The Case Of The Fallen Saviour


Compared to other launch systems,
free-fall lifeboat accidents are relatively rare.
This one was just a drop in the ocean.

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Maersk Pomor

We’ll call him Ivan, not his real name but he was a real person, the 3rd Engineer aboard Maersk Pomor in January 1998 when it arrived at the port of Gladstone, Queensland, Australia. Like the rest of the 19 crew provided by Polar Crewing of Murmansk, he was Russian.

His ship, the Maersk Pomor was a four years old, 48,000 tonne dead weight geared bulk carrier owned by NB Shipping of Nassau, Bahamas, where she was flagged, and managed by NB Maritime Management AB of Helsingborg, Sweden. Most important for our story is that above her poop deck, supported on an inclined ramp, was a totally enclosed free-fall lifeboat, entered through the stern and held in place by a hydraulically operated hook.

Hook release wheel, note steel bolt to prevent accidental use.

To activate this type of release a pin has to be removed from a stainless steel bolt which passes through the spokes in the wheel to stop them turning. Typically, a hydraulic valve must be checked.

On the coxswain’s chair were stencilled the words “Chief Mate”. So we can assume he knew where to sit.

In front of the seat were the main lifeboat controls, including a small black wheel. Beside the seat was a spoked wheel positions fore and aft.

All launch instructions are in English but there are pictorial signs indicating that it is a hook release.

You’re probably familiar with this sort of lifeboat, you might have one like it on your ship.

An Inspector Calls

Now let’s go to the morning of 2nd January 1998. The ship has been loading coal bound for India since the previous day. A surveyor from the Australian Maritime

Safety Authority comes aboard to conduct a Port State inspection.

He checks the ship’s certificates and the officers’ qualifications. Every is in order. Next he wanders around the ship checking out its equipment accompanied by Ivan, the second mate and the electrical engineer.

Hook release warning sign

It’s about 9.45 when the surveyor and the group reach the lifeboat.

The surveyor wants to see the engine running forward and astern so Ivan climbs into the lifeboat, leaves the door open, and starts the engine. and the surveyor’s satisfied. Ivan stops the engine.

Heading for a fall

Ivan is still in the lifeboat when the surveyor wants the rudder to be turned to port, then to starboard. As he gives his instructions he points to the rudder, then to port, then to starboard.

Lifeboat controls. Written on the coxswain’s seat “Chief Mate”

Ivan tries to turn the spoked wheel beside the coxswain’s seat. It doesn’t move.

The surveyor repeats his request. The electrical engineer and the third mate speak to Ivan in Russian. Ivan looks around the boat for something then restarts the engine and tried the spoked wheel again. This time the wheel turns, but the rudder doesn’t.

Without warning, the lifeboat slides down the ramp and hits the water with an enormous splash. There’s a brief glimpse of Ivan lying on the bottom boards of the lifeboat before the door slams shut.

The AMSA surveyor calls for the ship’s rescue boat to be lowered then hurries down to the wharf, asks a trucker to call for an ambulance and prepares to swim out to the lifeboat, now drifting 150 metres away.

After calling for an ambulance, the trucker also prepares to swim out with the surveyor but before they canget into the water there’s a shout from the ship – the rescue boat has been launched with the electrical engineer, the mate and a welder.

The electrical engineer and welder get aboard the lifeboat. Inside, Ivan is conscious, in pain and can’t move. The electrical engineer operates the lifeboat and brings it to the wharf as the welder tends Ivan.

Two ambulances arrive and paramedics check Ivan. He’s got mild concussion, superficial lacerations to his scalp and complains of pain in his lower back, the lumbar region. He’s strapped to a stretcher and trucker lifts him onto the wharf with the supplies crane on the back of his truck.

In the hospital at Gladstone, Ivan is discovered to have a crush fracture of the first lumbar vertebrae and pieces of the vertebrae have penetrated in his spinal canal. Put simply he’d broken his back and his injuries had the potential to cripple him for life.

Putting the pieces together

There are two different explanations for what happened, both involve confusion and neither speaks well of the ship-board training regime. Obviously Ivan turned the spoked wheel, but did he know what he was doing? Did he really intend to release the hook? Or did he think that the hook release was, in fact, that steering gear.

First, let’s look at what we do know:

The lifeboat’s coxswain seat had Chief Mate stencilled on it. That suggests that few others, if any, were expected to know how to operate the lifeboat.

Ivan had been aboard for 10 and a half months. Lifeboat drills should have been carried out every month as part of abandon ship drills and the lifeboat release mechanism itself should have been tested every three to six months with a restraining strop or maintenance wire fixed to prevent it from launching. At most he could have undergone nine or 10 abandon ship drills and at least one, and two tests of the lifeboat release mechanism but it seems unlikely that he had much, if any, experience of actually operating the lifeboat release gear, especially if the Chief Mate was the only one in the coxswain’s seat.

Written instructions were in English. The crew were Russian and that was undoubtedly their working language. That Ivan needed an interpreter suggests that his English fluency was limited and confusion possible. In fact, one survey concluded that almost 1 in five maritime accidents involve failures of communication.

Just below the spoked wheel was a blue and white warning sign saying “Release Falls”, showing a hook being released from the eye of a davit ring. That dissonance, so to speak, between the sign and the way the lifeboat was actually launched could have caused a ‘disconnect’ in understanding that made the sign to be irrelevant to the task at hand, especially if the person was not familiar with the launch mechanism.

When the spoked wheel didn’t turn initially both the electrical engineer and the 2nd mate spoke to Ivan in Russian. They could see what he was doing but don’t appear to have been aware of the dangers it presented.

No restraining strop or maintenance wire was fitted for the inspection. That itself shows that safety awareness wasn’t very sharp. They must have been fitted if the release mechanism was being tested regularly, but it didn’t occur to Ivan, the 2nd Mate or the Electrical engineer, to take that basic safety precaution.

Then there’s that spoked wheel. At first, Ivan could not move it. The electrical engineer and the 2nd mate gave him some sort of advice in Russian, we don’t know what that was, then he started the engine and moved the wheel, but there was no interlock between the engine and the spoked wheel. Ivan must have removed the retaining pin of the safety bolt and released the safety bolt. Had they not been in place initially, then Ivan could have turned the wheel when he tried it the first time.

Do What?

The question is, what was he trying to do?

Investigators for what was then the Maritime Incident Investigation Unit believe he was trying to follow the surveyor’s instructions to move the rudder and mistook the release wheel for the steering wheel. They argue “Although the fact that the 3rd Engineer restarted the engine could indicate that he was in fact following the launch procedure, he should have known that operation of the release gear without the lifeboat being secured by other means would result in the launch of the lifeboat. Also, that he would contemplate a launch with only himself in the boat and without securing himself in the coxswains seat is incredible and difficult to accept. More likely is the supposition that, having not been able to turn what he thought was the steering wheel, the 3rd Engineer restarted the engine on the chance that the steering was power assisted. .. It is also difficult to accept that the Surveyors requests, made as simple, one word directives, accompanied by pointing gestures, could be misinterpreted as meaning test the release gear. ”

According to the electrical engineer, who spoke to Ivan both in the lifeboat following the incident and in hospital later, it was impossible for Ivan to operate the engine and other controls while sitting in the coxswain’s seat in its launch position and he is right and it’s a problem with this type of design.

For launch, the coxswain’s seat is inclined backwards so that the coxswain is looking at the ceiling. He cannot operate the engine or steering controls from this position and can only reach the spoked release wheel and it’s difficult for him to move the seat unto the post-launch position. It’s an arrangement that has been the subject of criticism.

While laying injured in the lifeboat, Ivan told the electrical engineer that he had fulfilled exactly the first command of the surveyor to turn the rudder to starboard, using the steering wheel. But did not hear the next command to put wheel to port because of the noise of the engine. He had seen pointing gestures of Surveyor and thought that he had pointed to the spoked wheel and wanted him to test the Release Gear. Ivan believed that the lifeboat had been secured with a strop or maintenance wire. The electrical engineer says Ivan understood clearly what he was doing.

Memories of startling events are often unreliable . We cannot know what Ivan was thinking at the time of the accidental launch, perhaps not even Ivan himself and he was suffering concussion when he gave his account.

In fact, it hardly matters. No matter who’s right, Ivan and the crew hadn’t been adequately trained in freefall lifeboat safe handling procedures.

If the surveyor and investigators are right, then Ivan and the others hadn’t been adequately trained in, or drilled in, the lifeboat’s controls and didn’t know the difference between the release wheel and the steering wheel.

If Ivan and the electrical engineer are right, then none of those on the platform had been adequately trained in, or drilled in, appropriate safety measures.

Avoiding a drop in the ocean

So what can you do? It depends on two things, your position on the ship and your determination to be pro-active about safety and encourage your shipmates to be safe, too.

Look at the lifeboat on your ship. Talk with other crewmembers, find out how much they know.

If you have a freefall lifeboat on your ship, learn how it works. Take notice of what’s going on during drills and tests of release gear. It isn’t rocket science and in a real emergency there’s a possibility that the person designated to be coxswain wont be able to do the job.

It was obviously possible to test the release gear, and to carry out abandon ship drills, without the coxswain’s seat being occupied. It’s not a good idea, and in the case of this kind of arrangement, in which critical controls aren’t available when the seat is in the launch position you’d better make sure you know what to do about it.

If you don’t, positively, know what a control is for, leave it alone.

A wise master won’t just depend on minimal mandated drills to ensure that his crew know how to use lifesaving appliances. Think about occasional show and tells in the mess or recreation room.

If the majority of people on your ship share and commonly communicate in a language that isn’t English look out for safety-critical signs that are only in English. Make sure crew can understand them and it’s a good idea to put up translations of the signs. In a crisis people’s fluency in a second language can fall dramatically.

People sometime think very literally so make sure that pictorial signs match the equipment. A hook coming off a davit ring is not an accurate portrayal of what happens with a freefall lifeboat.

Obviously, communications were an issue in this case. When given an instruction its a good idea to repeat it back to the person giving the instruction to ensure you’ve understood it. If you’re giving an instruction make sure the person you’re giving to repeats it to you. That way you both know its been understood.

This is a situation in which a briefing would have been a good idea, and something that the surveyor should have done before Ivan got into the lifeboat or the second mate, electrical engineer or Ivan could have initiated. That briefing should have covered what Ivan was expected to do and what safety arrangements were in place.

If that briefing had been carried out, I probably wouldn’t be telling you this story.

Current IMO rules and regulations on the use of restraining strops or maintenance wires on lifeboats are shortsighted and have led to the frequent deaths of seafarers, but they are the rules. If you’re going to get into a lifeboat, whether it’s freefall or davit launched ask yourself ‘is this a drill?” if the answer is “no”, fit a restraining strop or maintenance wire to avoid accidental launch.

You might get it wrong, but it’s easier to apologise for fitting a safety device when the rules say you shouldn’t than console a dead crew members family.

This is Bob Couttie wishing you safe sailing.

Relevant Posts

Free Fall Lifeboat Hazards – A Drop In The Ocean

Training Resources

IDESS Interactive Technologies offers a modestly-priced separate module on lifeboats:

Survival Craft and Rescue Boats.

Freefall Lifeboats