The Case of the Deadly Saviour


Where is the most dangerous place on your ship? The cargo holds? The chain locker? The galley? The rolling deck in a storm?

No, according to the UK’s MAIB and other organisations, it’s the lifeboat.

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Lifeboat-related deaths and injuries are more common than those in man overboard incidents and about the same as deaths and injuries in enclosed spaces.


Exterior and interior of lifeboat following accidental fall. Not from the Cape Kestrel (Courtesy ATBS)

But here’s the rub. Seafarers fall overboard or enter unsafe spaces in the normal course of their work. Every single lifeboat death and injury is incurred during drills to ensure that the dead and injured seafarers knew how to use the lifeboats.

If you compare the number of hours spent in cargo holds and other enclosed spaces, and time spent on deck with the handful of hours spent in lifeboat drills the risk in lifeboat drills is several orders of magnitude greater. One can only wonder what those rates might be when lifeboats are used for real. Scary isn’t it?

Here’s this week’s episode:


The People

As usual the real names of the people involved in this episode aren’t important, so we’ll call the Master Frank. He’d been a master for 30 years, it was now 2001 and his current vessel was the Cape Kestrel.

The Mate, we’ll call him Steve, had joined the ship three months before, he’d only got his mate’s license that year and his assignment to the Cape Kestrel as Mate was a promotion.

The Chief Engineer, Bill, joined the Cape Kestrel in August 25, 2001, about five weeks before the incident.

Tony, the First Engineer joined the ship in February, 2001.

The Shipcape-kstrel.jpg

The Cape Kestrel

The Cape Kestrel, is a bulk carrier with a complement of 21 officers and crew.On October 11, 2006, she anchored 16 miles off the coast of Dampier, Western Australia to wait for a cargo of iron ore bound for China.

The Lifeboats


Cape Kestrel portside lifeboat

The Cape Kestrel was equipped with two davit-launched, twin fall, 26-man totally enclosed lifeboats. Each lifeboat was six and a half metres long, 2.4 metres wide and weighed nearly three tonnes unladen, getting on for five tonnes fully laden, with a cockpit dome so the coxswain could see out and a forward hatch window. The lifeboats were designed to be boarded in the stowed position from an embarkation platform. As a safety precaution, limit switches were installed to switch-off the winch and prevent the davit arms coming up against stop on the davit frame and cauing damage. The lifeboats were tested once a week and there had never been a problem.

The Drill

The next morning, October 13, the weather was clear and the seas calm with a swell of around 30cm. Frank decided to hold a lifeboat drill and discussed it with Steve over breakfast. When they’d finished, Steve told the bosun to prepare the lifeboat for lowering. The second engineer went to the starter panel for the davit winch, which was in the rather noisy air conditioner room ,and made sure there was power to the winch. He went to the davits and checked that the power indicator on the remote hoist control was lit.

Everything was ready for the drill. As Frank watched from the bridge, Steve, together with the third mate, the bosun, who d prepared the boat for launch, the second engineer, who d checked the power to the winch and the remote control for the hoist, and an ordinary seaman stepped onto the embarkation platform in their lifejackets and hardhats, entered the lifeboat, strapped themselves into their seats, and Steve secured the hatch.

At around 08.45 Steve activated the release inside the lifeboat and she moved out and down to the water. Once in the water, the lifeboat crew unstrapped themselves, went out and released the lifeboat from the falls, and fore and aft painters secured the lifeboat alongside.


Diagram of the Cape Kestrel Lifeboat davit arrangement

On the deck of the Cape Kestrel, two seamen greased the falls and the sheaves on the davits and an AB stood by with the remote control for the hoist and a handheld radio.

It took about 30 minutes to test the lifeboat engines and check her out, then she was reattached to the falls. Steve called Frank on his walkie-talkie that the boat was ready, Frank told him to hoist the boat, then told the AB by radio to recover the lifeboat.

Meanwhile, Steve strapped himself into the coxswain s seat and the Third Mate and Second Engineer strapped themselves beside each other in side amidships positions to port. The bosun was at the forward end of the boat, the Ordinary Seaman was seated to starboard, neither of them secured.

What Goes Down Doesn’t Come Up

The AB pressed the button on the remote control. Nothing happened. He told Steve on the lifeboat there was a problem. By now the lifeboat was rolling in the swell and putting tension on the falls. Steve told the AB to talk to Tony, the first engineer. Tony went to the starter panel in the air conditioning room. A circuit breaker had tripped. Tony reset the circuit breaker. The AB tried the remote control again but the circuit breaker tripped once more.

There was no electrician on the ship and none of the engineers knew much about the circuitry of the lifeboat. Tony told Steve they d have to lift the lifeboat manually with the winding handle.

The AB turned the winding handle but the process was taking a long time. Tony spoke with Steve on the radio, he thought it might be possible to locate the problem with the remote control.

Tony told the AB to listen for unusual sounds from the winch, so he stopped hoisting and did as he was told but there weren t any odd noises from the winch. The noise came from Steve who wanted to know why the hoisting had stopped. Tony told him he d power up the winch at the lifeboat starter panel in the air conditioning room since there seemed to be something wrong with the electrical circuit.

Tony told the AB to alert him when the boat was at main deck level because he couldn t see it from the air conditioning room, then physically pressed the contactor in the winch-motor starter box.

Heading For A Fall

The lifeboat lifted from the water. Frank gave orders that the crew should disembark at the main deck.

When the lifeboat reached main deck level the AB alerted Tony, who let go of the contactor and the winch stopped. Steve, opened the hatch and looked out. He told Frank that the lifeboat was too far from the main deck for its crew to disembark. Frank told Steve to bowse the lifeboat against the side of the ship. Steve and Frank argued. Frank had never allowed the lifeboat to rise beyond the main deck level when hoisting because he didn t trust the limit switches.

Steve pointed out that the boat was designed to be disembarked at the embarkation deck and told Tony to continue hoisting.

The lifeboat had already been hanging in the air for 15 minutes, the first engineer didn t consider the situation allowed time to resolve the problem with the remote control.

Bill, the chief engineer, heard the discussion between Steve and Tony, went down to main deck. Tony told him that the breaker kept tripping and Bill watched as Tony operated the contactor.

Steve knew about the limit switches on the davit arms that would automatically stop the winch so it should have been a safe maneouvre. Unknown to him or Tony, pressing the winch contactor manually by-passed the limit switches and every other electrical safety interlock.

Tony pressed the contactor and listened in the noisy air conditioning room for the noise made by the lifeboat when it was swung in toward the embarkation deck. To Frank, watching from the bridge, the lifeboat seemed to be coming in too fast and the limit switches did not seem to operate.

The arms of the davits came up against the frames with a noise that could be heard inside the bridge. In the air conditioning room it sound like a drum. The winch still turned. In the split second the steel strands on the forward falls thinned like stretched toffee and snapped. The davits dropped outwards.

The lifeboat bow dropped towards the sea, for a moment the aft falls held, supporting the boat vertically, then they, too, parted and the boat plunged 20 metres to the water below.

As she hit the surface the forward hatch window shattered, water poured in until the boat righted herself.

The second engineer was thrown on top of the OS on the starboard side, both were injured the third mate s head was smashed against the boat, his hardhat was shattered but, despite injuries to his forehead and above one eye, he lived. He got to the bilge pump and started pumping water out of the boat. Steve was slumped in the coxswain s seat, semi-conscious, eyes half open. Only the bosun was unhurt. The bosun and the OS moved the mate to make him comfortable, he was in great pain, then the OS had to rest, he was hurting, too. The second engineer went back to his seat and was sick.

Later, the injured men were evacuated by helicopter. Thanks to his hardhat, the third mate was able to rejoin the ship before it sailed. The second engineer and the OS were repatriated to their homeports. Steve was hospitalized in Australia with a broken pelvis and damaged eye socket for four months.


The fall fractured the Third Mate’s hardhat, not his skull

They were lucky to be alive.

The Lessons

A year ago, the Safety of Life At Sea, SOLAS, convention was altered so that seafarers no longer have to be inside lifeboats when they’re launched and recovered during drills, but there’s still a long way to go on lifeboat safety.

We ll be looking at other lifeboat issues again in future episodes of the Maritime Accident Casebook so I ll just talk about this one incident.

If Steve had listened to Frank and disembarked at the main deck, the lifeboat might still have fallen but nobody would have been injured. Some masters refuse to allow crew to be in the lifeboat during recovery and launch, embarking and disembarking them by ladder from the ship s deck. Others fix maintenance tackle during launch and recovery with a crew onboard to back up the falls in case they break.

The trigger for the accident was the failure of the remote control, or, more accurately, the tripping of the circuit breakers, but the engineers lack of knowledge of how the safety-critical electrical systems worked was a key element, a card in the house of cards, that led to the accident. The Chief and First Engineer may have made different decisions if they d known that manually pushing the contactor by-passed the safety systems.

They might, and should, have stopped the electrical hoist before contact was made with the limit switches then continued the recovery using the winding handle.

It is in the mindset of engineers to solve problems, and engineers are good at it, but it’s important to know what problem to deal with. In this case the perceived problem was ‘how do we get the lifeboat up?”, the real problem was why the remote control did not work. The engineer solved the problem of how to get the boat up, at serious cost.

If you re an engineer, ask yourself how the safety-critical electrical circuits work on your vessel, especially the lifeboats and make sure you know the answers, particularly if your ship doesn t carry an electrician.

As is often the case, the equipment itself was trying to send a message. Why didn t the remote control work? Because the circuit breakers activated. Why did the circuit breakers activate?

No reason was ever found for the failure of the remote control or the tripping of the circuit breakers.

When the falls were examined and tested it was found that below their layers of poor condition grease and hard particulate contamination they had suffered corrosion that reduced their effective working load by 20 per cent although they were well within their certificated working life. Their condition would have put more strain on the winch, which would have needed to draw more power to wind them.


Snapped falls and closeup of corrosion

The circuit breakers were designed to trip if the winch drew too much electrical load.

After the falls were replaced the remote control worked perfectly, the contact breakers did not trip. There was nothing wrong with the circuit. My guess, although it s not explicit in the official report, is that the breakers tripped because the winch had to draw extra power to recover the badly corroded falls.

The failure of the remote control was a symptom, not a cause. It was a message no-one was really listening to.

Another message, prehaps, is look after your lifeboat because one day you may need it to look after you.

If you have have opinions on this, or any other Maritime Accident Casebook, episode, or want to share your experiences, go to or drop me an email at

This is Bob Couttie wishing you safe sailing.

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