficult to engagecorrectly. A similar minor injury was incurred when trying toreconnect a quick release hook after maintenance. This resulted incuts to fingers.

• Other incidents include gripe releases under tension where aseaman was struck heavily by the freed end of the gripe and onewhere a seaman caught his finger in the gripe release mechanism.

• More minor incidents include a seaman attaching his safetyharness to the davit and being pulled off balance when the davitwas lowered and a seaman losing balance whilst attempting tostart a lifeboat engine. The seaman struck his head, rather thanfracturing a wrist as noted in Serious Injury section.

Summary of Incidents leading to Injury.All injuries caused to personnel due to equipment failure relate to theHook/Hook Quick Release mechanisms on totally enclosed lifeboats.These incidents account for 50 percent of the reported injuries andhad potential to incur fatalities.

Many of the other injuries could have been avoided with more care,but the present equipment design and operation creates inherent risk,such as the means to reconnect the lifeboat to falls prior to recoveryand the means of starting lifeboat engines by hand.

N.B The charts in the Serious and Minor Injuries sections assumethat “Equipment Failure” relates directly to a failure of the equipmentand “Human Error” relates to following incorrect procedures or takinginsufficient care.

Causes of Minor Injuries

77

Equipment Failure

Human Error

Breakdown of Equipment Failure

Hook/Hook ReleaseEquipment Failure



Reasons Atributed to Hook/Hook Release Mechanism Faults

13

4

6

1 1

Equipment/MaterialFailureDesign Fault

Lack of ProperMaintenance Failure to follow ProperProceduresLack of Proper Training

Hook/Hook Quick Release Mechanisms

As previouslynoted, incidentsattributed to faultswith theHook/Hook releaseMechanism are thegreatest singlegroup. Of these 25incidents, over50% are due tofailure of theequipment or ofthe material. When

Design Fault is added some 68% of these incidents can then begrouped as a single “Design factor”. If at the design stage therequirement for non-critical maintenance was addressed, theincidents categorised under Lack of Proper Maintenance may not haveoccurred. Therefore, all but 2 of these incidents can be attributed topoor design of the Hook/Hook Release Mechanism.

Lessons LearnedIt appears that little has changed in the incident types reportedbetween this survey and that conducted in 1994 by OCIMF and ICS.The main difference is that in this report no fatalities are noted. Thismay be due to the fact that seafarers are now more aware of the risksinherent with lifeboat operations and in drills or exercises personnelare often excluded from risk where possible. Unfortunately this mayreduce the effectiveness of some training exercises such as simulatinga real emergency situation and therefore fully familiarising crew in thedesigned use and limitations of the equipment.

Both this report and the 1994 survey show that the design andconstruction of lifeboats and their auxiliary equipment, such as hookand hook release equipment and winch brakes continue to play asignificant part in incidents involving lifeboats. The purpose of alifeboat is designed to evacuate personnel from a ship and save life.Retrieval of the boat is a secondary factor almost entirely confined tothe mechanics of training exercises/drills. However, it would appearthat the designers of such boats and their securing methods have notaddressed this secondary factor with sufficient thought. This can beillustrated by the design of complicated hook release equipment.Once assembled and maintained correctly such equipment can bevery reliable, however, should a small error in the location or areduction of clearance occur with even seemingly minor parts,disastrous consequences can ensue. Making minor adjustments tothese complicated arrangements is prone to error when securing aboat on its falls in a seaway. Design factors also apply to types of



materials used. Should the hook release equipment be manufacturedfrom a material susceptible to wastage then reliability andmaintenance can be severely affected.

Another example of the poor design of equipment (i.e. the assumptionthat recovery is of limited importance) is the report of a Freefalllifeboat that took a full day to recover. The equipment was unable torecover the boat in a single pull, necessitating the crew evacuating theboat from a hazardous position to reduce the winch load.

Operational human error does not appear to be a direct cause of manyincidents. Human error in design and not adequately specifyinglaunch and recovery equipment standards for practical eventualities isapparent.

One positive note is that a lack of supervision or training during drillsdoes not appear to be a major factor.



RecommendationsThe reported incidents and findings show that the marine communityneeds to further improve standards for the design, manufacture andmaintenance of lifeboats in a bid to ensure that not only can they beused in an emergency but can also be operated regularly at drills in asafe manner.Some of the recommendations that follow reiterate recommendationsmade in the 1994 report. Their validity can only be strengthened bythe apparent need for repetition.

It is recommended that Ship Operators and Owners should:

• In the case of totally enclosed lifeboats with a hook releasemechanism, review the correct operation of the hook release anddraw up instructions and drawings detailing the correctcomponents, their location and method of operation. Theseinstructions to be specific to the equipment fitted on board thevessel and to be provided to all seamen who are likely to beinvolved in the maintenance and operation of such equipment.

• Incorporate procedures requiring the boat recovery process to besuspended once the boat is clear of the water and ensure that thehook release mechanism is correctly secured prior to recovery ofboat to embarkation deck.

• Review maintenance procedures in light of these reportedincidents. Particular component failures to consider are: -1. Hook/ Hook release mechanisms to be inspected to ensure that

all components are within tolerance, there is no build of scale,and that there is no wastage that could either weaken theequipment or cause it to operate incorrectly. This includes therelease cable, which has been subject to a number of incidentreports.

2. Winch brake linings to be regularly inspected for contaminationand lining thickness. The associated remote lowering wires arechecked to be in good condition and to operate correctly, bothon the stowage drum and within the boat.

3. Lifeboat falls should be lubricated and inspected regularly. Atappropriate intervals they are to be renewed or end for ended.

4. Cut outs for recovery winches should be regularly checked forcorrect operation to prevent over stressing falls and davits.

• Consider installation of a secondary manual override lock to thehook release mechanism that can be released from a central pointin the boat but ensures that there can be no inadvertent release ofthe hooks, either through human error or a hardware fault, duringmaintenance or drills.

• Further ensure that training includes personal safety specificallywith regard to lifeboats, ensuring that seafarers are made aware ofhazards such as releasing gripe wires under tension.



Lifeboat and associated equipment Designers / Builders /Installers should: -

1. Simplify the design of operating equipment with a view toincreasing reliability, easing maintenance ensuring simplicity ofoperation with regard both to launching and recovery. Componentsrequiring fine tolerances should be avoided or constructed ofmaterial not prone to wastage.

2. Provide hatchways in enclosed boats of sufficient size to enableeasy access for connection of hooks. This should take into accountthat the reconnection may be required in a seaway, not in stillwater.

3. Ensure that hatchways are suitable for evacuating injured and/orstretchered personnel either to another boat or by helicopter.

4. Provide a means of positive indication that hook release systemsare fully engaged and locked for recovery, preferably from thecoxswains conning position. This should be mechanical, directlyconnected to the hooks and not involve secondary indication suchas lights, the position of the release handle, etc.

5. Simplifying the brake system for the davits/falls to improve ease ofmaintenance and increased reliability. Increasing brake capacity towell above the weight of a fully laden lifeboat would help ensurethat braking ability is maintained even if the system weakened.

6. Provide a method of indicating brake lining wear or contaminationexternal to the winch to alert ship staff of a problem.

7. Ensure that remote brake release systems from within the lifeboatare reliable and not inherently liable to snag within the boat.

8. Ensure that the recovery systems, especially the winches, aresufficiently strong to enable a lifeboat to be recovered easily andquickly with a normal drill complement onboard.

9. Ensure that boarding at the stowed position can be undertakeneasily and safely for maintenance, whilst also ensuring safe andquick access can be achieved at embarkation level (if different) inan emergency.

10. Ensure that there is a suitable method such as a hose connectionfor testing/flushing water-cooled lifeboat engines and spraysystems with freshwater when boats are in the davits.

Flag States, IMO and Classification Societies

1. Review and qualify the existing requirements under SOLAS Ch3Regs 51 and 52 – The SOLAS Training Manual and MaintenanceInformation/Records. In many cases the current details of lifeboatsand their equipment provided are inadequate or generic. FlagStates should compel owners/operators to ensure that suchinformation is specific to each individual vessel and sufficientlydetailed for vessel crews to operate easily and identify, assess andrepair any individual component with ease.



2. Review other existing regulations to consider if changes may benecessary to ensure the safe and efficient launching and recoveryof lifeboats during drills/training exercises (and for rescue if thelifeboat is a designated rescue boat) bearing in mind the pointsraised in this report.

3. In the case of Free-fall lifeboats, review the existing test launch andrecovery requirements with particular regard to permittingsimulated launches such as unmanned release onto a stop-chockafter a few centimetres of travel and ensuring the recoverymechanism has sufficient excess power to lift cradle and laden boateasily and rapidly.

4. Review maintenance and survey requirements to confirm thatlifeboats and their associated systems fully meet the level ofassurance required in (2) and (3) above with regard to launchingand recovery in regular drills and exercises.

Attachment 1Brief Description of the Incident Established Cause Type of boat

Attachment 1Page 1

Serious Incidents

The lifeboat was in the process of beinglowered to embarkation deck for survey.A rope became entangled in the afterdavit release mechanism causing it torelease. The boat became suspendedfrom forward hook distorting the davitarm, which required landing for repair.The boat was seriously damaged.

Design Fault Totally Enclosed withOnboard release

When lowering the boat the forward davitarm became momentarily delayed inrelease due to the forward retainingclamp being partly still in place. Whenfreed the forward arm lined up with aftarm the shock to the system caused theforward hook to release. The boat wasseriously damaged.


Whilst lowering boat to embarkationdeck the brake failed to hold and thelifeboat proceeded to sea level in anuncontrolled manner. The vessel had tostop engines and take all way off. Thewinch brake was overhauled prior torecovery of the boat. The lifeboatsuffered minor damage.

Equipment/materialFailure

Totally Enclosed withOnboard release

During launching of port side lifeboat,the forward quick release hook openedwhilst boat was about 5m above waterline. This caused substantial damageto the lifeboat and minor damage tothe aft davit.



Both boats were being lowered to theembarkation deck as part of a drill. Bothlowered with minimal braking as theremote wires from the boats wereincorrectly adjusted. A turn was takenoff the remote wire for starboard boat,which had the effect of stopping it. Theport boat continued to sea level and, asthe vessel underway at full sea speed atthe time the lifeboat was a total loss.Davits on the port side also sufferedconsiderable damage.




Attachment 1Page 2

During an in water test of the starboardlifeboat engine in the water, the lifeboat'smotor stopped after approximately 10minutes of running due to overheatingand impossible to restart. The portlifeboat was lowered to the water torescue the starboard lifeboat, but itsengine also seized for the same reason.Both boats recovered by vessel heavinganchor and manoeuvring into position.



The starboard lifeboat was being loweredon brake. When lifeboat reachedembarkation deck it would not stoplowering. When boat hit water, theweight came off of falls & the brake thenmoved to stop position. The surging ofboat in seaway first released forward fall& then the after fall. The lifeboat was atotal loss.



During the hoisting of the lifeboat, justprior to reaching stowed position, the afthook released causing the boat to fall onthe structure below. One sheavemounting and both hooks were damaged.The boat was badly damaged.



During recovery of the lifeboat the winchmotor was stopped but the lifeboat hadinertia and touched to the davit. Theforward fall parted. The boat was kept onthe aft fall. The outside of the fallappeared good but the inside was foundto be badly corroded. The boat sufferedminor damage.



Whilst lowering boat the brake wasunable to stop the boat at deck level. Itcontinued lowering to sea level. Thevessel was underway at the time and hadto be stopped and all way taken off. Theboat was found to be badly damagedafter it had been recovered by shipscrane. The davits also sustaineddamage.



The starboard lifeboat lowered to decklevel. When tried to lift it, was notpossible to do it either by winch electricmotor or by hand. Found winch 2nd stepshaft broken. Provisional repairs done tobe able to recover the boat.



During port life boat brake loadingcapacity test, the brake failed and theboat lowered uncontrollably to the water.The boat suffered minor damage.




Attachment 1Page 3

During routine maintenance the forwardremote release cables on both boatsfailed due to internal corrosion of thewires.



The crewmember responsible for takingsafety pin out on aft davit arm did not doso. When the brake was released only theforward davit arm went down. The brakewas applied as soon as crew attendingthe lowering observed the fault. Howeverthe forward part of the boat swungagainst the deck below sustaining minordamage.

Failure to follow correctprocedure


During a drill the lifeboat was hoisted upto its final position when it was observedthat the bow was in place but the sternstill a few centimetres away from its finalposition. Air motor restarted and the aftfall parted causing the after end of theboat to fall damaging both the boat anddavits. The boat was a total loss.



During survey the port lifeboat waslowered to water. Prior to recovery afailure in the forward securing devicewas found. The release pin wasmanually secured with spanner and ropelashing. Whilst stowing the forward hookreleased, the boat fell to the water. Theboat was seriously damaged.



The lifeboat was lowered belowembarkation deck and stopped. At thatmoment both the fore and aft hooksreleased and boat fell into the water.The boat was seriously damaged.

Lack of propermaintenance inaccordance withinstructions


A lifeboat remote lowering wire parteddue to corrosion and erosion of handle.The failure of the handle caused wire torun out and could have had disastrousconsequences had the equipment failedin use, especially in an emergency.



During lowering of the lifeboat the self-unlocking forward release hook released.The dynamic loading on the aft hookcaused this to break and release and theboat fell to the water. The boat was atotal loss.



Brake failed to hold after 5 men boardedboat at embarkation deck. Forwardtricing pennant released and the forwardpart of boat lowered on its own. Menevacuated prior to any injury occurring.The boat suffered minor damage.


Open with onboardrelease


Attachment 1Page 4

Whilst launching a lifeboat one of thehooks did not release. It was not repairedon water but the released hook wasreconnected and the boat was recovered.Crew did not disembark at embarkationdeck and when boat reached the davithead previously unreleased hook let go.The boat suffered minor damage.



Seaman was hit on the head under hishard hat by the swivel block to hookswhilst trying to reconnect at the end of adrill. The swivel had not taken out thetwist in the fall wires.

Lack of proper training Open with onboardrelease

Starboard lifeboat due for launching andtrials. The boat was waterborne, motorrunning and shaft engaged. Afterreaching full speed the motor suddenlystopped. The gripe wire had fouled thepropeller. The boat suffered minordamage.

Physical conditionaffecting operation


Non Serious Incidents

When hanging the boat off on strops tocarryout maintenance the boat toppled inthe davits causing punctures to the hullof the boat where it contacted the davits.


Damage to lifeboat engine caused bytesting in davits. The arrangement forsupplying cooling water led to watersiphoning into exhaust.


Lifeboat release arm and lead blockswere damaged when plastic coveredremote lowering wire became kinked andsnagged in lifeboat deckhead onlowering.


Safety lock on the release mechanism notcorrectly reset after a previous drill.


Lifeboat hook safety locking handle failedto re-engage after resetting thedisengaging gear.


The boat was being retrieved when therelease wire became snagged causing thebrake to release and lower the boatuncontrollably.


Lifeboat remote release mechanism failedto release boat due to misalignment ofbrake winch release handle.



Attachment 1Page 5

Morse cable for release gear partedduring testing.



When the port lifeboat was launchedand in the water it was attempted torelease the hooks. It was found that onlyaft hook would release, the forward hookcam was not opening. When release leverre-set, aft hook cam was found to beclosing properly; the forward hook wouldnot open or close although indicator wasindicating either open or closed.



While trying to rehook the wire falls, anofficer suffered from a wound caused bypinching by the hook mechanism.Difficulty is always experienced in tryingto succeed to rehook both falls, forwardand aft, in the same time and to engageboth simultaneously from the inside withthe pneumatics.



During routine maintenance of the hooksto port lifeboat, the lever release gearbroke.



The lowering brake malfunctioned.Holding efficiency was found to bemoderate and would not have beensufficient to safely lower a fully loadedboat in an emergency.



Water Sprinkler Pump clutches werefound not to be properly coupled toengine thus the water spray system wasinoperative.



The hoisting/recovery winch hadinsufficient power to recover boatproperly. The power pack had to berestated several times to recover theboat. Crew manning the lifeboat had todisembark from a very precariousposition.


Freefall

After quarterly maintenance to thestarboard lifeboat during brake testing,once releasing both retaining lashings,the lifeboat lowered by itself very gentlyand rested on the maintenance strops.



The forward port lifeboat gripe wire wasfound broken in two pieces. The gripewas corroded and rotten inside plasticsheathing. The rupture position was inthe wire located at forward end. Thelifeboat was restrained by the aft gripe.




Attachment 1Page 6

While recovering the port lifeboat fromthe water, the brake failed lowering theboat back to the water. The lifeboat wasrecovered using the parts of thestarboard winch brake. No damage toeither lifeboat. Both lifeboats secured.



During routine drill, lifeboat lowered toembarkation to embarkation deckwithout any problem. After hoisting theboat for about 6 inches, with motor, thebrake failed causing the boat to lowerdown until it stopped on maintenancestrops.



Port lifeboat engine hand starting spurgear broken.



Lifeboat engine failed to operate during aroutine test.



Starter for lifeboat engine failed duringweekly test of engine



It was attempted to release the lifeboatwhen one foot above water.Release system failed to operate whenonload. Drill was aborted.



Lifeboat was lowered to sea level, but notinto the water, with no crew in the boat.The remote control wire was used byactivating remote control lever on deck.When boat was at release level the boatrelease wire parted as it had becometangled and subsequently snagged in theboat.



During an emergency drill the remotecontrol wire came under heavy loadwhich caused the pulley to break. Thiswas caused by the triangular handle onthe release wire becoming snagged. Thecounter weight on the wire swung andbroke the side window.



The seaman clearing gripes had hissafety harness attached to davit. Hesignalled that he was clear but when thelifeboat was lowered towardsembarkation deck the davits pulled onsafety harness pulling the seaman off hisfeet into the davit.


Open without onboardrelease

During preparation to lower the portlifeboat when releasing the slip hookturnbuckle of the gripe a seaman wasinjured when the slip hook released withgreat force due to a tension build up in




Attachment 1Page 7

gripe and associated gear.

When trying to hand start lifeboat enginethe Officer fell forward injuring his wrist.



A seaman injured his finger, whichrequired one stitch, while releasing thepelican hook of lifeboat lashings. Thefinger was trapped between pelican hookand locking device.



During the Safety Equipment Survey thestarboard was lowered into the water. Arating was standing in the door entranceand steadied himself by holding the dooredge. The door shut trapping his thumb.



Aft gripe was not properly released whenlifeboat was lowered. This caused a turnfall wire to jump from the drum. Thiscould have had serious consequences.

Lack of propercommunications duringoperations


The sprinkler system ineffective due toan accumulation of salt in the system.



Lifeboat hooks failed to re-engage afterdrill. The problem was traced to burredhooks, caused by rust and scale, and aseized release cable



It was found that an onload cam releasepin was seized and thus not operationalthus the release would have not havebeen operational in an emergency.



Davit and gripe securing hooks and leverpins corroded with a build up of paintnot enabling a smooth operation



Water Sprinkler Pump found seized withSalt accumulation. Preventativemaintenance procedures not followed



On trying to release hooks only theforward hook was activated - aft seizedwith paint




Attachment 1Page 8

When trying to manually start a lifeboatengine insufficient engine speed hadbeen built up prior to engagingcompression levers. The engine 'kickedback' causing the seaman to lose balanceand strike his head

Lack of proper training Open without onboardrelease

During retrieval of starboard lifeboatfrom the water, the forward and aftreleasing gears were connected. The boatwas lifted just clear of the water on thelifeboat falls. Checks were made on thereleasing gear hooks prior to hoisting thelifeboat fully home and it was observedforward hook was not properly locked in.Lowered lifeboat to reconnect properly.

Lack of proper training Totally Enclosed withOnboard release

During recovery of the boat the ChiefOfficer was hit by aft block

Physical conditionaffecting operation


Minor Incidents

Both gripes were found to have nearlyparted under protective PVC coating onthe wires.


The boat did not stow squarely onretrieval. When attempting to level theboat the locking pawl on one drum didnot properly engage resulting in the aftend of the boat falling in an uncontrolledmanner.

Design Fault Open with onboardrelease

Chief Engineer caught his finger in thequick release mechanism whilstreconnecting hook after maintenance.


Release gear Morse cable parted whilstboat was waterborne.



Pull wires of the release mechanism ofboth lifeboats found to be unsuitable forfurther use.



Fall wires of both lifeboats found to beunsuitable for further use.



During recovery after routine lowering(drill) of starboard lifeboat, the remotecontrol lowering wire became jammedbetween cheek and sheave of one of theleading blocks and parted.



During routine 3 monthly inspection ofthe lifeboats winch brakes & gear case, itwas discovered oil from gear case hadleaked into brake housing of port lifeboatlimiting its effectiveness.




Attachment 1Page 9

During testing and preventativemaintenance the release gear was foundto be worn. Equipment replaced andadjusted as necessary prior to testing forcorrect operation.



During routine weekly test of thestarboard lifeboat, it was not possible tostart the lifeboat engine using the handstart device. The lifeboat engine couldonly be started electrically.



The starboard lifeboat engine failed tostart after becoming increasingly difficultover a period of time. Furtherinvestigation revealed damaged drivegear for the balance shaft.



The electric motor of the lifeboat recoverywinch was found to be inoperative due toa short circuit.


Open without onboardrelease

During testing pull-chain for the releasegear parted at weld. Replaced by newone.


Freefall

The lifeboat was lowered & released. Theboat was exercised and then recovered.When the free wheel unit housing wasremoved to inspect the conical brakelining, oil was found within the housing.



Both lifeboats were lowered to the waterand released. The lifeboat hook releasesystem was delayed (previouslyexperienced this problem)



During inspection to enclosed portlifeboat, it was noted that forwardstopper for cradle holding lever (alsonamed cradle hook) was cracked andslightly bent. Crack looks old. Stopper iswelded on plate for 3/4 of its length.



During weekly routine inspection, foundpressure controller of port lifeboat aircylinder system defective (no air flowthrough controller)



While lowering starboard lifeboat to thewater, the remote control wire did notpay out in line with the falls but coiledundetected, bending and finally breakingthe bracket.



A routine lifeboat engine check revealedthe crankshaft pulley was broken in wayof key-way.




Attachment 1Page 10

Testing the air system main valve stuck.Opened and brought into operation.


Freefall

Lack of proper maintenance - nodescription given.



Port lifeboat winch brake slipped, whenfound cradle released, cradle movedhalfway down to rest position slowly onfree fall arrestor.



Testing the air system the main valvewas found to be seized.

It was opened and brought intooperation.


Freefall

Morse cables found to be unsuitable forfurther use


Freefall

Lack of proper maintenance. Failure tofollow preventative maintenance aftereach use.



Winch Motor Burnt out - Physical wearof insulation.Short circuit.

Others Totally Enclosed withOnboard release

During tests winch mechanism found tobe faulty. A worn bearing was found.Cause unknown.

Others Totally Enclosed withOnboard release

Lifeboat Incident Survey

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