SB 027-15

INCIDENT INVESTIGATION

Investigation Report & Root Cause Analysis

Location: At Dubai Anchorage

Date and Time: 27-Aug-2014 at around 0840 Hrs LT.

Location: Aft Boat deck

Incident: Injury to Master during lifeboat lowering

Brief summary of the incident:

On 27th Aug 2014, while the vessel was at Dubai anchorage awaiting STS operations, vessel planned to lower the Free fall lifeboat by davit into water for maneuvering. After obtaining permission from Dubai Port control, vessel commenced lowering the boat by davit launching. While attempting to heave life boat by davit, the gear clutch/brake assembly was found slipping and not holding the boat. The lifeboat weight was on davit hook and the hydraulic release mechanism had been set free. The Master was standing on the opposite side of the brake while the OS was trying to hold the lever in such a position that the boat could be heaved back up. Bosun was at the winch control, heaving up the winch. Due to the slipping clutch, the winch was running without heaving up the boat, unless the brake lever was held in an intermediate position. During the operation, suddenly the brake Lever swung around by 270 degrees, hitting the master on the lower left abdomen, resulting in a deep gash. Master suffered a 20 cms horizontal cut on the lower abdominal wall and was sent ashore for medical treatment and later repatriated back home. The vessel is an LPG carrier fitted with a freefall lifeboat of 28 persons capacity. Davit and winch system particulars: Davit System: Free-Fall system for lifeboat D-FG. 70 Maker: Davit International GmbH Sequence of Events:

On 27th Aug 2014 at Dubai anchorage, vessel planned to lower the Free fall lifeboat by davit into

water for maneuvering. The weather was calm and the vessel was not being subjected to any

weather-induced movements.

After obtaining permission from Dubai Port control, vessel commenced lowering the boat by releasing the hook for davit launching.

SB 027-15

INCIDENT INVESTIGATION The crew assembled and removed the weather lashing from the poop deck. The boat was then secured by boat wire slings to the lifeboat davit fall hooks. Crew removed the lifeboat securing by unlocking the sen-house slip. At this time the brake lever of the winch was hanging almost vertically downwards. The crew tried heaving the boat using manual cranking failing which, the winch motor was used to heave the lifeboat falls to take the weight on the falls and also by adjusting the winch brake lever in approximately horizontal position facing towards the aft part of the vessel. After taking the weight of the lifeboat on the falls, the crew continued to heave the lifeboat to free her from the release hook. Since the boat was not getting heaved up fully, the crew tried heaving by manual cranking, but failed to heave the boat any further. 3rd Officer went inside the lifeboat and secured himself on the coxswains’ seat and released the lifeboat by free fall release method (by using hydraulic jack). On releasing the free fall hook, the boat moved about 3 metres on the davit track by having weight on the davit hooks. The winch brake lever was adjusted by moving slightly up and down such that the boat remained on the track and the crew confirmed that the weight is fully on the lifeboat falls and the winch brake is holding. The boat was heaved up by motor by adjusting the brake lever and brought to a position less than half a meter from the embarkation deck. The 3rd Officer disembarked from the boat safely. The crew tried to heave the boat back to securing position but the boat was not getting heaved up either by motor or by manual cranking. Again the crew tried heaving the lifeboat by motor, even though the motor was turning; the winch was still not getting engaged. The crew tried adjusting the brake lever to an intermediate position so that they could heave the lifeboat falls. The clutch was getting engaged and disengaged at some intermediate position of the lever. At this time, the master who was standing on the opposite side of the brake approached the winch brake assembly to inspect the system. During such continuous clutching and declutching, there was a sudden jerk on the brake lever (due to motor power). This caused the lever to slip out of the hands of the OS and swinging around by 270 degrees, hitting the master on the lower left abdomen, resulting in a deep gash. The brake lever handle stopped after striking the stopping bar on the assembly. Master was feeling light pain and was shifted to the ships’ hospital to check the injured area and found the deep gash at the left lower abdomen area. The first aid was administered, no excessive bleeding was observed and the Master was not experiencing major pain and he was conscious and in normal condition. Master was under continuous observation and he was fully conscious and normal. His vital parameters were found normal. Dressing was applied and movements were restricted to reduce effect.

SB 027-15

INCIDENT INVESTIGATION The local agent and office was informed and service boat was arranged immediately for shore medical treatment.

Investigation and Cause Analysis:

An investigation was carried out by the ship staff immediately after the incident, followed by

interviews of the Master, Chief Officer, 3rd Officer, 4th Engineer, Bosun and OS to establish facts and

arrive at conclusions.

Work/rest hours records were reviewed and found that the crew member was well rested and was

not affected by fatigue.

Breath alcohol test of the crew member involved in the task was carried out and found none of the

crew members under the influence of alcohol.

Further thorough investigation was carried out by the Marine Superintendent and Technical Superintendent at vessels’ next port of call for detailed cause analysis. The investigation took into account the antecedents with regard to maintenance and work carried out on the lifeboat winch to ascertain conditions and causal factors.

A. Annual thorough examination of free fall lifeboat system: Vessel was taken over from previous management on 23rd Dec 2013. The Annual thorough examination of free-fall lifeboat was due in Jan 2014; hence the same was arranged on 19th Jan 2014. Messer’s Cargo Gear Services (I) Pvt. Ltd. attended vessel to carry out the same in the presence of Class surveyor. The winch break mechanism was checked during the servicing and the same was tested to the satisfaction of the ship’s officer.

Furthermore, the position of the manual brake handle was horizontal (correct position) as evidenced by a photograph taken on 18th January 2014 during the Annual service by approved shore workshop.

Photograph taken during Annual maintenance- 18th January 2014.

SB 027-15

INCIDENT INVESTIGATION Photographs of the internal mechanisms like the clutch plate and manual brake linings did not show any signs of abnormality to warrant failure.

B. Life boat lowering in April 2014: The life boat lowering was due in April 2014, the vessel tried to get permission in Ruwais and Tuticorin. Due to security reasons, Permission was not granted. Hence the life boat was not lowered to water level but the vessel simulated Lifeboat freefall on 15th May 2014. No abnormality noted or reported during this exercise. Statutory requirements make it mandatory for the lifeboat to be launched in water and manoeuvred once every three months. In the case of free-fall lifeboats, the only dispensation offered is that the boat can be launched either in free-fall mode OR by secondary means. This failure to comply with statutory requirements, though not having a direct bearing on the present incident investigation, warrants necessary corrective and preventive action(s).

C. Wire renewal in June 2014: In June 2014 the wire renewal was carried out by ship staff. The photograph of the wire renewal

clearly shows the position of the brake lever facing vertically down. This position of the brake lever is incorrect, the correct position as per Maker manual is reproduced in this report. It could not be clearly established why and when this handle moved to this position, as the internal inspection subsequent to the incident did not reveal any abnormal wear down of the brake lining or damage thereof that caused the handle to shift by such an extent. It is hence assumed that the handle was moved to the vertical downward position during the renewal of the fall wire in June 2014. This change, made for whatsoever reasons, turned into a latent condition and became a

SB 027-15

INCIDENT INVESTIGATION contributory cause to this incident.

Correct position of the brake lever handle:

SB 027-15

INCIDENT INVESTIGATION

D. Life boat lowering in Aug 2014: The life boat lowering was next due in Aug 2014 and which was taken up by the ship staff. During this operation, the brake lever of the winch was hanging vertically downwards and the incident occurred during this operation. The following pertinent points were noted with regard to the operation of the lifeboat winch:

1. In the normal correct position of the lever, the operator does not have to touch the

brake lever at all. The weighted end on the lever will automatically keep the brake

activated at all times. The problem was with the lever’s incorrect position which had

made the brake slip. If the lever is vertically down, the person operating the brake

will have to move the lever clockwise against the weighted end and thus have great

difficulty in applying the brake. It can be clearly seen that the whole purpose of the

weight on the handle is lost if the lever is facing vertically down.

Furthermore, the instructions for hoisting using electric power as mentioned in

Section 3.2 Functional description of the Maker Manual clearly forbids the lifting of

the brake lever handle during hoisting operations. Extract of the manual is

reproduced below:

2. The lifeboat winch mechanism here is designed to hoist and lower the boat using

the electric motor. Therefore the brake lever (if in the correct position) should

always be in the braking position. If the lever is not applying the brakes,

transmission from the electric motor gear is not passed to the winch gear and the

electric motor will just freewheel without turning the winch.

3. The lifeboat can also be lowered in a controlled way by lifting the brake lever. Lifting

of the lever will release the brake and the lifeboat will lower by its own weight.

4. A centrifugal brake is also provided, which will control the speed of descent in case

the mechanical brake lever is lifted up (released) completely.

SB 027-15

INCIDENT INVESTIGATION 5. The act of lifting the brake handle to facilitate hoisting, in contravention to Maker’s

instructions, was caused due to wrong position of the brake handle. Examination of the brake winch assembly: The entire brake clutch assembly was dismantled to assess the damage and better understand the cause of this incident.

It was found that the clutch plate was broken as a result of the continuous clutching/declutching

carried out with the brake lever held up during hoisting. No signs of wear of the brake pads were

evident to suggest the handle’s vertically downward position.

Failure of Barriers:

The generic Risk Assessment D-017 - Lowering /Launching of Lifeboat clearly identifies hazards

posed by brake malfunction. This hazard was not addressed by appropriate and effective control

measures.

The failure to plan the task and review Maker’s instructions prior to execution resulted in a possible

missed opportunity to identify the incorrect position of the handle.

Correct position is 15 deg above

horizontal in this direction

The lever slips down from the above

position with time (because of wear

down of the brake friction lining.

Holes are given to readjust the lever

back to 15 deg above horizontal.

SB 027-15

INCIDENT INVESTIGATION

Cause Analysis:

Direct Cause:

1. Improper Position of the Brake lever (latent condition): The lever was positioned vertically down instead of 15 degrees above horizontal (ref figure).

2. Use of defective equipment: The lifeboat winch was used without realizing that the position of the brake lever was wrong and could result in a mishap.

3. Defective equipment: The vertically downward position of the winch brake handle resulted in a condition where the winch would not perform as intended. The equipment was used without identifying this condition due to lack of knowledge and failure to refer to Maker’s instructions. Indirect Causes: A. Inadequate equipment:

The wrong position of the manual brake lever in the lifeboat winch made the winch partially defective, rendering it incapable of operation for the purpose and method intended.

B. Inadequate work standards:

1. Risk assessment not effective / Change in job scope: The assessment of the job with regard to the launching instructions was not carried out. The crew did not carry out a detailed risk assessment for the hazards posed by malfunctioning brake (already identified in the generic Risk Assessment sent by office to all ships).

2. Procedure not available: No procedure / work instruction for lowering boat using davit was available near the launching area.

3. Procedures not referred: Maker’s manual was not referred prior davit launching

of free fall lifeboat or when the hoisting operation was found to be taking place only when the brake lever was lifted.

SB 027-15

INCIDENT INVESTIGATION Inadequate knowledge: 1 .Inadequate awareness of crew: Procedures for lowering free fall lifeboat was not clearly understood by the crew 2. The lifting of the brake handle to enable hoisting operation of the winch as an abnormal condition was also not identified due to inadequate knowledge.

Root Cause (s):

1. Lack of proper planning with regard to the assessment of risk for the launching of free fall lifeboats and review of Maker’s instructions with regard to the operation of the winch.Non-compliance with regard to preparing / reviewing Risk Assessment for the launch of lifeboat.

2. Lack of standard with regard to check of equipment (lifeboat winch) prior to operation.

3. Lack of compliance with statutory requirements of mandatory launching of lifeboat in water.

Corrective Actions:

1. Circulate the analysis of the incident highlighting the need of Risk Assessments to cover and address all possible hazards while lowering of free fall lifeboats.

2. Training session for Free fall lifeboat launching instructions by free fall launch, davit launch and simulation launch to be carried out regularly.

3. Detailed instructions for simulation testing and davit launching to be prepared and posted near the lifeboat.

4. Arrange for spares and shore servicing by makers approved service technicians for overhauling of the damaged lifeboat davit winch brake and clutch assembly.

5. A fleet alert to be sent to all vessels to check the lifeboat brake mechanism with regards to

maker’s manual. Brake lever position to be monitored during routine LSA rounds by senior

officers and weekly checks.

SB 027-15

INCIDENT INVESTIGATION

7. The Planned Maintenance system (PMS) to be reviewed with regard to jobs associated with

lifeboat winch and the position and correct functioning of brake handle to be checked and

recorded at a suitable interval.

SB 027-15

INCIDENT INVESTIGATION Please note that there are some pictures depicting the injuries sustained in the following pages and

might cause discomfort to certain individuals.

APPENDIX

Fig: 1 Pictures of the Master after the Incident:

Pictures of incident site:

Fig: 2 Position of the Master and OS at the time of incident

SB 027-15

INCIDENT INVESTIGATION

Fig: 3 Initial Position of the brake Lever where OS was holding

Fig 4: Final Position where Brake Lever handle hitting Master after rotating by 270 deg.

SB 027-15

INCIDENT INVESTIGATION

Fig 5: Picture of shattered Clutch plate and damaged needle bearing.