An improperly reset hook was to blame for the unintentional release
of a freefall lifeboat from a bulk carrier in the Indian Ocean in 2014,
the Australian Transport Safety Bureau has determined.
The Malta-flagged MV Aquarosa was transiting the Indian
Ocean en route to Fremantle, Western Australia on March 1, 2014 when its
freefall lifeboat was inadvertently released during a routine
inspection.
The accident seriously injured one of the ship’s engineers,
who was inside the lifeboat when it was released. The ship’s crew recovered the lifeboat after about 5 hours and resumed its voyage, arriving in Kwinana, near Fremantle, a week later where the injured engineer was transferred to hospital.
In its final report, the ATSB said that its investigation determined
that the lifeboat on-load release was incorrectly reset after it was
last operated before the accident. When the engineer operated the manual
release pump to inspect the equipment, the reset release tripped
unexpectedly. The lifeboat launched when the simulation wires failed.
The investigation found that although there was an indicator to show
that the hook was in the correct position, there was nothing to indicate
that the tripping mechanism was correctly reset.
It was also found that
the design and approval process for the lifeboat’s simulated release
system had not taken into account effects of shock loading on the
simulation wires.
What happened
On 1 March 2014, Aquarosa was transiting the
Indian Ocean en route to Fremantle, Western Australia, when its freefall
lifeboat was inadvertently released during a routine inspection. A
ship’s engineer, the only person in the lifeboat at the time, was
seriously injured in the accident.
About 5 hours after its release, the ship’s
crew recovered the lifeboat and resumed the voyage. On 8 March, the ship
berthed in Kwinana, near Fremantle, and the injured engineer was
transferred to hospital.
What the ATSB found
The ATSB found that when the lifeboat on-load
release was last operated before the accident, it was not correctly
reset. Consequently, when the engineer operated the manual release pump
to inspect the equipment, the incorrectly-reset release tripped
unexpectedly.
The simulation wires, designed to hold the lifeboat during
a simulated release, failed and the lifeboat launched.
The investigation found that although there
was an indicator to show that the hook was in the correct position,
there was nothing to indicate that the tripping mechanism was correctly
reset. It was also found that the design and approval process for the
lifeboat’s simulated release system had not taken into account effects
of shock loading on the simulation wires.
What's been done as a result
Aquarosa’s shipboard procedures were revised
shortly after the accident. Changes included the introduction of a
requirement to notify the officer of the watch before entering the
lifeboat. Notices were posted at the on-load release hydraulic pump
positions, stating that the pumps must not be operated without the
master’s permission.
Via a circular, Aquarosa’s managers, V.Ships,
notified all ships in its fleet of the accident and its internal
investigation findings. The circular also required the masters of all
ships fitted with the same type of on-load release, to similarly revise
the instructions for its operation and resetting. In addition, masters
were required to review the simulation wire maintenance and inspection
regime.
On 17 March 2014, the ATSB contacted V.Ships,
the ship’s flag State (Malta), Bureau Veritas, the lifeboat
manufacturer, the International Association of Classification Societies
and the Australian Maritime Safety Authority (AMSA) and advised them of
the ATSB’s preliminary findings. The parties were asked to identify
ships equipped with similar freefall lifeboat arrangements and to advise
operators of those ships to take safety action to prevent a similar
accident.
In response, AMSA informed its surveyors of
the accident and the ATSB’s preliminary findings, and asked them to pay
particular attention to these issues during flag and Port State
inspections.
Safety action by the manufacturer included
placing alignment marks on the release segment of new on-load releases
mechanisms, to indicate when they are correctly reset. A lock-out
‘maintenance pin’ is also being provided for all new on-load releases to
ensure the release cannot trip while maintenance is being performed.
Safety message
When designing and certifying equipment such as on-load release
systems for lifeboats, all facets of the equipment’s possible operation,
use and environment must be taken into account and allowed for. Only
then can fully comprehensive instructions be documented, enabling
seafarers and others to safely use and maintain the equipment under all
conditions.
The full ATSB report can be found HERE.