TSB Canada issued its investigation report on the injury during a lifeboat drill onboard the passenger vessel Amadea, while moored in Quebec, in September 2018. TSB found that manually overriding a winch system’s built-in safety feature and not wearing protective equipment contributed to the serious head injury.
The incident
On 09 September 2018, a crew member of the passenger vessel Amadea was seriously injured while stowing lifeboat No. 4 after a regular lifeboat drill.
At the time of the occurrence, the Amadea was berthed at section No. 21 in the port of Québec, Quebec. The injured crew member was transported to a local hospital by ambulance.
Probable causes
The investigation revealed that the injured crew member was not trained or familiarized with the task and was unaware of the risks and hazards associated with it.
- The electromechanical limit switches, with their positions set at 20 cm before the davit arms reached their stops, required extensive additional manual winching to complete the stowage of lifeboat No. 4 following the lifeboat drill.
- The lifeboat falls were not of equal lengths and as a result the fore davit arm contacted its stop before the aft davit arm.
- The crew members had to continue manual winching to bring the lifeboat to its stowed position which put increased tension on the winch system, making manual winching more difficult.
- To make manual winching easier, the bosun used a lever-type tool in the spokes of the brake release hand wheel to increase leverage resulting in greater disengagement of the electromagnetic brake, and eliminating the drag that would normally be present in the brake system.
- The relief ordinary seaman and able seaman continued manual winching and the excessive tension on the winch system caused them to let go of the crank handle. Because the electromagnetic brake was released, the crank handle suddenly kicked back and spun backwards, hitting the ordinary seaman on the head.
- The ordinary seaman was not wearing protective headgear, and sustained serious head injuries.
The investigation also found that the onboard safety management system did not include training or any formal operating procedures on lifeboat recovery and stowage, or on operating the davit winches.
If crew members are not trained in the safe operation of critical shipboard equipment such as life saving appliances, there is a risk that they will not operate such equipment in a safe manner.
In regards to the equipment design, it was determined that if the design allows operators to override or disable its built-in safety features, these features will not function as intended, increasing the risk that the crew will be injured while operating this equipment.
Additionally when operating lifeboat winches and davits, and when using lashings, crew members need to wear proper personal protective equipment.
See also: How to tackle head injuries on board
Actions taken
Following the occurrence, the vessel’s manager Bernhard Schulte Cruise Services had lifeboat No. 4’s davit and winch inspected.
In addition, it updated the Amadea’s training manual so that it now includes a procedure for lifeboat recovery. This procedure specifies that crew members must wear protective headgear (helmet), gloves, and safety shoes while performing any activity involving lifeboat winches, davits and lashings.
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