Japan’s Transportation Safety Board (JTSB) issued an investigation report on the fatality of a crew member onboard the cargo ship ORANGE PHOENIX, after falling from a lifeboat to the deck during an abandon ship drill in November 2019.
The incident
The cargo ship ORANGE PHOENIX with the master, Navigation Officer A, Navigation Officer B, and 18 crew members aboard started anchoring around 10:00 on November 16, 2019 in Wakayama Shimotsu Port, Wakayama Prefecture, to wait for entry into the port.
The master instructed the crew to conduct launching of a lifeboat in an abandon ship drill that has been implemented every month, and Navigation Officer A, Navigation Officer B, and eight crew members started the launching work.
The crew members dropped a free-fall lifeboat that was installed on the stern deck in an empty state to the sea surface while hanging it with a hoisting wire. After that, they hoisted the lifeboat up to the original lifting and recovery position and hooked the hook of the release system installed at the stern of the lifeboat on the ring of the boat davit.
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After that, Navigation Officer A entered the lifeboat from the doorway on the stern side of the lifeboat for conducting operation to restore the release system that fixes the hook hooked on the ring. Navigation Officer B was taking photographs near the doorway in the bent-over posture to keep the photographs as a record of the drill.
Around 11:20, when Navigation Officer A operated the release system and slightly inserted the safety pin, the hook was suddenly released and the lifeboat moved approx. 1.5 to 2.5 m downward on the guide rail. Thereby, Navigation Officer B lost his physical balance and fell head-first to the deck that was approx. 6 m below.
Upon receipt of a report by radio from Navigation Officer A, the master notified the agent of the fall and called for rescue. The agent notified Japan Coast Guard of the fall. Navigation Officer B was transferred to Japan Coast Guard’s helicopter that came to assist upon receipt of the notification, and was then taken by ambulance to a hospital in Osaka Prefecture. However, he was pronounced dead by a doctor, and the cause of death was confirmed as brain contusion.
Probable causes
The accident probably occurred in a manner that, when the Vessel was doing the lifting and recovery of the lifeboat, Navigation Officer B lost his balance and fell to the deck because he was taking photographs in a bent-over posture at the doorway at the stern of the lifeboat without wearing the safety belt, and the hook of the release system was released from the ring of the boat davit and the lifeboat moved downward along the guide rail.
It is considered probable that the hook of the release system was released from the ring of the boat davit because it is likely that the lock piece was not hooked in the appropriate place.
Actions taken
Company A issued a document concerning the accident to gain the attention of all the vessels it manages and also implemented the following measures:
- The master and the chief officer provide the crew members with on-site education concerning the release system restoration procedures using an actual lifeboat on a regular basis.
- The master provides the crew with on-site education concerning appropriate equipment, such as a safety belt, for work in a high place.
- The master holds a meeting before an abandon ship drill and provides explanation to the crew concerning the prediction of danger, thereby having each crew member become aware of safe work.
- Before conducting a lifeboat lifting and recovery work, the chief officer thoroughly ensures the following: the hook of the release system is hooked on the ring of the boat davit; the hoisting wire is not released until the hook is completely fixed; the reset position of the hook is confirmed by the green paint of the lock piece; the hook is surely fixed with the safety pin lock by inserting the safety pin.
- Each vessel holds an onboard safety meeting and gives explanation about the details of the accident, and reports the record of implementation of on-site education to Company A.
- Company A’s supervisor visits the vessels Company A manages and confirms that the release system is actually operated in an appropriate manner.
Recommendations
It is probable that the following actions will be useful in preventing the reoccurrence of a similar accidents:
- When lifting and recovering a lifeboat, crew members make sure to do the next work after confirming that the lifeboat was fixed by surely conducting the lifeboat release system restoration operation.
- When doing work at a place involving the risk of a fall, crew members appropriately use a safety belt.
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