Volume 13: Number 4: October 2006

Safety - lifeboat special

New research provides a different perspective

Loss of life and serious injury arising from lifeboat accidents continues to feature regularly despite a pattern of such accidents having been apparent for many years.

The IMO has identified several causes of these accidents and by virtue of new regulations under SOLAS (MSC1026) have attempted to rectify the deficiencies in the maintenance of lifeboats and their operation by requiring that certain maintenance and repair tasks have to be carried out by the manufacturer or by a service company licensed by the lifeboat manufacturer. However, a new report issued under the auspices of the UK Marine and Coastguard Agency identifies the design of lifeboat release mechanisms as the main problem.

The Agency instructed Messrs. Burness Corlett – Three Quays Ltd, a well known naval architect and consultancy firm, to study the safety of lifeboats and their launching systems and to recommend improvements for the performance of lifeboat systems in order to prevent future accidents with davit mounted, side launched lifeboats. Their report recognised that poor maintenance, poor crew training and poor implementation of Safety Management Systems were all issues that directly caused or contributed to the majority of accidents. However, a root cause, and therefore the source of a potential solution, was the poor design of lifeboat systems and more specifically lifeboat release mechanisms.

The report pointed to Marine Accident Investigation Bureau data which attributed accidents to the individual parts of lifeboat launching systems. Accidents arising from winch failure, the operation of the falls and bowsing tackle featured highly in the report although no single element was identified as a predominant cause of accidents. The striking feature of the data was the high incidence of fatalities arising from hook release systems' failure; hook-related incidents constituted only 12% of all accidents but caused approximately 60% of the fatalities. Accordingly, the research concentrated on those incidents involving lifeboat hook release systems.

Unexpected or unintended release of lifeboat hooks typically leads to the entire lifeboat dropping uncontrollably into the sea or one end of the boat dropping, with serious consequences for any crew members in these lifeboats. Typically it is not the hook itself which fails but rather the hook release mechanism.

Since 1983 SOLAS has required that enclosed lifeboats have an onload release mechanism. This was an attempt to resolve difficulties that crews had in simultaneously releasing both hooks in the offload position i.e. when the lifeboat was afloat. There are many onload release designs but the report points out that they are all essentially 'unstable' in that the weight of the boat alone, minor vibrations or increase of load, acting upon the hook, tends to cause the hook to open. The operating mechanisms do not force the hook to open but are designed only to release the restraining device, usually present in the form of a cam or stopper. The unfortunate consequence is total reliance on one mechanism, the cam or stopper, which if it fails or is operated in error, inevitably results in unintended and catastrophic release of the life boat. This high risk situation is compounded by designs that result in the operating mechanism for these safety devices being placed at a distance from the actual hooks and the cam/stoppers. In practical terms this means that the crew member operating the release mechanisms cannot easily observe the release mechanism upon which the safe operation of the boat depends.

The contribution of lifeboat manufacturers to the research appears to have been limited but they quite rightly pointed out that many incidents involving failure of hooks resulted from poor maintenance and lack of understanding by the crew of the release mechanism.

Lifeboat servicing companies that contributed to the research stated that the wide variety of different hook types and release mechanisms means that even Class surveyors may not sufficiently understand the way hooks work. Further, they agreed that most operating wires are a frequent source of problems because of seizing, insecure fastening, stretching and incorrect adjustment arising from poor maintenance. As a result, the cams or stoppers acting as safety devices were often not operating properly.

The report acknowledged throughout that the failure of Safety Management Systems on board were compounded by difficulties in maintenance of the release mechanisms, the large variety of designs with which crew might be expected to familiarise themselves, language difficulties, interpretation of poorly drafted manufacturer's construction manuals and a possible general reduction in seamanship skills. The report stated that the highlighting of these deficiencies in IMO and flag state circulars appears to have had little effect in reducing the accidents and resulting fatalities.

The report concluded: that whilst on-load release mechanisms may satisfy current regulations they are inherently unsafe by design and not fit for purpose; that there is no dependable defence against the defects or faults in the operating mechanisms arising from errors by the crew in operating the release mechanisms and therefore concluded that human error was inevitable under the difficult working conditions. It was inappropriate for a critical safety system to be subject to a single human error and that the solution lies in radical redesigns such that hook or release mechanisms would fail to a safe condition.

The report recommends that release hooks which are of an unstable design be identified with a view to being withdrawn and replaced by more stable and safer designs.This is understood to mean that the operator of the lifeboat would have to use positive force to release the hooks in the on-load position.

Perhaps of more practical use for officers and crews, the report recommends that because of the serious nature of the hazard, consideration is given to the immediate implementation of a system whereby maintenance shackles are rigged to bypass the on-load release hooks during the lowering and recovery of lifeboats at the time of mandatory lifeboat drills but are disconnected at all other times. No detailed advice was given as to how this could be safely undertaken. Officers and crews should note that this report is fairly new and we are yet to see the extent to which the authorities will adopt its findings and implement them, particularly the use of maintenance shackles to bypass the on-load release mechanism.

No comfort can be taken from the fact that the report suggests that better maintenance and training of crew will not meaningfully reduce the incidence of regular lifeboat accidents. Indeed, officers and crew should, by virtue of the fact that the report has identified that current designs are susceptible to single human error with catastrophic results, consider this as additional reason to ensure that all officers and crews are made fully familiar, as soon as practical after joining a vessel, with the proper maintenance and operation of the lifeboats as described in the lifeboat manual.

Hidden corrosion causes crew deaths

A Member's ship suffered an accident which provides an insightful reminder of how it is the least obvious and least accessible areas of the lifeboat which can give rise to the risk of catastrophic failure.

The Member's ship was undertaking a lifeboat drill of a fully enclosed lifeboat from gravity-type davits.The boat had been lowered to the boat deck and five crew members had entered into the lifeboat, all properly attired with life jackets. The third mate operated the remote davit brake release from inside the boat. Having lowered the boat 2 or 3 metres the mate engaged the brake in order to test it. The lowering stopped with a jerk and simultaneously a loud bang was heard and the lifeboat's stern detached from the falls and swung downwards, continuing to swing forward, rotating around the forward block. After describing a wide arc the forward hook then opened and released the forward fall. The boat, upside down, then fell into the sea approximately 16m and the boat remained upside-down in the water. Three of the crew members escaped but with significant injury, unfortunately two crew members died.

Following recovery of the lifeboat it was revealed that the aft hook assembly was found to be completely severed from the keel block but with the keel stay securing bolts still in place.

In addition to significant structural damage suffered by the forward structure of the lifeboat, the forward suspension ring revealed a bend approximately 10° at the hook end and the forward hook release mechanism was found to be in a tripped condition.

A probable sequence of events was that the sudden shock when the mate halted the lowering process had caused the keel stays or fixing plate to fail (having little remaining strength) and separate from the keel block. When the lifeboat had rotated by approximately 35° the forward suspension ring made contact with the main pivot pin causing, as further rotation occurred, a progressively increased opening force from the forward hook mechanism. As the lifeboat rotated the forces in the horizontal plane caused deformation within the structure of the foredeck – the foredeck structure failing and at the same time causing the bending of the forward release operating wire and consequently the part rotation of the cam release pin. A combination of the partly opened release cam and the increasing opening load caused by the suspension ring, being caught against the pivot pin, acting as a lever, resulted in the release of the forward hook. The lifeboat now being detached from both hooks fell approximately 16m to the water.

The conclusion of investigators was that the wastage of the keel stays was ongoing over a lengthy period and had gone unnoticed. The wet, salty and warm conditions of the enclosed lifeboats were ideal for ongoing corrosion of the stays. The fact that plywood bulkheads existed at the forward and aft ends of the lifeboat, albeit with access hatches, contributed to an inspection of these points being overlooked. The ship's Safety Management System only expressly referred to maintenance of the release system and associated cables/wires and controls. There was express reference to the maintenance manual, however, which did refer to the need to inspect for corrosion. Clearly, it would have been preferable if the manufacturer's manual specifically referred to corrosion at the location of the keel connection as it is to some extent natural that crew would concentrate maintenance efforts on moving parts rather than the structure of the lifeboat. The keel plates had in fact been overhauled and painted 17 months earlier but this was not in accordance with the manual and investigators speculate that had the work been done by the manufacturers of the lifeboat equipment, as is now required (MSC Circular 1026), the corrosion would have been spotted and dealt with properly and the accident may not have happened.The report also states that the Classification Society inspected the lifeboat 6 months before the incident on behalf of flag state. Port state investigators concluded that this survey must have been deficient.

It is worth pointing out that this is the second incident where an incorrect type of suspension ring had been utilised by the ship. The suspension ring utilised was of an elongated oval shape and not a circular design as recommended by manufacturers. As a result the lifeboat, the forward fixing plate having failed, was not free to swivel in the vertical plane on the aft hook without the suspension ring (oval) catching on the pivot pin and acting as a fulcrum causing deformation of the foredeck and eventually bending of the release wires such that the forward hook was released.

The cam mechanism for the onload release was criticised by Port State control as being overly sensitive to the additional force transmitted from the heavily loaded hook as it could not withstand the partial rotation of the cam release pin.

Two identical incidents

Two fatalities, nine injured

In the first incident the port lifeboat was swung out as part of a drill with five crew members on board. The davits reached their outboard extremity i.e. came to rest on their stops, when the aft release disengaged and the stern of the lifeboat released and fell. The forward release hook assembly was torn from its fastening and the boat inverted and fell into the sea some seven metres below. The five crew members were trapped inside the boat upside down, two of them died from their injuries, the other three were rescued.

The ship was provided with a totally enclosed lifeboat manufactured by Pesbo S.A., design. The lifeboat was fitted with a wire-operated simultaneous hook release system designed to work both on-load and off-load (when afloat). The on-load release lever is connected by operating wires to the stopper which acts as a break by engaging into the rear body of the lifeboat hook thereby preventing the hook from disengaging from the lifeboat fall suspension ring. The hook itself is designed to self-release when on-load with minimal force/assistance from the off-load mechanism. When off-load i.e. when the lifeboat is in the water, it would be necessary to use the off-load lever in order to swing the hook clear of the suspension rings. A number of clearance settings exist with regard to the stopper and the hook to ensure that it remains engaged. The maintenance of and prevention of slack in, the operating wires is crucial.

Investigations revealed a number of errors and failures in the maintenance and operation of the on-load release system. Although not causative of the accident the davit falls link assembly was of a different type to that recommended in the lifeboat manufacturers manual. Importantly the hook was not properly positioned therefore the weight of the boat was on the tip of the hook. Of greater significance was evidence that the steel pawl or stopper acting as a brake to the release of the hooks was not fully engaged in the step of the hook body thus allowing the lifeboat hook to swivel open whilst on-load as a result of minor increase in load or vibration. In this case that increase in load/vibration occurred when the davits came to rest on their stops.

Whereas the manufacturers' manual clearly stated the need to check tolerances and clearances in the on-load pawl/stopper mechanism and the connecting rods and wires, it is possible that the importance of the pawl/stoppers being engaged properly before any drill or indeed any launch of the lifeboat was inadequately emphasised in the manual. Its importance therefore was inadequately transferred to the Safety Management System and thereby to the training and familiarisation of the crew with the lifeboat operating mechanisms.

The crew's readiness and ability to check this crucial mechanism was hampered firstly by the fact that the release mechanism is extremely difficult to view, it being difficult to obtain a good line of sight down the back of the lifeboat falls to the mechanism, and even then, especially in poor lighting conditions, difficult to distinguish the extent to which the mechanism is engaged. Further, those taking part in the exercise i.e. those operating the release mechanism, do so from inside the enclosed lifeboat whereas the pawl/stopper upon which the whole system relies are outside the lifeboat enclosure.

It is also unfortunately the case that had the Safety Management Systems on board been implemented properly, most importantly, recent IMO Resolution 152 (78) requiring that lifeboats be lowered from their stowed positions without any persons on board during lifeboat drills, the loss of life and injury may have been avoided.

The second incident occurred a year later involving the same design of lifeboat, this time during the raising of the lifeboat following the successful launching during a drill. Whilst being raised the lifeboat self release operated and the lifeboat fell eight metres into the water resulting in the six crew members on board suffering injuries, commonly spinal injuries of varying degrees. Again the restraining pawl/stopper device was suspected as not having being properly engaged before the lifting of the lifeboat had commenced. The failure of the crew within the fully enclosed lifeboat to go outside the lifeboat and check this mechanism is perhaps more understandable when the lifeboat is afloat.

The correct re-positioning of the on-load and off-load release levers within the lifeboat is also crucially important. On the second incident there was speculation that the mechanical interlock device which is attached to the onload release lever but prevents the off-load release lever (which actually moves the hook open) from moving was not fully engaged. Indeed one of the investigating party stated that the off-load lever could be moved up and down freely when it should be been prevented from doing so by the interlock device.

Inadequate familiarisation

The Association, unfortunately, has tragic experience of the result of crews simply not becoming familiar enough with the operation of lifeboats when joining a new ship.

The ship in question was newly-built in Japan. The Chief Officer and Third Officer had been demonstrated the use of the lifeboats at the builders yard which included the operation of release levers and the lowering of the starboard lifeboat into the water. Following delivery of the vessel several days later, whilst on passage from Japan to Australia, the Watch Officer heard a loud crashing sound from the port side and observed immediately that the port lifeboat had fallen in the water. It subsequently became clear that the Chief Engineer and the First Engineer were both in the port lifeboat having entered with a view to starting the engine. The lifeboat was observed floating upside down. A rescue operation was immediately initiated but unfortunately both the engineers died as a result of the incident. To add to the tragedy the Chief Officer who, mid-ocean, had managed to board the up-turned lifeboat with a view to rescuing the engineers, was washed off the lifeboat and despite extensive searches, was never found.

Investigations concluded that the engineers must have operated the on-load release mechanism in error. The release mechanism does include a safety pin/lock and an interlock lever. However the conclusion of the investigations was that the engineers had operated these mechanisms incorrectly causing the lifeboat to fall into the sea.

The Lifeboat Constructors' Manual is 31 pages long. The release mechanism is complex as can be seen from the photograph on the right. What is clear is that whereas demonstrations were given to the Chief Officer and the Third Officer, the two engineers were not sufficiently familiar with the lifeboat mechanism. Indeed, no on-board lifeboat drill had taken place prior to the accident.

It would appear that lifeboat mechanisms have over the years become more and more sophisticated but this complexity has not necessarily been accompanied by the simplification of the operating procedures. Seafarers should accept that despite the increased sophistication the importance of becoming familiar with the operation of the lifeboats remains critical if such catastrophic consequences as described are to be avoided.

Navigation and Seamanship

Inappropriate use of GPS contributes to grounding

The dangers of fatigue have been the subject of a number of industry publications in recent times. An investigation conducted by the UK Marine Accident Investigation Branch (MAIB) into the grounding of the British registered general cargo vessel, LERRIX off the Darss Peninsular in the Baltic Sea, apart from identifying fatigue as a principal cause, identifies other factors contributing to the incident which have not had extensive publicity.

On the LERRIX it was common practice on board for officers to send the watchman below to attend to other duties. At the time of the incident, the Master dismissed the watchman and remained alone on the bridge where he proceeded to set up his own navigational system using a laptop computer and a portable GPS receiver. He then proceeded to make himself comfortable and fell asleep.

As the Master was not aware that the ship was equipped with a watch alarm, he had never tested it (if he had done so he would have found out that it did not work). Had the watch alarm been functional and set before the watchman was dismissed, the grounding could have been prevented. A watch alarm is designed to alert the Watchkeeper at pre-determined intervals by way of a flashing light and then audible alerts on the bridge followed by an alarm in the officers' cabins. In this case the buttons to activate the alarm were located next to the autopilot, but were unmarked.

The Master was using a handheld GPS receiver connected to a laptop computer running pirated software. This was being used as the principle navigational information system onboard the ship. The software had been downloaded from the Internet in 1999 and was outdated. Indeed, as the software was pirated, it could not be updated. The Master therefore was using outdated charting software to monitor the progress of the ship and to plot fixes on the British Admiralty paper charts.

The Owners of the ship had no rules regarding the use of such equipment, were unaware of its use on the ship and supposed that normal protocol was being followed using paper charts.

Such electronic navigational aids are very useful when properly used - with use of waypoint alerts, cross track alarms, and depth alarms, as well as the requirement to periodically verify the system's accuracy by fixing using alternative means eg radar or visual fixes.

The absence of such warnings and alerts left a virtually passive display on the computer screen allowing the Master to lose awareness of the true position and course of the vessel. The MAIB report stated that 'colour displays are seductive, and poorly used equipment can easily lead to a false sense of security and a state of lowered alertness'.

It is therefore important that shipowners adopt rules regarding the use of such equipment. If computer based aids are being used, Owners should ensure that legitimate software is installed on the system and that this is regularly updated. Proper instruction on the use of watch alarms and navigational software alarms is also essential.

'Report on the investigation into the grounding of M/V Lerrix off the Darss Peninsular, Baltic Sea, Germany, 10 October 2005', Report 14/2006, April 2006 – for the full text of the report go to :

www.maib.gov.uk/publications/investigation_reports/2006/lerrix.cfm

Use of Argentinean charts in the Paraguay-Parana Waterway

We are advised by our correspondents in Buenos Aires, that the Argentine Naval Hydrographic Service strongly advises all ships navigating in the Paraguay-Parana Waterway to use Argentine charts with a scale of 1 : 25,000. These charts are updated twice monthly so provide the best available data for safe navigation. The charts are available in paper form as well as on CD.

It is the intention of the Naval Authority to make the use of Argentine charts compulsory in the near future. We understand from our correspondents that this course of action has been taken in response to several recent groundings. Owners are advised to check the current status of the regulations with their local agent prior to arrival.

Mariners' routing guide to the Baltic Sea

The Helsinki Commission (HELCOM) has produced a mariners' routing guide for the Baltic Sea.

The HELCOM Transit Guide for the Baltic Sea, which supplements the nautical chart portfolio for the Baltic Sea, provides essential information for safe navigation in the region which otherwise would have to be obtained from several different sources.

The Guide is a chart-sized document and includes information on reporting systems, ice conditions, maritime assistance services, special regulations, as well water levels and land rise. Currently available only in paper form a webbased version is under development which is expected to be available early in 2007; it will be free to access.

Paper copies of the Guide are available from the German Federal Maritime and Hydrographic Agency (BSH) and cost EUR 24. To order a copy access the following url for information;

http://www.bsh.de/en/Products/Charts/Routeing%20Guides/index.jsp

For more information about the work of HELCOM – the governing body or the Convention on the Protection of the Marine Environment of the Baltic Sea Area, go to;

http://www.helcom.fi

Miscellaneous

Drugs – recent cases of 'Narco Torpedos' in Spanish ports

The Association's correspondent in Barcelona has reported a number of recent cases of drugs being found inside 'torpedos' attached to ship's hulls when they arrive in Spanish ports. Often the ships are targeted by the authorities because they have come from known drug trafficking areas although often the authorities have received a 'tip-off' that drugs are likely to be found.

The penalties can be very harsh if crew members have been found to be involved with the smuggling but even if no charges are brought against the Master and crew, the process of interviewing the crew often results in significant delays to the ship pending the results of such investigations.

In the recent cases, the Masters and all the crew were detained for questioning but were released without charge but if circumstances had been different there could have been serious consequences for all concerned. The correspondent has provided some guidelines that might help if ships are detained.

• Master and crew's attitude:

  there must be absolute co-operation at all times with the investigating authorities to persuade the Civil Guard and criminal court to adopt a more friendly and open approach to the case.

• Ship black-out:

  if the police request the Master to black out the ship so that the diver can inspect the hull, a formal letter must be sent to the Harbour Master holding him liable for whatever consequences could arise from the black-out.

• Media:

  strict instructions should be given to port agents and all concerned that no information should be given to the press or other media without authority from the owner.

• Hull inspection:

  once the authorities have completed their inspections, the owner should conduct their own survey to make sure there is no damage to the hull which could endanger the ship.

Directory of MARPOL reception facilities in the US

In Federal Regulation 71 FED Reg. 52811 the US Coast Guard announces that it has established a website, (http://cgmix.uscg.mil/default.aspx), allowing users to search for MARPOL Service Facilities ( reception facilities) in US ports. By going to 'MARPOL Certificate of Adequacy' then the 'search' option and entering the type of facility sought (eg MARPOL Annex I, II or V) and the state and/or city, the user will be provided with an alphabetical list of ports and terminals holding valid Certificates of Adequacy for reception facilities. This information should make it easier for ships in the US to comply with applicable discharge requirements.

Recent publications

• Shipping Industry Guidance on the use of Oily Water Separators

  Guidance on the use of oily water separators to ensure compliance with MARPOL has been produced jointly by BIMCO, Intercargo, the International Chamber of Shipping, the International Shipping Federation, Intertanko and the Oil Companies International Marine Forum.

  The booklet can be freely downloaded from the following website:

  www.marisec.org/ows/index.htm

• ISGOTT – New Revised (Fifth) Edition

  The International Safety Guide for Oil Tankers and Terminals (ISGOTT), Fifth Edition, is now available from publisher Witherby & Co. (Marine Publishing) for GBP 180. The new edition includes a free CD version which features a search facility as well as printable forms and checklists.

  Publisher's contact details are as follows:
  Tel: +44 (0)20 7251 5341
  Fax: +44 (0)20 7251 1296
  Email: books@witherbys.co.uk

Editor's message

The editors are always looking for ways to maintain and increase the usefulness,relevance and general interest of thearticles within Risk Watch.Please forward any comments to: rwatched@triley.co.uk