On 1 April 2020 TORM MAREN was located approx. 115 nm off the coast of Guinea.
While adrift, it was decided to conduct a rescue boat drill and thus the boat was lowered with three persons on board.
After having sailed for approx. 1.5 hours the boat was brought alongside and attached to the rescue boart hook and hoisted to deck level.
As the crew was about to bring the rescue boat into the cradel, the boat fell into the sea, approximately 17 meters.
All three crew on board the boat suffered serious injuries.
Reliability of the rescue boat system was achieved by technical redundancy enabling the rescue boat to be launched if e.g. the ship had a power outage. However, the reliability of the davit’s man-riding capability relied entirely on inspection and preventive maintenance by competent personnel.
Preliminary investigation found that the wire lifting rope was severely corroded which caused it to part during retrieval of the rescue boat. The corroded wire rope was, however, part of a larger system comprising mechanical components, PMS, regulation, safety management system and training regimes. The parting of the wire rope was thus not the cause of the accident in itself, but an accident event which required an investigation of the circumstances leading to the deterioration of the wire rope.
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This investigation would enable a broader understanding of why the man-riding capability of rescue boat system failed resulting in the boat falling into the sea. The reliability of the man-riding capability of the rescue boat system was susceptible to single point failure and relied therefore entirely on an effective PMS. DMAIB’s analysis hence focused the investigation on why the company PMS was not able to prevent the wire rope from deteriorating.
Even though the company’s PMS instructed the officers to inspect and maintain the wire rope, they did not act upon the deteriorating condition of the wire rope. Neither did any of the other officers who continuously inspected, maintained and operated the rescue boat system even when the wire rope was readily visible.
The reason why the condition of the wire rope was not recognised as being detrimental to the functioning of the rescue boat system was a combination of three factors:
- Firstly, the manufacturer’s manual and PMS which did not specify how to assess the condition of the wire rope.
- Secondly, an absence of training in assessing the wire rope’s condition.
- Thirdly, the PMS activities were compartmentalised which in practice meant that only one person was assessing each component.
Additionally, all the factors were compounded by the thorough examination performed by service providers which made the officers trust not only the load bearing capability of the wire rope, but the man-riding capability of the system as a whole.
After the incident, the company initiated the following preventive measures in order to prevent similar, future accidents:
- ”Identified minimum required certification for all wire ropes used for lifting appliances. Dialogues was taken with wire manufacturers to enhance guidance for inspection, assessment and discarding of life saving appliance wire ropes.
- Learning engagement tool rolled out fleetwide to enhance ship staff knowledge on upkeep on wire ropes. Tool has been developed in line with company’s Safety Leadership Philosophy, where we aim at enhancing soft skills of our seafarers.
- Renewal frequency has been reduced to one year and frequency interval will be reviewed in future.
- Reporting of PMS job routines have been enhanced to bring out leading indicators and create more barriers i.e. photograph template.
- Reporting of Service providers that conduct annual examination have been aligned with format used in PMS routine to pick up leading indicators and create further barriers.
- SMS procedures enhanced by including awareness of single point failure concept and importance of its checks before engaging personnel on to these lifting equipment
- Working together with flag state to highlight absence of mechanical redundancies in the systems such as brake, hook, wire rope at industry level
- Few additional measures introduced:
- Sharing fleet wide safety flash and incident for learning purpose
- Detailed incident investigation report
- Feedback from entire fleet for the condition of falls and hooks
- Paused all lowering of boats immediately after the incident and resumed only after introducing reviewed procedures and detailed checks
- Identified standard lubrication products for full fleet
- Enhanced focus on Life saving appliances during internal and external audits to increase
awareness and confirm on board assessment.
- Sharing of learnings with Oil Majors, so the information sharing can be done for a wider
range of stakeholders
- Immediate incident info-sharing with peers to help them assess taking pro-active measures
- Shared the information of the incident with HILO. HILO uses the shared data points to
provide predictive risk model for enhancing safety onboard. This forum shares information
across the shipping companies.”
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