Lack of familiarity and training, combined with the abence of a fall preventer led to the deaths of two seafarers and serious injuries to two other when a lifevoat fell 30 metres from its recently-installed on-load release hook during a drill aboard the Marshall Islands-flagged drilling rig Ocean Ambassador says the Brazilian Maritime Authority. The incident has generated considerable interest due to the involvement of the Triple 5 hook made by Survival Systems International hih has a good safety record.
The lifeboat fell because the Triple 5 hook had not been properly adjusted after installation, leaving a gap through which the suspension ring of the lifeboat falls passed during the incident. No-one one Ocean Ambassdor had been been given training regarding the Triple 5 hook or its characteristics, no maintenance manual was onboard Ocean Ambassador and none had been requested.
On 17 May 2010 at 10.00 hours in the morning, the Marshall Islands flagged platform Ocean Ambassador was at position 23o39’20”S / 041o 27’50”W in the Campos Basin, 80 nautical miles from the Cabo Frio coast, carrying out a drill using lifeboat No. 2, in compliance with Rule 19, sub paragraph 3.3.3 of the SOLAS Convention.
While recovering lifeboat, after carrying out tests of motor and the spraying system, nearly at the height of the main deck the lifeboat released itself from the eye bolt connected to the forward hook of the Triple 5 release mechanism, remaining vertical for some moments when the after hook, which now supported all the weight of the lifeboat, released it to drop into the sea from a height of about 30 meters.
As a result of this accident, two crewmembers died and another two suffered serious injuries.
The ‘Master Coastwise’, MCB, who died of his injuries, had boarded Ocean Ambassador at 1000 that morning. Says the report: “…it was concluded by the investigators that he had not had enough time to receive the transfer of service and not enough to read the register book with the notes of the Master Coastwise that he had relieved”.
At the same time, Ocean Ambassador did not have a deck officer responsible for lifeboats and other LSAs and their equipment a breach of Brazil’s safe manning rules.
No copy of the Triple 5 Release Mechanism Operating & Maintenance Manual was onboard Ocean Ambassador.
Although the Trile 5 hook should be completely closed the ones on the damaged lifeboat showed a gap of 24.5 millimetres. It is not possible to determine the actual condition of the hooks prior to the attempted recovery but examination of the remaining undamaged lifeboat on the rig showed a gap of 11 millimetres.
During post-accident examination of the lifeboat investigators of the accident asked the representative of the manufacturer of the Triple 5 equipment, if it was normal for there to be a small opening in the hook of the Triple 5 Release Mechanism. He replied that the normal situation is it to be totally closed.
Investigators concluded that there had no breakage of components of the device, “it being possible to affirm that the eyelet passed through the clearance between the hook of the Triple 5 device and the safety retention, a clearance excessive and in disagreement with that recommended by 6.5 tonne Triple 5 Release Mechanism Operating & Maintenance Manual”.
Says the report: “…statements of crewmembers of the platform, that there was ignorance of part of the crew, of the release mechanism of the lifeboat (Triple 5 device) as well as of its maintenance, conditions and functioning, principally of the opening of approximately 11mm of the hook of the device… the crewmembers mention the hydrostatic sensor and one of them mention the safety pin revealing ignorance of the functioning of the “Triple 5” whose manufacturer claims as an advantage exactly the nonexistence of these two items … The personnel involved on the drill had not had training given by the manufacturer, which should occur by the fact that the device being new, different and unknown to the crewmembers …The crewmembers tend to generalize the functioning of the “hooks” which is interpreted as ignorance of the equipment in particular; and one of the crewmembers directly in charge of the maintenance and operation of the Triple 5 release mechanism stated ignorance of the measurements and clearances established by the 6.5 tonne Triple 5 Release Mechanism Operating & Maintenance Manual. ”.
The 6.5 tonne Triple 5 Release Mechanism Operating & Maintenance Manual establishes that the distance that the hook should project itself is 2 3/8 ins, 60 millimetres, This was not the case on the lifeboats on Ocean Ambassador.
While the manual says that the clearance between the hook and the latch is regulated by the adjustment of a Teleflex cable “ … the Manual does not explain how to do it, being incomplete” says the report.
Brazil’s Maritime Authority says: “A lifeboat release mechanism meeting the requirements of the 1983 Amendments to the International Convention for the Safety Of Life At Sea, 1974 (SOLAS 74) is a complex mechanism and most accidents have been attributed to a lack of understanding of how this equipment works in relation to satisfactory release of the boat during launching and the safe and effective re-connection of the boat for hoisting following a launching.
“Damage and casualties can result from either of these operations if crewmembers are not familiar with the operating procedures and fail to understand the principles of operation of the mechanism. Particular care needs to be taken to ensure that the ‘on-load’ hooks are properly connected to the lifting rings and the operating mechanism is locked in place before starting to launch or hoist the boat. In addition, the equipment needs to be maintained regularly by trained and qualified persons to ensure that casualties do not result from a malfunction”.
If a fall preventer had been in place, fatalities and serious injury might have been avoided. Says the report “The Owners should consider the possibility of the use of Fall Preventer Devices (FPD) as a way to minimize the risks of injuries or fatalities in cases of faults in the devices of release of the life-saving craft, or accidental release of the sustenance hooks, giving additional safety . .. Nevertheless these devices should not be considered as a substitute for the release mechanisms”.
Change management is not covered in depth in the report but it was obviovusly an issue. The Triple 5 hook system differs from other systems which means that seafarer’s familiarity with other systems did not fully transfer to the Triple 5 hook.
The master’s unfamiliarity with the system, the lack of an officer responsible for LSA, the lack of an onboard manual and inadequate training of the crew in this case highlight the importance of managing change, especially when it involves safety critical equipment such as lifeboats.