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.

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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.

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.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.

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Annex 2 Form T710 - Lifeboat Launch Checklist

26

27

Annex 3 Form L703 – Davits and Associated Equipment Checklist

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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

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