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crew to connect the Fall Preventer Devices (FPD) (Figure 3) to the for- the men in the boat not to release the FPDs until he had connected
ward and aft hooks. After both FPDs had been secured, the lifeboat was the gripes to the davit arms (Figure 4). The aft gripe had been secured,
lifted from the water, though some members of the lifeboat crew were and the bosun was connecting the forward gripe when the C/O came
not convinced that the hooks had been correctly reset. When reaching to the lifeboat and instructed the men in the boat to release both
the embarkation deck, all six crewmen disembarked from the lifeboat FPDs. As soon as the forward FPD shackle pin was removed, the hook
before it was hoisted into its davit. The lifeboat was then left unsecured opened, and the forward end of the ship fell onto the handrails on the
in the davit for about 20 minutes while the crew took a break. deck below (Figure 4), striking and injuring the bosun as it fell.
After the break, the C/O instructed the ship`s bosun and two crewmen The emergency services were called, and the bosun was taken to a
to secure the lifeboat. The two crewmen boarded the lifeboat to assist local hospital for medical assessment. It was found that his injuries
in positioning the gripe wires forward and aft. The bosun instructed were not serious, and he returned to the ship the following day.

Figure 3: Fall preventer device fitted to starboard lifeboat Figure 4: Gripe wires (on starboard lifeboat)
Source: Maritime Accident Investigation Branch Source: Maritime Accident Investigation Branch

Lessons Learned of training and the failure to undertake the requisite

SOLAS emergency drills on the ship.
The following lessons learned have been identified. These are - Following the incident, the ship’s safety committee
based on the information available in the investigation report conducted a meeting and recorded that there had
and are not intended to apportion blame on the individuals or been no incidents or near misses on board.
companies involved: - The manager’s review of the incident identified
shortcomings in the crew’s emergency preparedness
• The accident followed a communication breakdown between training but did not create an action plan to improve
the crew, who were not empowered to challenge orders or emergency response standards on its ships.
participate in the decision-making process on board. This • The company’s SMS contained comprehensive maintenance
became evident when some of the crew members did not schedules for the lifeboats and their on-load release and
challenge the C/O during the hoisting of the lifeboat, even retrieval systems (LRRS), e.g., inspecting the release gear
though they were not convinced about the hooks being cor- on a monthly basis, which included checking the “status of
rectly reset, and again when the C/O asked them to release the reset” and “that there was no dirt or foreign matter on
the FPD contrary to the instructions given by the bosun. the moving part.” Just a few weeks before the accident, the
• The company’s onboard Safety Management System (SMS) ship’s maintenance records indicated that the release gear
was ineffective and poorly implemented. The crew had not had been checked and was in “good” condition. However, the
been adequately trained and were unfamiliar with operating investigation identified that the moving parts of the hook
onboard safety equipment, which was further highlighted release mechanism on the port lifeboat were dirty and had
by the following findings identified by the investigation been painted, as had the reset indicator. Additionally, the
(although the crew’s inadequate training and unfamiliarity release gear cables were found seized and damaged when
with the safety equipment did not directly contribute to this inspected after the accident. The release gear on the star-
incident): board lifeboat was in a similarly poor condition.
- The company had advised that the FPDs were fit- • Despite records to the contrary, it was apparent that no
ted to the starboard lifeboat while the ship was on maintenance or inspections of the LRRS had been carried
passage, which rendered the lifeboat inoperable in an out since the annual inspection and service six months prior
emergency and is contrary to both the IMO’s and the to the incident.
company’s own SMS requirements, demonstrating a
lack of understanding of the device’s correct use. Source: The Investigation Report Published By The Maritime
- The crew’s performance during the fire drill re- Accident Investigation Branch (Maib)
quested by the PSCO was indicative of the poor level

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