OPTIMISM Training Platform

Table 18: Micro Presentation of a Review of an Accident – Review 4

 

Title: An Investigation into Root Causes of Accident – Freefall Lifeboat

Accident Investigation Review 4 - Freefall Lifeboat

1. Introduction 

In this accident investigation was carried out by a qualified accident investigator employed by an Accident Investigation Agency. 

The investigation aimed to demonstrate the difficulties to establish the root causes of accidents. 

2. Background

The International Safety Management (ISM) Code, adopted by the International Maritime Organization (IMO), establishes a framework for safe operation and management of ships and the prevention of pollution. Shipping companies are required to implement and maintain effective safety management systems that comply with the ISM Code. The accident investigators were responsible for proposing remedies to ensure the accident does not happen again and in the process identify any other contributing root causes.

3. Methodology

The investigation by the accident Investigators involved a review of accident using any documents forwarded to them to carry out the investigation according to the Agency rules and practice. The Investigators employed an approach to evaluate the accident and its root causes against the requirements set forth by the Agency.  C4FF reviewed the information available primarily from accident investigation report with a view to find out if ISM can be more effectively implemented or its effectiveness improved.

4. Investigation

The crew on the bulk carrier were carrying out a free-fall lifeboat drill at Port when the wire rope slings holding the lifeboat failed and it fell approximately 14 m to the water. There were 2 crew members in the lifeboat at the time. Both crew members were seriously injured and were transferred to hospital. 

Findings

4.1 Investigation Practice

The Investigation took place in accordance with the Accident Investigation Agency procedures and practice. The Investigators examined various aspect of the accident and SMS Manual containing policies, procedures, and records/documents as well as non-Quality Assurance and Control deficiencies to ensure their findings would stop this accident from happening again. 

4.2 Accident investigator’s Report

Recommendations have been produced by the accident investigator to have trainings for the crew on carrying out free-fall life boat operations. According to the report the failed sling assembly and the failed lifting brackets have been replaced with a newly manufactured, load tested, and certified sling assembly and the vessels. Lifeboat sling assembly was also included in the ship’s wires and ropes inspection log. An SMS circular was utilized for the vessels in which includes an extra safety meeting to be carried out with all crew participating to avoid recurrence.  Fully trained personnel are utilized to regularly carry out inspections and maintenance of lifeboats and associated equipment in adherence with approved practices. Lifeboat drills are conducted in accordance with applicable International Convention for the Safety of Life at Sea (SOLAS) regulations. All equipment is easily accessible and durable in rough conditions. All tests for safety and life-saving equipment are conducted to IMO guidelines. Unscheduled internal audits of the vessel have been carried out.

5. Observations 

The investigators' report on lifeboat safety compliance has raised significant concerns regarding the maintenance and operational practices on board. The report identified an error in the maintenance of lifeboats, emphasizing the critical importance of having qualified personnel carry out these tasks in strict adherence to approved practices. Additionally, the report highlights the need to apply health and safety requirements to lifeboat drills, which must be conducted in accordance with the Safety of Life at Sea (SOLAS) regulations. Furthermore there was evidence of specific mistake concerning inadequate knowledge of lowering lifeboats. 

6. Comments

Accident investigation on the bulk carrier highlighted the importance of effective implementation of the ISM Code for safe ship operations. Deficiencies in lifeboat maintenance and operational practices were identified, emphasizing the need for qualified personnel and adherence to approved procedures. Health and safety requirements for lifeboat drills, in accordance with SOLAS regulations, were emphasized to prevent accidents. The investigation underscored the challenges in determining root causes and recommended continuous improvement and crew training to enhance ISM Code effectiveness.