Canada’s Transportation Safety Board (TSB) issued an investigation report on the uncontrolled fall of a rescue boat during a drill onboard the RoRo passenger ferry ‘Queen of Cumberland’ in April 2018 off British Columbia, that caused two injuries. The investigation found that incorrect securement led to the fall.
The incident
On 18 April 2018, the crew on the RoRo passenger ferry ‘Queen of Cumberland’ were using an onboard davit to hoist the vessel’s rescue boat out of the water during a drill, when the hoist cable parted.
There were two crew members in the rescue boat at the time, who fell approximately 11 m to the water along with the rescue boat.
Both crew members were injured, one of them seriously, and the rescue boat was damaged.
Probable causes
The investigation found that the rescue boat painter (rope) was not secured with sufficient working length, thus exerting a force on the rescue boat and cable as it was being raised. The resulting side load caused the hoist cable to get pinched and break, resulting in the boat falling into the water along with the two crew members.
- During a man-overboard exercise, the rescue boat painter had been secured to a cleat on the ferry that did not leave enough working length for the rescue boat to be hoisted up to deck 5.
- The reduced length caused the painter to become taut and exert a force on the rescue boat as it was hoisted using the davit.
- The force on the rescue boat caused a side load on the hoist cable as the rescue boat continued to be hoisted; the hoist cable inclined to an angle of approximately 45°, came out of the davit sheave, and became pinched between the top of the sheave flange and the cable keeper.
- The pinching of the hoist cable as the rescue boat continued to be hoisted caused individual wires to break and the hoist cable to part.
Conclusions
- If changes in shipboard equipment are not managed effectively and necessary updates to maintenance systems and schedules are not made, there is a risk that maintenance will be inadequate or overlooked, resulting in failure of equipment and/or injury.
- If changes in shipboard equipment are not managed effectively and necessary updates to operational procedures and training are not made, crew may not be proficient in the use of the equipment, increasing the risk of accident or injury.
- If there is no assessment of the operation of new equipment to identify or mitigate any residual issues or shortcomings, there is a risk that the equipment will not operate as intended, jeopardizing the safety of the crew, the vessel, and the environment.
- The davit’s limit switch was incorrectly rigged during servicing in June 2016; this went uncorrected during subsequent inspections and maintenance routines. The limit switch was for overhoist protection rather than side-load protection, and its rigging did not affect its functionality.
- The company’s rescue/shepherd boat training facility is not equipped with a pivoting davit.
Actions taken
Following the incident, the company issued a fleet-wide Operations Bulletin advising of the occurrence and prohibiting the use of all luffing davits throughout the fleet, except in emergencies.
It also issued a Fleet Operations Directive, advising that a fleet-wide technical inspection of all rescue boat davits was in progress to verify the equipment’s fitness for purpose and another Fleet Directive to remove the “emergency use only” restriction on davit and rescue boat operations.
On 31 August 2018, following another incident with a rescue boat onboard the Spirit of Vancouver Island, BC Ferries reinstated an “Emergency Use Only” restriction for all davits and rescue/work boat combinations. Other than for real emergencies, no personnel are permitted to be in the boat when it is being lowered and/or raised.
By 2019, the company had also replaced the davit, trained the crew on davit operations, completed risk assessment for the launch and recovery of rescue boats, created a Nautical Standards group to manage fleet operations safety-critical assets and conducted internal and external audits, among others.
Recommendations
BC Ferries completed a Divisional Inquiry into the Queen of Cumberland occurrence, recommending:
- Review davit design and operator warnings.
- Assign specific, dedicated operational resources to manage safety-critical assets.
- Conduct an assessment of safety-critical asset (systems) management.
- Conduct a risk assessment of the launch and recovery of rescue boats.
- Improve emergency-scene management at terminals (including drills).
- Conduct an assessment of water rescue preparedness at terminals.
- Improve operational training related to the launch and recovery of rescue boats.
- Conduct an audit of Standardized Education and Assessment (SEA) training processes.
- Conduct an assessment of Fleet Maintenance Unit (FMU) quality assurance processes (safety-critical).
- Develop and enforce new governance and quality assurance processes in the computerized maintenance management system (CMMS).
- Issue a joint communication regarding the importance of reporting safety events.
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