Peter Goldmann, the late Swedish film director who pretty much created the modern music video used to tell me ‘RTFM’ when I couldn’t work something out – “Read The f*&$king Manual”. Probably a good motto to judge by the UK’s MAIB report on a lifeboat incident aboard the Stena Britannica.
Here’s the synopsis:
“The passenger/ro-ro ferry Stena Britannica was undertaking a routine lifeboat familiarisation drill whilst alongside in good weather conditions. Having been lowered to just above the water both starboard lifeboats were in the process of being recovered when the electric motor on No.1 lifeboat winch burnt out and stopped, leaving the lifeboat suspended about 2.4m below the davit heads.
With no means of effecting a repair, the recovery of the lifeboat continued by hand. Although the boat was raised to the davit heads and then started to be luffed in, this proved laborious, and the decision was taken to swap over the operational motor from No.3 lifeboat davit to complete the recovery. On removing the damaged motor from No.1 lifeboat winch, the lifeboat unexpectedly released and lowered to the water at a controlled speed. No damage was sustained and the operational motor was then successfully transferred and used to recover No.1 lifeboat.
Subsequent investigation revealed that when the damaged motor had been removed, the pinion gearwheel shaft also withdrew from the housing. The crew had no appreciation that this shaft formed part of the geared connection between the roller ratchet freewheel assembly (which holds the load) and the wire/pulley. The removal of this shaft therefore disconnected the gearing and released the load to lower on the integral centrifugal brake. Although the risks associated with the removal of the pinion gearwheel shaft were not clearly described in the lifeboat davit system manual, there were references to precautions to be taken before working on the davit mechanism. No attempt was made to consult the manual before the damaged motor was removed.
The vessel’s managers conducted an investigation into the incident and as a result have:
- Made the davit manufacturer aware of the incident.
- Provided an alternative method for the emergency retrieval of lifeboats.
- Issued formal instruction regarding the securing of lifeboats before working on the winches and brakes.
- Posted notices at each lifeboat, on the Planned Maintenance system and in the maintenance manual warning of the dangers of removing a winch motor when the lifeboat is not fully secured.
- Made the sister vessel within the Stena Line fleet aware of the incident.
The Chief Inspector of Marine Accidents has written to the vessel’s manager, strongly advising that they:
- Review their company processes and procedures regarding the conduct of unplanned rectification work undertaken by ship’s staff on lifesaving apparatus;
- Ensure that an adequate risk assessment is in place covering the maintenance and repair of lifesaving systems by ship’s staff;
- Review the conduct and planning of lifeboat drills to ensure compliance with both statutory requirements and company procedures;
- Review the condition and specification of other lifeboat winch motors to ensure that they could not contribute to further incidents.”