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Marine Safety Investigation Unit
MARINE SAFETY INVESTIGATION REPORT
Safety investigation into the lifeboat accident on board the
Maltese registered bulk carrier
NIN
in position 09° 37.0’S 034° 58.7’E
on 06 January 2013
201301/003
MARINE SAFETY INVESTIGATION REPORT NO. 01/2014
FINAL
ii
Investigations into marine casualties are conducted under the provisions of the Merchant
Shipping (Accident and Incident Safety Investigation) Regulations, 2011 and therefore in
accordance with Regulation XI-I/6 of the International Convention for the Safety of Life at
Sea (SOLAS), and Directive 2009/18/EC of the European Parliament and of the Council of 23
April 2009, establishing the fundamental principles governing the investigation of accidents
in the maritime transport sector and amending Council Directive 1999/35/EC and Directive
2002/59/EC of the European Parliament and of the Council.
This safety investigation report is not written, in terms of content and style, with litigation in
mind and pursuant to Regulation 13(7) of the Merchant Shipping (Accident and Incident
Safety Investigation) Regulations, 2011, shall be inadmissible in any judicial proceedings
whose purpose or one of whose purposes is to attribute or apportion liability or blame, unless,
under prescribed conditions, a Court determines otherwise.
The objective of this safety investigation report is precautionary and seeks to avoid a repeat
occurrence through an understanding of the events of 06 January 2013. Its sole purpose is
confined to the promulgation of safety lessons and therefore may be misleading if used for
other purposes.
The findings of the safety investigation are not binding on any party and the conclusions
reached and recommendations made shall in no case create a presumption of liability
(criminal and/or civil) or blame. It should be therefore noted that the content of this safety
investigation report does not constitute legal advice in any way and should not be construed
as such.
© Copyright TM, 2014.
This document/publication (excluding the logos) may be re-used free of charge in any format
or medium for education purposes. It may be only re-used accurately and not in a misleading
context. The material must be acknowledged as TM copyright.
The document/publication shall be cited and properly referenced. Where the MSIU would
have identified any third party copyright, permission must be obtained from the copyright
holders concerned.
MARINE SAFETY INVESTIGATION UNIT
Malta Transport Centre
Marsa MRS 1917
Malta
iii
CONTENTS
LIST OF REFERENCES AND SOURCES OF INFORMATION .......................................... iv
GLOSSARY OF TERMS AND ABBREVIATIONS ................................................................v
SUMMARY ............................................................................................................................. vi 1 FACTUAL INFORMATION ........................................................................................1
1.1 Vessel, Voyage and Marine Casualty Particulars .......................................................1 1.2 Description of the Vessel and Lifeboat Arrangements ...............................................2 1.3 Crew on Board ............................................................................................................3 1.4 Starboard Lifeboat Davits and Winch .........................................................................3 1.5 Winch Brake Assembly ..............................................................................................4 1.6 Inspection and Maintenance of Lifeboats and Launching Appliances .......................6
1.6.1 Weekly maintenance...............................................................................................6 1.6.2 Three-monthly maintenance ...................................................................................6 1. 6.3 Annual maintenance ...............................................................................................6 1.6.4 Periodic servicing and maintenance by Hansa Lifeboat Limited ...........................7
1.7 Cargo Ship Safety Equipment Certificate ...................................................................7 1.8 Narrative .....................................................................................................................7 1.9 Weather Conditions...................................................................................................10 1.10 Post-accident Inspection of the Winch Brake by the Chief Engineer .......................10
2 ANALYSIS .................................................................................................................11 2.1 Aim ...........................................................................................................................11 2.2 Deployment on Board and Subsequent Safety Investigation ....................................11 2.3 Review of Human and Documentary Evidence ........................................................11
2.3.1 Examination of the winch brake ...........................................................................11 2.3.2 Risk assessment ....................................................................................................14 2.3.3 Maintenance and inspection of lifeboat and launching
appliances – weekly, monthly annual and periodic servicing ..............................14 2.3.4 Annual survey endorsement by BV ......................................................................17 2.3.5 Other observations - safety management system ..................................................18
3 CONCLUSIONS .........................................................................................................21 3.1 Immediate Safety Factor ...........................................................................................21 3.2 Latent Conditions and other Safety Factors ..............................................................21 3.3 Other Findings ..........................................................................................................21
4 ACTIONS TAKEN .....................................................................................................22 4.1 Safety actions taken during the course of the safety investigation............................22
5 RECOMMENDATIONS .............................................................................................23
ANNEXES ...............................................................................................................................24
iv
LIST OF REFERENCES AND SOURCES OF INFORMATION
Bureau Veritas. MSIU Communication.
Crew members MV Nin.
International Association of Classification Societies [IACS]. MSIU Communication.
International Maritime Organization [IMO]. (2009). International convention for the
safety of life at sea, 1974 (Consolidated ed.). London: Author.
IMO. (2009). MSC.1/Circ.1206/Rev.1: Measures to prevent accidents with lifeboats.
London: Author.
IMO. (2010). ISM Code and Guidelines on Implementation of the ISM Code 2010.
London: Author.
Managers MV Nin.
Marine Accident Investigation Branch. (2001). Review of Lifeboat and Launching
Systems’ Accidents. Southampton: Author.
Merchant Shipping Directorate, Transport Malta.
Transport Malta. (2012). Periodic Servicing of Launching Appliances and On-Load
Release Gear. Administration Requirement 1.11.4, issued by the Merchant
Shipping Directorate on 20 October 2012.
v
GLOSSARY OF TERMS AND ABBREVIATIONS
AB Able Seaman
AMOS Asset Management Operating System
BV Bureau Veritas
°C Degrees Celsius
NE North-East
ENE East-North-East
HSSC Harmonized System of Survey and Certification
IMO International Maritime Organization
IOPP International Oil Pollution Prevention
ISM International Safety Management
Kg Kilogrammes
kW Kilowatts
LT Local Time
M Metres
mm Millimetres
m min-1
Metres per Minute
MCA Maritime and Coastguard Agency
MSIU Marine Safety Investigation Unit
RPM Revolutions Per Minute
SMS Safety Management System
SOLAS The International Convention for the Safety of Life at Sea, 1974, as
amended
USA United States of America
vi
SUMMARY
On 07 January 2013, the Marine Safety Investigation Unit (MSIU) was notified of an
accident that had taken place on board the Maltese registered Nin during an ocean
voyage from Bahia Blanca to New Orleans. The accident involved a brake failure on
one of the lifeboat‟s winches during a routine abandon ship drill.
At 10551 of 06 January 2013, the master announced an abandon ship drill. The
weather was clear with a light to fresh breeze. He decided to combine the drill with
the weekly lifeboat inspection. This involved swinging the lifeboats out from their
stowed position without crew. The crew mustered at their designated boat stations.
First, lifeboat no. 2 (port side) was swung out and re-stowed. Then, at 1118, lifeboat
no. 1 (starboard side) was swung out by pulling the remote control brake handle on
the boat deck. When outboard and clear of the davits, the remote control brake handle
was released to stop the movement. However, the wire falls continued to run out.
Efforts to arrest the descent of the lifeboat by pushing down on the winch brake
handle were unsuccessful. The downward movement continued until the lifeboat hit
the sea. At the time, the ship was underway making 11 knots.
As a result of the impact, the lifeboat door opened and water started flooding inside.
The starboard lifeboat started to list. In the meantime, the master slowed down the
main engine. Shortly afterwards, the forward on-load release gear opened and the
painter parted. The lifeboat held by the aft wire falls was pushed further away by the
motion of the vessel. A line from the aft mooring winch was passed and the lifeboat
was hauled-in under the davits. However, the pounding and pitching of the lifeboat
caused the wire falls to slack, resulting in the release of the remaining on-load hook
mechanism. The lifeboat was now adrift and floating free.
The vessel was turned around to recover the lifeboat. After several attempts, the
lifeboat was brought alongside and at 1405, it was finally hoisted up with the ship‟s
cargo cranes and secured on deck.
1 Unless otherwise stated, all times are ship‟s time.
vii
The safety investigation identified poor condition of a ball bearing inside the winch as
the immediate contributing factor to the uncontrolled descent of lifeboat no. 1 during
the routine abandon ship drill at sea.
Recommendations have been made to the vessel‟s managers with the scope of
reviewing and updating the safety management system with respect to the
maintenance of lifeboats and training of personnel carrying out inspections, including
compliance with procedures established in the IMO guidelines, the ISM Code and
SOLAS regulations during periodic servicing and maintenance of lifeboats, launching
appliances and on-load release gear.
Other recommendations were issued to the flag State Administration and to Hansa
Lifeboat to ensure an effective lifeboat maintenance regime.
1
1 FACTUAL INFORMATION
1.1 Vessel, Voyage and Marine Casualty Particulars
Name Nin
Flag Malta
Classification Society Bureau Veritas
IMO Number 9211547
Type Bulk Carrier
Registered Owner Punta Maritime Limited
Managers Tankerska Plovidba d. d.
Construction Steel
Length overall 172.0 m
Registered Length 165.7 m
Gross Tonnage 17928
Minimum Safe Manning 16
Authorised Cargo Solid cargo
Port of Departure Bahia Blanca, Argentina
Port of Arrival New Orleans, USA
Type of Voyage International
Cargo Information 26, 724 tonnes of Urea
Manning 21
Date and Time 06 January 2013 at 1118 (LT)
Type of Marine Casualty or Incident Less Serious Marine Casualty
Location of Occurrence South Atlantic Ocean in position
09° 37.0‟S 034° 58.7‟E
Place on Board Boat deck / Overside
Injuries/Fatalities None
Damage/Environmental Impact None
Ship Operation On passage
Voyage Segment Transit
External & Internal Environment NE winds at 15 knots and 1.2 m swell.
Visibility reported good.
Persons on Board 21
2
1.2 Description of the Vessel and Lifeboat Arrangements
Nin is a conventional geared log / bulk carrier designed with cargo holds forward of
the engine-room and the accommodation superstructure. The vessel has a length
overall of 172 m and a deadweight of 28,373 tonnes. Propulsive power is provided by
a 5-cylinder MAN-B&W 5S50MC, two stroke, slow speed direct drive diesel engine,
producing 5392 kW at 104 rpm. This drives a single, fixed pitch propeller, giving a
service speed of 14 knots.
Nin carries two totally enclosed lifeboats (Figure 1). Each lifeboat is 6.5 m in length
and weighs 2810 kg and is designed to carry 30 persons. The vessel is fitted with a
set of davits consisting of a cradle, davits frame and on-load gear release system. The
lifeboats are designed to be boarded in the stowed position from embarkation
platforms; therefore, they are not fitted with tricing pendants and bowsing tackle.
Hanging-off pendants on each end allow overhauling and maintenance of launching
appliances and on-load release gear mechanisms. The starboard lifeboat is also the
vessel‟s designated rescue boat.
Figure 1: MV Nin’s port side lifeboat
3
1.3 Crew on Board
The ship had a crew of 21 on board, who were all Croatian nationals. The master, the
chief engineer and the second mate had joined Nin on 11 October 2012, whilst the
chief mate had embarked on 25 September 2012. All crew members were
appropriately qualified and had completed their familiarisation checklists in
accordance with the Company‟s Safety Management System (SMS). The vessel‟s
manning level was in excess of the number stipulated in the Minimum Safe Manning
Certificate.
1.4 Starboard Lifeboat Davits and Winch
The davits are of the hinged-type, designed to swing-out and lower the lifeboat by
gravity from a remote control line, either from inside the lifeboat or from the boat
deck (Figure 2).
Figure 2: Nin’s starboard lifeboat davits and winch on the boat deck
4
A permanently mounted electric motor on the winch drives the wire drum for the
hoisting and recovering of the lifeboat. The starboard lifeboat has a hoisting speed of
18 m min-1
at 3.26 tonnes load. A safety limit switch automatically cuts off the power
to the electric motor before the davits‟ arms reach the end of the stowing position. A
hoisting handle is used to manually secure the lifeboats and davits in their final
stowed position. In addition, each lifeboat winch is equipped with a reduction gear,
non-return clutch, governor and gravity brakes and a hand brake lever. The davits and
winch were manufactured by Sekigahara Seisakusho Ltd., and tested and approved by
Bureau Veritas (BV).
1.5 Winch Brake Assembly
Each of the lifeboat‟s winch assembly (Figure 3) is fitted with two brakes. The
centrifugal type brake shoes push against the drum under the effect of centrifugal
forces and automatically limit the lowering speed of the winch to about 60 m min-1
.
As for conventional lifeboat winches, the centrifugal brake is not designed to stop the
lifeboat‟s descent. Its function is limited to controlling the speed of descent.
The second brake is known as a gravity or hand brake. Its external operating lever is
fitted with a heavy weight having the effect of applying the brake by gravity when the
operating lever is released. Braking forces are generated by friction between the
brake drum and the brake shoe lining2. The hand brake is released manually by either
lifting the lever by a remote line from inside the lifeboat, or from the boat-deck. This
allows the winch to lower the lifeboat under gravity. Conversely, releasing the hand
brake will stop the lowering operation.
2 The brake shoe lining is replaced when the grooves worn out.
5
Brake assembly
Clutch assembly
Brake lever
Figure 3: Starboard lifeboat winch and motor assembly
6
1.6 Inspection and Maintenance of Lifeboats and Launching Appliances
The inspection and maintenance of lifeboats and launching appliances on Nin is
controlled and managed through a comprehensive computer-based maintenance
management system called Asset Management Operating System (AMOS). AMOS
defines maintenance instructions and schedules for the crew. The ship‟s Operating
Procedures‟ Manual states that the maintenance schedule is “based on requirements of
SOLAS (regulations III/19 and III/52), as well as flag or company requirement.”3
1.6.1 Weekly maintenance
The details of the weekly inspection and maintenance of the lifeboats, which are
carried out by the third mate, are defined in the AMOS Maintenance Schedule Form
C713 - Lifeboat & Equipment Checklist. On a weekly basis, and in weather
permitting conditions, the lifeboats (with no persons on board) have to be swung out
from their stowed position to ensure satisfactory operation of the launching
appliances. On 02 January 2013, i.e. four days before the accident, the third mate
reported carrying out satisfactory weekly maintenance of the starboard lifeboat
(Annex 1).
1.6.2 Three-monthly maintenance
The ship‟s AMOS also provides for a three-monthly inspection and maintenance
schedule. The items listed in Form T710 - Lifeboat Launch, include maintenance of
lifeboats, launching davits, release gear, and operational test of the on-load and off-
load gear release functions. Evidence indicated that the maintenance was
satisfactorily completed on 08 December 2012 by the chief mate (Annex 2). On this
occasion, the starboard lifeboat was launched and recovered from the water.
1.6.3 Annual maintenance
The annual maintenance is described in Form L703 – Davits and Associated
Equipment. A compiled Form showed that the necessary work was carried out by the
chief mate and the chief engineer on 25 September 2012, except for the inspection of
brake and the dynamic winch brake test (Annex 3). The Form indicated that the
brake inspection and the dynamic winch brake test had been carried out by an
authorised shore technician.
3 Vessel Operating Procedures‟ Manual, Life-Saving & Fire-Fighting Equipment, paragraph 3.2.
7
1.6.4 Periodic servicing and maintenance by Hansa Lifeboat Limited
The vessel‟s managers engaged Hansa Lifeboat Limited, whose service engineer
boarded Nin on 25 September 2012 at Tate & Lyle Terminal, Silvertown, UK. The
service engineer, who was certified by the manufacturer to carry out maintenance,
carried out an annual thorough examination of the port and starboard lifeboats and the
associated launching appliances. Subsequently, Hansa Lifeboat Limited issued a
statement confirming that their licensed service engineer had carried out periodic
maintenance of the lifeboat arrangements in accordance with SOLAS Regulation
III/20.3.2 and MSC.1/Circ.1206/Rev.1 (Annex 4). A second statement also issued by
Hansa Lifeboat Limited certified that the davits and winches were operative, also in
accordance with SOLAS Regulation III/20.3.2 and MSC.1/Circ.1206/Rev.1
(Annex 4). Both statements were dated 25 September 2012 and endorsed by the
master.
1.7 Cargo Ship Safety Equipment Certificate
Nin‟s Cargo Ship Safety Equipment Certificate was issued by Bureau Veritas (BV) on
behalf of the flag State on 02 April 2012. It expires on 26 July 2015. Following the
periodic service and maintenance by Hansa Lifeboat Limited, BV endorsed the annual
survey on the Cargo Ship Safety Equipment Certificate on 03 October 2012.
1.8 Narrative
Nin was en route from Bahia Blanca, Argentina to New Orleans, USA. The speed
was logged at 11 knots. On the morning of 06 January 2013, the master called a
safety meeting prior to an abandon ship drill, which had to be carried out in
conjunction with the weekly inspection of the lifeboats. This involved the swinging
of the lifeboats from their stowed position to ensure satisfactory operation of the
launching appliances. Operational hazards were discussed and risks assessed
(Annex 5).
At 1055, the master sounded the general alarm and announced the abandon ship drill.
All crew members mustered at their designated boat stations. Lifeboat no. 2 (port
side) was swung out and successfully re-stowed. At 1118, lifeboat no. 1 (starboard
8
side) was prepared for launching. The second mate was in charge of the launching
operation and the bosun was operating the remote control handle. The lifeboat was
plugged, lashings removed and the painter made fast. As instructed by the second
mate, one of the ABs closed the lifeboat doors but did not secure the closing handles.
The master instructed the second mate to launch the starboard lifeboat. The bosun
released the gravity brakes by pulling up the remote control handle. When the
lifeboat was clear of the davits, the remote control handle was released to stop the
downward movement. However, the wire falls continued to run out. Efforts by the
bosun and the AB to arrest the descent (by pushing down on the gravity hand brake
handle) were unsuccessful. Eventually, several seconds later, the lifeboat hit the sea.
At the time, the vessel was full away on passage in the South Atlantic Ocean, in
position latitude 09° 37.0'S and longitude 034° 58.7‟N.
As a result of the impact, the forward doors opened, and water eventually flooded
inside. The master, who was monitoring the launching operation from the bridge,
immediately slowed down the vessel‟s main engine. The bosun tried to heave up the
lifeboat but there was extraordinary strain on the electric winch and davits‟ arms
because of Nin‟s headway. The davits twisted and shortly afterwards the forward on-
load release gear opened and the painter parted. The motion of the vessel pushed the
lifeboat further away and astern of the vessel. A line was passed using the aft
mooring winch to re-position the lifeboat under the davits.
As soon as the lifeboat was brought under the davits, the pounding of the seas
activated the other on-load release gear. The lifeboat was now listing and free from
the vessel. Preparations were then made to recover the lifeboat. The master turned
the ship around to bring the lifeboat as close as possible to the vessel‟s parallel body.
After several attempts, the master managed to bring the lifeboat alongside. At 1405,
the crew finally hauled in the lifeboat on deck, using the ship‟s cargo cranes.
The lifeboat sustained severe hull damages (Figure 4) and the davits were bent and
twisted (Figure 5). Both cradles were severely damaged. About one metre of hand
railing was also damaged. There were, however, neither injuries to crew members nor
oil pollution from the lifeboat‟s engine or fuel tank.
9
Figure 4: Damages to the starboard lifeboat
Figure 5: Damages to the starboard lifeboat davits
10
1.9 Weather Conditions
The weather was clear with a North-Easterly moderate breeze. The East-North-East
swell was between one to two metres high. Visibility was clear and the outside
temperature was recorded at 29°C.
1.10 Post-accident Inspection of the Winch Brake by the Chief Engineer
Following the accident, the chief engineer suspected damage inside the winch brake
mechanism. On 08 January 2013, whilst still at sea, he dismantled the unit and after a
thorough examination, he found rust and the outer ball bearing in the brake
mechanism intermittently seized. However, he was unable to determine the cause of
the seizure of the ball bearing.
11
2 ANALYSIS
2.1 Aim
The purpose of a marine safety investigation is to determine the circumstances and
safety factors of the accident as a basis for making recommendations, to prevent
further marine casualties or incidents from occurring in the future.
2.2 Deployment on Board and Subsequent Safety Investigation
Although there was neither loss of lives nor reported injuries, and the accident was
classified as a less serious marine casualty, a decision was taken to conduct a safety
investigation into the occurrence with the aim of identifying the events which led to
the failure of the winch brake mechanism, and the factors that may have contributed
to its failure.
The interviews with several crew members, copies of ship's documents, lifeboat
instruction manuals, maintenance and service records, inspection reports and check
lists, statutory certificates, extracts from the vessel operating procedures and internal
investigation reports were all collected from the ship. Photographs of the lifeboat,
davits and winches were also taken. Additional information was provided by the
master, ship‟s managers and other organisations and agencies during the course of the
safety investigation.
2.3 Review of Human and Documentary Evidence
2.3.1 Examination of the winch brake
The examination of various components of the failed winch brake, which had been
previously opened by the chief engineer whilst the vessel was still at sea, showed
surface corrosion. Some of the parts were in a poor state, which suggested lack of
maintenance. There was extensive pitting and rust; a condition which could not have
reached the state so soon after the periodic service and maintenance (Figures 6 to 9).
12
Figure 6: Part of the starboard lifeboat winch brake assembly
Figure 7: Parts of starboard lifeboat winch brake assembly
13
Figure 8: Starboard lifeboat winch shaft
Figure 9: Starboard lifeboat ball bearing in winch assembly
14
2.3.2 Risk assessment
The abandon ship drill on 06 January 2013 was preceded by an operational risk
assessment. The task-based specific hazards were assessed by the master who, with
respect to the winch brake, considered its failure as „unlikely‟. Nin had recently
completed an annual thorough examination and on 08 December 2012, the starboard
lifeboat was successfully lowered and retrieved. Therefore, the master had no reason
to suspect that anything was amiss and the subsequent failure of the winch brake
during routine abandon ship drill was not anticipated.
2.3.3 Maintenance and inspection of lifeboat and launching appliances – weekly,
monthly, annual and periodic servicing
The weekly inspection on Nin is defined in Maintenance Form C713. Between 21
July 2012 and 02 January 2013, the condition was always reported as satisfactory by
the third mate. The analysis of the documents did not reveal evidence to suggest that
the maintenance programme was supervised by either the chief mate or the chief
engineer, (Nin‟s designated officers responsible for maintenance). Nonetheless, the
managers clarified that the third mate was assisted and supervised by senior officers
and that the chief mate electronically signed-in to update AMOS. In any case, there
was no indication that this could have contributed in any way to the failure of the
brake mechanism.
Monthly inspection and maintenance are mandatory and an essential requirement of
the SOLAS Convention, the flag State administration, and the manufacturer.
SOLAS regulation III/20.7 requires the following:
Monthly inspections
- All lifeboats, except free-fall lifeboats, shall be turned out from their stowed
position, without any persons on board if weather and sea conditions so allow;
- Inspection of the life-saving appliances, including lifeboat equipment, shall be
carried out monthly using the checklist required by regulation 36.1 to ensure that
they are complete and in good order. A report of the inspection shall be entered
in the log-book.
Administrative Requirement 1.11.4 on „Periodic Servicing of Launching Appliances
and On-Load Release Gear‟ issued by Transport Malta‟s Merchant Shipping
Directorate, inter alia states:
15
The examination, repair and testing of launching appliances and on-load release gear
for lifeboats, davit-launched life rafts, rescue boats and fast rescue boats should be
based on the guidance contained in MSC.1/Circ.1206/Rev.1.
Weekly and monthly inspections and routine maintenance as specified in the equipment
maintenance manual(s) should be carried out by the ship‟s crew under the direct
supervision of a senior officer in accordance with the maintenance manual(s)…
The on board manufacturer‟s Instruction Manual for the lifeboats‟ davits and winches
established procedures for routine maintenance. Section 5 of the Manual stressed the
importance of monthly maintenance and inspections of lifeboat winches4.
The Manual highlighted the following maintenance tasks:
To change oil when it is discoloured to brown or milky white;
In case of oil shortage, fill oil to a mid-level of the oil gauge;
Remove the front cover of brake housing and check wear on governor brake lining.
Replace if worn to 2.3 mm or less;
Remove hand brake lever and holding cover. Pull disc brake and check wear.
Replace disc plate if worn out and no grooves found in the disc plate lining;
Check winch gear teeth and replace if found abnormal;
Check the bush, bearings and oil seal and replace if found abnormal; and
Tighten bolts and nuts evenly if found loose.
Notwithstanding these requirements and instructions, the monthly maintenance
procedure was neither found in the vessel‟s Operating Procedures‟ Manual nor in
AMOS.
Rather, Nin had a three-monthly inspection regime. Maintenance Form T710 defined
inspection of lifeboats, davits, release gear, and operational test of the on-load release
function, which the chief mate had found satisfactory on 25 August and 08 December
2012. However, Form T710 made no reference to the manufacturer‟s monthly
instructions on maintenance of winches. Thus, the safety investigation concluded that
winches and its brake mechanism remained without inspection and maintenance even
4 Instructional Manual on Boat Davit & Winch, Sekighara Seisakusho Ltd., pp. 23-25.
16
in the three-monthly inspections, except that on 22 July 2012, the winch gearbox was
topped up with oil.
According to Form L703, annual maintenance was performed by the chief mate and
the chief engineer on 25 September 2012. However, the Form was appended with a
note, “brake inspection done by authorised davit service staff”5. Form L703 remained
unsigned by either officers. Nonetheless, evidence showed that on the same day, a
service engineer from Hansa Lifeboat Limited attended the vessel. Hansa Lifeboat
Limited certified both davits and winches as fit and operative in accordance with
MSC.1/Circ.1206 Rev.1. These documents were accepted and endorsed by the
master.
The periodic maintenance by Hansa Lifeboat Limited was supervised by neither of
Nin’s senior officers. Both the chief engineer and the chief mate respectively claimed
to have been engaged elsewhere during concurrent Statutory surveys with the BV
surveyor, and cargo operations. Their presence on the boat deck was infrequent and
they saw neither the hand brake unit being dismantled nor the condition of the ball
bearings. Moreover, it also transpired that the crew did not perform weekly or
monthly inspections in the presence of the service engineer as part of the annual
thorough examination6, although both officers claimed being present at the dynamic
winch brake tests.
Even though Nin was lying port side alongside at Silvertown during the periodic
service, it did not transpire to the master that the ship‟s gangway and terminal
infrastructure would be obstructing and preventing the release gear or winch brake
tests of the port lifeboat. Indeed, Nin’s managers later informed the MSIU that the
dynamic winch brake test on starboard lifeboat was done at Silvertown whereas that
for the port lifeboat was done by the crew at another port, i.e. Sluiskil on 12 October
2012. Reportedly, Hansa Lifeboat Limited‟s service engineer was not present on
board at Sluiskil and therefore photos of the test were subsequently sent to the service
engineer from the ship for his approval.
5 Vide Annex 3 in this safety investigation report.
6 MSC.1/Circ.1206/Rev.1 Annex 1 Appendix paragraph 2.
17
On 25 March 2013, Hansa Lifeboat Limited was notified of the safety investigation
that MSIU was carrying out in accordance with the relevant SOLAS and EU
Directive. Hansa Lifeboat Limited was requested to confirm the dynamic test of the
lifeboat winches, and send their engineer‟s report and other information relevant to
the safety investigation. In spite of repeated requests7, Hansa Lifeboat Limited only
replied to the MSIU‟s first email but did not provide any information, other than
sending photos which it indicated as having been taken on board at the time of the
service engineer‟s visit (Annex 6).
To this effect, and in the absence of a more thorough input from Hansa Lifeboat
Limited, the safety investigation was unable to verify the extent of application of
MSC.1/Circ.1206 Rev.1; especially requirements of paragraph 2.9, 3.1, 3.3 and 4.1 to
4.5 in Appendices to Annex 18.
2.3.4 Annual survey endorsement by BV
According to SOLAS regulation III/20, as amended, launching appliances (including
on-load release gear), should be maintained, and have to undergo a thorough
examination during the annual surveys required by SOLAS regulation I/7 or I/8 as
applicable. Although a Bureau Veritas (BV) surveyor was on board for Class and
Statutory surveys whilst Nin was alongside at Silvertown, he was neither requested to
examine nor witness the winch brake and the on-load release gear tests. Nonetheless,
between 25 September and 03 October 2012, the attending BV surveyor witnessed the
test of lowering the starboard lifeboat to the water level.
Additionally, he carried out verification of documents of the port and starboard
lifeboats‟ launching appliances for the thorough examination and dynamic winch
brake test by a competent person. Similar verification of documents was done on the
lifeboats‟ on-load release systems and that they were also subjected to a thorough
examination and operational test by a competent person. Thus, information collated
in BV database (VeriSTAR) showed 03 October 2012 as the date when the Cargo
Ship Safety Equipment Certificate was endorsed after the annual survey. However,
7 The last request to Hansa Lifeboat Limited was sent on 22 August 2013 but no acknowledgement
was received.
8 These requirements relate to the annual thorough examination of winches, dynamic winch brake
tests and overhaul of on-load release gear.
18
clarification by Nin’s managers confirmed that the dynamic winch brake tests on the
port lifeboat were only done by the crew members at Sluiskil on 12 October 2012.
BV explained and clarified that during the annual safety equipment survey, their
surveyors would verify that the annual inspection of lifeboats and davits had been
carried out by a manufacturer recognised company in accordance with
MSC.1/Circ.1206/Rev.1 and would only carry out a visual inspection. If it is found
satisfactory, no additional tests would be required.
Although, this is in accordance with the Harmonized System of Survey and
Certification (HSSC) guidelines, a visual inspection of the documentation would not
necessarily guarantee that there is absolute compliance with relevant requirements.
Irrespective of any restrictions which may have been present at the time, the absence
of a surveyor was an important (missing) preventive barrier; this accident actually
being a case in point.
2.3.5 Other observations - safety management system
At the time of the accident, Nin’s managers held a valid Document of Compliance.
Moreover, on 06 August 2012, BV issued Nin with a Safety Management Certificate.
These two documents confirmed that both Nin and her managers satisfied the
requirements of the ISM Code. The vessel‟s Operating Procedures Manual on „Life
Saving and Fire Fighting Equipment‟ stated that maintenance schedule and
instructions established in AMOS software were based on SOLAS regulations III/19
and III/529.
However, on 27 September 2012, Nin was detained after a port State control (PSC)
inspection at Silvertown by the UK‟s Maritime and Coastguard Agency. Amongst the
detainable deficiencies were failure to comply with defined operating procedures,
inadequate fire and abandon ship drills, and the ISM Code was not compliant with
respect to section 7 on shipboard operations10
.
9 SOLAS Regulations III/19 and III/52 refer to inspections, maintenance and instructions for onboard
maintenance were amended and renumbered III/20 and III/36 respectively in the 2004 consolidated
edition of SOLAS.
10 Section 7 of the ISM Code states that [t]he Company should establish procedures, plans and
instructions, including checklists as appropriate, for key shipboard operations concerning the
safety of the personnel, ship and protection of the environment. The various tasks should be defined
and assigned to qualified personnel.
19
The PSC officers had observed general failure of ISM compliance and called upon the
master to invite Class on board in order to carry out full Safety Construction, Safety
Equipment, Loadline and IOPP surveys, further to an additional ISM verification. To
this effect, Tankerska Plovidba d. d. conducted an unscheduled audit at the following
port of call, i.e. Sluiskil, the Netherlands on 11 and 12 October 2012. Although, the
auditor mentioned that the master should get clear instructions on promotion of safety
culture and planned maintenance system, it does not appear to have identified
procedural shortcomings in the SMS or AMOS.
Evidence indicated that Nin’s SMS was not up to date. It neither referred to SOLAS
regulations III/20 and III/36 as amended, nor to the IMO approved guidelines of
MSC.1/Circ.1206 Rev.1. Therefore, AMOS seemed to have remained deficient -
particularly with respect to maintenance of lifeboat and launching appliances.
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THE FOLLOWING CONCLUSIONS, SAFETY
ACTIONS AND RECOMMENDATIONS SHALL IN NO
CASE CREATE A PRESUMPTION OF BLAME OR
LIABILITY. NEITHER ARE THEY BINDING NOR
LISTED IN ANY ORDER OF PRIORITY.
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3 CONCLUSIONS
Findings and safety factors are not listed in any order of priority.
3.1 Immediate Safety Factor
.1 The starboard lifeboat hit the water during an abandon ship drill whilst the
ship was underway due to a mechanical failure of the winch brake mechanism.
3.2 Latent Conditions and other Safety Factors
.1 One of the ball bearings on the starboard lifeboat winch mechanism was found
seized due to excessive corrosion.
.2 The vessel‟s operating procedures with respect to maintenance of lifeboat and
launching appliances were not fully compliant with the ISM Code, amended
SOLAS regulations III/20 and III/36, and IMO approved guidelines.
.3 Instructions on monthly maintenance and inspections recommended by the
manufacturer on lifeboat winches were missing in the vessel operating
procedures manual and maintenance database AMOS.
.4 The manufacturer‟s recommended monthly maintenance on the lifeboat
winches did not form part of the onboard inspection or maintenance regime.
.5 Periodic maintenance works by Hansa Lifeboat Limited were unsupervised by
Nin’s senior officers.
3.3 Other Findings
.1 The risk assessment conducted by the master did not anticipate lifeboat winch
brake failure.
.2 The dynamic winch brake test on lifeboat no. 2 at Sluiskil was not attended by
the service engineer from Hansa Lifeboat Limited.
.3 Evidence did not indicate that following the dynamic winch brake test, brake
pads and winch components were re-inspected.
22
.4 Evidence did not show that an examination of the release gear after the
dynamic winch brake test was carried out.
.5 The safety investigation did not have evidence to confirm that the on-load
release gear on both lifeboats were overhauled.
4 ACTIONS TAKEN
4.1 Safety actions taken during the course of the safety investigation
Following the accident, Nin’s managers have:
amended the annual Maintenance Form L703-Davits and Associated
Equipment. The procedure now requires that maintenance is to be carried out
by a certified service provider in the presence of a responsible senior officer;
instructed the ship‟s crew to take photos of essential parts of the winch brake
and hook release mechanism; and
sought technical advice from the lifeboat/davits manufacturer on how to secure
the davit cradles during weekly maintenance and drill to prevent similar
accidents.
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5 RECOMMENDATIONS
In view of the conclusions reached, and taking into consideration the safety actions
taken during the course of the safety investigation,
Tankerska Plovidba Managers d. d. is recommended to:
01/2014_R1 address their safety management system in respect of maintenance of
lifeboats and launching appliances in line with IMO Resolution A.741(18), as
amended, SOLAS 74, as amended, regulations III/20 and III/36,
MSC.1/Circ.1206/Rev.1 and Administration Requirement 1.11.4.
01/2014_R2 establish procedures to identify training requirements of crew members
undertaking inspection and maintenance of lifeboats, launching appliances and
associated equipment are carried out in accordance with procedures established
under section 10 of the ISM Code, SOLAS 74 Chapter III as amended, and
MSC.1/Circ.1206/Rev.1.
01/2014_R3 organise training, and where necessary refresher training courses to
personnel undertaking weekly and monthly inspections and maintenance of
lifeboats, launching appliances and associated equipment to ensure compliance
with section 6 of the ISM Code, SOLAS 74, Chapter III as amended and
MSC.1/Circ.1206/Rev.1.
Transport Malta’s Merchant Shipping Directorate is recommended to:
01/2014_R4 draw the attention of ISM managers of vessels registered in Malta of
the contents of Administration Requirement 1.11.4.
Hansa Lifeboat is recommended to:
01/2014_R5 adopt procedures which assist its technicians to take assiduous
technical decisions during the overhauling and maintenance of lifeboats,
launching appliances and on-load release gear systems.
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ANNEXES
Annex 1 Form C713 - Lifeboat & Equipment Checklist11
11
The date on this Form has been erroneously entered as 02/01/2012 and should read 02/01/2013.
25
Annex 2 Form T710 - Lifeboat Launch Checklist
26
27
Annex 3 Form L703 – Davits and Associated Equipment Checklist
28
Annex 4 Maintenance Statement
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
Annex 5 Risk Assessment
44
45
Annex 6 Photographs taken during the annual service visit
46
47