That two men survived falling from a lifeboat in Southampton on 29 March 2012 was a matter more of luck than judgement. Others have not been so lucky. In its 66 page report on the incident the UK’s Marine Accident Investigation Branch continues to raise issues of concern, including lifeboat design, the use of safety equipment, lifeboat ergonomics and change management.
At 1020 on 29 March 2012, two crewmen fell 22m into the water from Saga Sapphire’s No 5 lifeboat while the ship was secured port side alongside in Southampton. They sustained minor injuries.
At 1000, as part of an expanded Port State Control inspection, a drill had been initiated and the starboard side lifeboats were lowered and held alongside deck 9 by their tricing pennants. No 5 lifeboat’s bowsing tackles
were rigged, tensioned from the coach roof and secured to bitts welded to the bowsing tackle blocks fitted to the lifeboat lifting plates. On the order to release the tricing pennants, the forward crewman, who was a first cook, was unable to remove the drop-nosed pin securing the tricing pennant hook release lever in the closed position.
The overseeing fourth officer went to assist. As he removed the pin and operated the release lever, the first cook stepped to one side and the forward bowsing rope came free from the bitts. Without tension on the bowsing tackle, the lifeboat swung violently away from the ship’s side and heeled to port. The fourth officer and first cook, who were not wearing any form of personal restraint, slipped from the smooth coach roof and fell into the water. They were quickly recovered by other members of the crew.
It was an accident waiting to happen: As the vessel emerged from a delayed refit on 16 March, it was found that the bowsing tackle ropes were too large to be held on the bitts, but no action was taken to replace them. The first cook had not received any training for his specific role and none of the lifeboat preparation party or crew wore a safety harness and tether; those harnesses that were on board were life expired. As the ship’s management team assisted with the refit project work, training oversight was inadequate, no one took responsibility for lifeboat training and the ship’s safety management organisation was improperly prepared for its operational role.
The Acromas Group has initiated a review of the refit project management and consequences of the refit completion delays. In addition, some changes have been made to the lifeboat-related documentation, equipment and procedures.
Recommendations have been made to Acromas Shipping Ltd to ensure its proposed changes to the operation of its lifeboats are formally approved; operating instructions for bowsing and tricing equipment across its fleet are consistent and accord with best practice; and that arrangements are put in place to ensure that future refit plans accommodate the need to fully establish the ship’s Safety Management Organisation and complete crew training before the vessel enters service.
Among the conclusions:
1. The first cook’s lack of experience and inadequate understanding of his lifeboat crew duties resulted in him being unable to operate the forward bowsing gear and to release the tricing pennant safely when instructed to do so.
2. The method of securing the bowsing tackle rope to the bitts makes the rope vulnerable to slippage, resulting in slackening of the bowsing tackle if the operator is not in-line with the bitts to back up the tail of the rope.
3. The tender coach roofs and the open lifeboats’ stem and stern compartment roofs, which were accessed by the lifeboat teams, were smooth and not finished with a non-skid application to prevent falling as required by LSA Code and Section 3.10 of
4. Requiring a single crewman to secure and hold the bowsing tackle rope and, at the same time, remove the drop-nosed pin securing the tricing pennant release lever, and then operate the tricing pennant release lever, risks overloading that person.
5. Commercial pressure impacted on the ship’s management team’s focus on preparing the vessel for its operational role.
6. The STO’s reporting line by-passed the SO and, despite having the ship’s overall training responsibility, there was no evidence that the onboard safety management team provided anything other than a superficial level of training oversight.
7. There was no evidence that the need to allocate time for training requirements had been integrated into the refit project management plan.
8. The quality and management of the lifeboat preparation training was below the standard necessary for the lifeboats to have been launched safely by the crew nominated on the muster/emergency plan.
9. No one formally took control of delivering the lifeboat-related training despite the master advising the STO to consult with the SO, and the master instructing the SO to prioritise lifeboat training.
10. Those involved in training management failed to identify the first cook’s lack of experience and to ensure that he had received sufficient training for his lifeboat crew role.
11. The ship’s safety management organisation was weak and ill-prepared for its operational role in areas of management and oversight of training, risk assessments and control of PPE.
Other safety issues identified during the investigation also leading to recommendations:
1. The revised method of securing the bowsing tackle tail rope to the ‘yellow bar’ welded to the lifting plate is potentially unsafe. The bar is an undocumented modification, there is no evidence it has been subjected to a load test, and it may well be unfit for the purpose for which it is now being used.
2. There is variation in the procedures promulgated on board for releasing the tricing pennants, which can cause confusion. Releasing the tricing pennants after the passengers have embarked in the lifeboat can lead to overload of the tricing pennant
and equipment failure. There should be uniformity in the operating procedure instructions.
3. Post-accident instruction promulgated by the ship’s manager, requiring the Saga fleet to operate the bowsing tackle and tricing pennants from within the lifeboats, cannot be achieved safely in all cases. The instruction is confusing and should be re-issued with clarification in respect of the required operating procedure.
4. The programmed training schedule for the “Lifeboat Preparation Teams” was intended to include the lifeboat crews but this was not made clear. It should be unambiguous that the training relates to both the preparation team and lifeboat crew.
5. The Certificates Checklist, which identified training needs, did not include lifeboat preparation and crew training requirements.
6. There is no evidence that the paint contaminated, webbing jacklines fitted to the roofs of Saga Ruby’s tenders to which the crew attach their safety harness tethers, have undergone any formal design consideration or load-testing. There is a risk that a shock-loading may cause the securing eyebolts or jackline to fail.
Safety issues identified during the investigation which have been addressed or have not resulted in recommendations
1. Neither the fourth officer nor the first cook wore a safety harness and tether despite working at height.
2. It was not possible, nor was it intended for a crew member standing inside a lifeboat, to operate the bowsing and tricing gear through the coach roof hatches.
3. The only satisfactory way of accessing the bowsing tackle and tricing pennant arrangements was by standing on the coach roofs of the tenders and on the stem and stern compartment roofs of the open lifeboats.
4. Neither the Malta administration’s FSI Reports, nor GL’s Survey Statement identified the omission of non-skid surfaces from the tender coach roofs or the open lifeboat stem and stern compartment roofs.
5. The use of the oversized bowsing tackle ropes identified in Palermo compromised safety because they jammed in the bowsing blocks and did not allow the rope to be properly secured to the bitts. Despite the master’s instruction to change them, it was
not fully implemented.
6. The amount of refit work undertaken by contractors on the passage to Southampton and the refit-related work undertaken by the crew, both in Palermo and while at sea, impacted on the availability of the crew for training and the quality of the training.
7. The delays in the refit completion date and the late delivery of the overweight lifeboats to the ship resulted in multiple changes to the muster/emergency plan, which had a negative effect on training continuity because of changing training needs.