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And that catch can kill
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We'll call them Jim, Karl, Leo, Mike, and Nick. Not their real names but they were real people and two of them are dead.
Jim was the junior of two chief officers. He'd only just been promoted. Karl was third officer, Leo was Fourth Engineer, Mike was a deck cadet and Nick was the bosun.
The Valparaiso Star was a 141 metres length overall reefer of 8,945 gross tonnes Bahamas-registered, and classed with Det Norsk Veritas. She was equipped with two twin-fall totally enclosed lifeboats, Pesbo models BSC25M-05, at a time when lifeboats were not required be self-righting or their hatches to be watertight. Those requirements came in with LSA regulations in 1998 and it was now 2005, seven years after the new regulations had effectively made them obsolete.
Pesbo BSC25m Lifeboat
The Valparaiso Star was docked at Setubal, Portugal and, as part of an internal audit, an abandon ship drill was ordered. It began at 07.45. Fifteen minutes later the crew was mustered ready to lower the portside lifeboat. Jim and the senior Chief Officer carried out safety checks then later personal safety gear was checked for those boarding the lifeboat.
That personal safety gear included fixed flotation lifejackets, the kind that doesn't inflate.
By 08.15 Jim, Karl, Leo, Mike, and Nick were aboard the lifeboat with Jim as Coxswain. Jim started the lowering from inside the lifeboat. It's recommended practice to release the lifeboat winch brake from inside and let it go but, like many seafarers, and with good reason, he didn't entirely trust the system so he had a crewman in deck controlling the brake.
Two minutes later the lifeboat davits reached the outboard rest position.
As the lifeboat fell, the forward hook arrangements
tore through the hull.
There was a loud bang and the stern of the lifeboat dropped as its on-load release hook failed. The boat fell aft-end first towards the water, then the forward hook fixings ripped away and she hit the water stern first and end on, the aft hatch shattered. She toppled over and came to rest upside down settling by the stern.
The lifeboat floats upside down shortly after the fall
Jim, Karl and Leo reached a small air pocket in the forward end of the upturned lifeboat. There was no sign of Mike or Nick.
Members of the Valparaiso Star jumped into the water to help but there was no access point above water, there was no way of reaching the men inside. They tried in vain to right the lifeboat. Attempts were made to use the ship's provisioning crane to right the lifeboat, but that, too, failed.
Crew from the Valparaiso Star try in vain to right the 1.9 tonne boat.
Inside the lifeboat, the men could hear the voices of those outside trying to right the lifeboat and could see light coming through the broken side-hatch of the vessel.
Rescue efforts continue as the capsized lifeboat is towed
alongside the Valaparaiso Star.
Leo took off his lifejacket, swam down to the broken hatch and escaped. Jim tried to persuade Karl to do the same but he refused. Jim took off his lifejacket, too, assured Karl he would get help and followed Leo out of the lifeboat. It is now ten minutes since anyone had seen Mike and Nick.
Jim and Leo have escaped but Karl, Mike and Nick are still inside as the ship's provisioning crane attempts to lift the lifeboat but fails.
After another two minutes, the harbour pilot boat, a fishing boat, some divers and a small leisure boat moved in to help and managed to release Karl.
Finally, a gantry crane was brought into play and managed to lift the lifeboat by its stern to expose the access hatch and Mike and Nick were take out. It was now 15 minutes since the lifeboat capsized. They were dead.
A gantry crane is brought in and lifting operations begin
Surprises and time travel
To work out what happened we need a few bits of surprising information and a touch of time travel.
Prehaps the first piece of information you should know is that on-load release accidents comprise about 16 percent of all lifeboat accidents but produce 60 per cent of the fatalities.
The on-load release hook on the Pesbo lifeboat featured a metal pawl that fitted into a notch at the back of the hook itself to prevent it opening under load. It was operated by a lever inside the lifeboat that was used to both open the pawl and allow the hook to come free of the falls when waterborne and to reset the mechanism for recovery. A second lever could be used to open the hook if it didn't free itself automatically.
Metal pawl (3 on left) is released by lever (8) on right
Another surprising piece of information is that the manufacturer's safe tolerances for the pawl were as small as two millimetres, about the width of a matchstick. A few licks of paint and that critical clearance vanishes. It's hard to see how such tolerances can be reliably maintained in the rugged marine environment.
Manufacturers recommended tolerance at B
is just 2mm, the width of a matchstick
Although Pesbo claims that its fitting are made of non-corrosive materials, and therefore don't need painting – although it doesn't say so in its manual - the hooks on the Valparaiso Star had been painted. There were also signs, in the BMA's opinion, that suggested to investigators that the hooks had not been adequately maintained.
The aft on-load release hook after the accident. Note heavy paint
and apparent lack of visibility of release mechanism.
A second surprising piece of information: There is no way of checking whether the all-important pawl is properly set from inside the lifeboat. It is assumed that if the lever is pushed home, so is the pawl. There is no easy way of visually checking whether the pawl is actually safely set in position.
Aft (left) and foreward (right) hook arrangements on lifeboat
Surprise number three, or perhaps it isn't a surprise: there was no provision to provide maintenance for the lifeboat without putting it in the water, where even a little bit of chop can make working on the boat difficult and the falls hard to attach. There are no hanging off arrangements from which the boat can be supported.
Forward release system, notice limited space
The Pesbo design appears itself to increase the chances of hooks being wrongly set.
Now for a bit of time travel. It's 6 August 2001 in Wellington, New Zealand and a Pesbo BS99M partially enclosed lifeboat is launched from the 12,596 tonne passenger and freight ferry Aratere. A different model lifeboat but its hooks have the same sort of pawl arrangement as those on the Valparaiso Star.
Passenger freight vessel Aratere
Aratere's lifeboat lowered
After driving the lifeboat around for a whilethe third mate in charge of the lifeboat brings it back to the Aratere for recovery. Together with three ABs the third mate fixes the falls back on the hooks. Both hooks have to be closed at the same time and it's difficult because of the slightly choppy seas.
The Aratere lifeboat hook release (above) and the on-load release system (below. Note the security brake pawl as on the Valparaiso Star). Note this model appears to have hanging-off arrangements.
It does seem that these lifeboats are only supposed to be recovered when the water's as smooth as mirrored glass.
The Third Mate tells the AB inside the lifeboat to push up the on-load release level, which he does with a bit of effort.
About a metre above the water the Third Mate stops the davit winch to test the brake. Immediately the forward hook on the lifeboat fails, dropping the bow into the water. Fortunately, nobody was injured, this time.
What had happened was that the hook had not been properly set and the pawl was pushed not into the notch it was designed for but hard against the hook, kept in place by the pressure of the lever arrangement. As on the Valparaiso Star, it was hard to see whether the pawl was in place or not.
Another amazing bit of information: The crew aboard the Aratere knew that this happened from time to time and that the lifeboat could be raised in that unsafe condition. In this case the jerk of the winchbrake braking was enough to open the hook and drop the boat.
The Britannia P&I Club's Riskwatch publication identifies yet another lifeboat incident, with the same causes, a year after the Valparaiso Star incident.
So, back to the Valparaiso Star. Here's my guess as to what happened.
After its previous launch on the 21st of June, the hook was not properly set and the pawl was left pressed against the hook with just enough pressure to keep the hook closed and allow the lifeboat to be recovered.. It remained in that condition until the 15th June when the davits moved to the outboard position for another launch and came to a stop with a jerk much like that which opened the Aratere's hook several years before.
This photograph shows the pawl on the Valparaiso Star lifeboat as it may have been during the launch (Soutrce: Britannia P&I Club Riskwatch).
And the rest you already know.
We'll be looking in depth at lifeboat safety in a future episode but the fact is that the situation is insane.
In an era which has seen radical change in navigational technology like ECDIS, GPS, AIS, and fundamental changes in how the industry operates with the introduction of containerisation and Ro-Ro, lifeboats have hardly advanced since the Titanic disaster in 1912.
Don't take my word for it. In 2001 Britain's Maritime Accident Investigation Branch had this to say: "Although the designs of lifeboat launching systems have developed over the years, many manufacturers have felt unable to offer innovative changes in design. Ship-owners have, for their own reasons, been unwilling to implement or finance any fundamental changes. As a result, the development of lifeboat launching systems has been.incremental, slow and usually in response to changes in legislation."
In March 2006, a devastating report commissioned by the UK's Maritime and Coastguard Agency, known as Project 555, said: "manufacturers of ships’ lifeboats appeared to decide not to co-operate with the study... Since the objective of the project is to identify design improvements contributing to the prevention of accidents, this shortfall in project output seems likely to delay design improvements and means that some preventable accidents are not prevented, thereby putting seafarers’ lives at risk unnecessarily. Given these circumstances, we do not understand the ethics of the manufacturers’ unwillingness to cooperate."
And neither do I. There are links to the Project 555 and MAIB reports on the Maritime Accident Casebook website, prehaps you can figure it out.
There are too many different designs of twin-fall hooks and release systems, more than 70 of them and some are downright dangerous. All are too complex, there are no functional standards as there are in other industries. There is little political will and little commercial pressure to make launching and recovering lifeboats safer and seafarers alive.
And that's not the ultimate madness. A lifeboat is, in fact, a people lifter, like an elevator or lift. But if you get into a lift on the 30th floor of a building and something goes wrong you don't fall 30 floors to your death, the lift stops because it's designed so that of something goes wrong people don't get hurt. It's called 'fail-to-safe'.
Lifeboat on-load release systems are designed to do exactly the opposite – to drop the boat if something goes wrong. Effectively, they're designed to kill, to 'fail to damned dangerous”.
Indeed, there is a systemic problem when it comes to lifeboats, and it isn't just the manufacturers to blame.
Over a three-month period in 2005 which ended the same month the men on the Valparaiso Star died, Australia's Maritime Safety Authority carried out a ship inspection campaign that focussed on lifeboat issues. Of 718 ships inspected 320 had something wrong with their lifeboats, 'deficiencies' in industry jargon. Just as worrying. the International Maritime Organisation had issued a circular on lifeboat safety in December the previous year but 102 of the ships inspected hadn't even heard of it and in 20 cases key personnel on board didn't even seen to know what actually was laid down in the ship's Safety Management System.
The offshore industry has had much more success because there is a recognition of the problem and projects like Step Change encourage a pro-active response to them.
Freefall lifeboats are an inherently better and safer option than twin-fall systems but what is really needed is a radical new thinking on ship evacuation.
Why are seafarers' lives considered less important that those of workers in the offshore oil and gas industry, which has a far better safety record and a more pro-active attitude when accidents do happen?
Life and LSA
In its report in the Valparaiso Star, the Bahamas Maritime Authority identified several elements of the Pesbo lifeboat itself that allegedly fell short of the mandatory Life Saving Appliances Code. The LSA Code demands that lifeboat access doors be watertight, the ones on the Pesbo lifboat appear not to have been watertight.
The Valparaiso Star lifeboat ashore. Note sliding windows through which survivors escaped.
The LSA Code requires that lifeboats in such conditions should be self-righting, but this lifeboat obviously did not.
There is also a requirement that there should be a clear indication of whether the on-load hook release is properly set. This was obviously not the case with the lifeboats on the Valparaiso Star nor, earlier, on the boat aboard the Aratere.
Why were the lifeboats allowed on board? Because they had been designed and installed before the LSA Code came into force in 1998 and therefore escaped those requirements.
Maritime Accident Casebook asked Pesbo whether any changes have been made to this model of lifeboat since 1998. Pesbo says that no significant changes have been made.
Pesbo has not yet responded to questions about the issues raised inn the report on the Valparaiso Star, if it does so we'll let you know.
Pesbo no longer manufacturers lifeboats but some 3,000 were made of different types. The company still promotes the BSCM25 model on its website, with sliding doors and the same on-release hook system. It claims these meet the requirements of the LSA Code.
In fact, the lifeboats passed inspection by the ship's classification society, by flag state inspectors, and by port state control inspectors. So the checks and balances that should have ensured seafarer safety failed.
One has to sympathise with those masters who are so reluctant to put lives at risk that they log lifeboat drills that didn't take place. But one can only condemn those in the AMSA study who claimed that lifeboat davits had been maintained when they clearly had not been.
There is one other factor in the deaths of Mike and Nick: They did not follow the procedures laid down in the ship's Safety Management System, which require that a lifeboat should be lowered and raised on its falls unmanned before putting crew aboard for a drill.
Clearly, whatever training the men on the Valparaiso Star had been given with regard to lifeboats it was ineffective.
You don't have much say in what lifeboats and release systems are used on your ship so for now we have to make the best of a very, very bad job. Be pro-active, look, ask questions, get answers.
Do you know what lifeboat procedures are laid down in your ship's safety management system? Make sure you do.
Your lifeboat will have an on-load release hook with some sort of safety catch. Do you know how it works, not just which levers to pull but the principles it uses? That knowledge could save your life.
Can you directly see if it is properly set? Don't trust a remote release lever. Go and see it with your own eyes.
Is it possible to devise some sort of visual confirmation, like witness marks, that will show whether it is properly set or not?
It does make sense to use an alternative method of suspension as a back-up if the falls or hooks fail such as maintenance shackles.The Bahamas Maritime Administration report strongly suggests using polyester suspension for hanging-off which can be cut free easily in an emergency. Some classification societies, and the IMO disagree but there is a loop-hole in the regulations that allows masters to take 'special precautions'.
There are two precautions that might have kept Mike and Nick stay alive even when the hook failed.
First, they should have carried, not worn, their lifejackets into the boat. Do not wear permanent bouyancy lifejackets into a totally enclosed lifeboat, they make moving around difficult and there's the chance of inadvertently moving a lever. A permanent bouyancy lifejacket is no value whatsoever inside a totally enclosed lifeboat and can be more dangerous than none at all.
It is possible that, if Mike and Nick were still alive after the fall, they were trapped underwater by the bouyancy of their lifejackets and drowned. Those who survived the Valparaiso Star fall had to remove their lifejackets to escape.
Carry your lifejackets into the boat.
They should have strapped themselves in to their seats. Strap yourself in. There's far less chance of being killed or injured if the lifeboat does fall. Keep the lifejacket on your lap because seatbelt are not designed to accomodate them.
And, of course, always wear a hard hat, properly fitted. Hard hats have saved other seafarers' lives in lifeboat accidents and could well save yours.
So, wear a hard hat, carry your lifejacket, strap yourself in.
At least then you'll have a chance. And remember the SMS, the line between those who live and those who die is usually drawn between those who follow the rules and those who don't.
If you'd like to comment on this or any other Maritime Accident Casebook Episode just email firstname.lastname@example.org or leave a post at http://maritimeaccident.wordpress.com. To make it easier try downloading the Maritime Accident Casebook toolbar.
This is Bob Couttie wishing you safe sailing.
ATSB Safety Bulletin 03