UK Marine Investigation Branch (MAIB) has published an investigation report into an incident that occurred on 4 March 2021, onboard Royal Research Ship Sir David Attenborough, where three of its crew members sustained minor injuries when a lifeboat fell into the sea during a familiarisation launch.
The incident
At about 1145 on 4 March 2021, while Royal Research Ship Sir David Attenborough was at anchor on Loch Buie, Isle of Mull, Scotland, three of its crew members sustained minor injuries when a lifeboat fell into the sea during a familiarisation launch. The three crewmen were inside the port lifeboat and had used its remote control system to start the launch.
The lifeboat fell from the davit onto the ship’s deck and was dragged over the side by the moving davit arms before it detached from its hooks. The crew on the deck of RRS Sir David Attenborough were unable to halt the launch sequence and prevent the lifeboat falling into the water. The accident occurred because a safety interlock had not automatically reset after a previous test of the lifeboat launch system.
When the remote control system was activated the winch brake released out of sequence and caused the lifeboat to prematurely lower from the davits during the launch. Sir David Attenborough had recently been handed over from the shipbuilder, Cammell Laird Limited, to the Natural Environment Research Council and British Antarctic Survey.
The launching of the lifeboat was the first opportunity for the crew to practice the procedure at sea. The investigation found that the required checks and planned maintenance on the davit had not been completed since it had been installed on the ship. The installation of the davit had not been fully completed in accordance with the manufacture’s specifications, but had been accepted by the approving authorities.
Following the accident, Sir David Attenborough returned to the builder’s yard and completed a period of defect rectification that included completion of the davit installation.
British Antarctic Survey has: modified its system of launching lifeboats for the purpose of training and drills so that launch and recovery is undertaken without embarked crew; rewritten the operating instructions for lifeboats in the Safety of Life at Sea manual, taking advice from Norsafe AS as the original equipment manufacturer; and written additional checklists for both the launching and recovery of the lifeboat.
Viking Life-Saving Equipment Ltd has: fitted a new tension weight and wire clamp and installed a training mode remote control system that meets the SOLAS requirement.
Conclusions
1. Safety issues
- The port side lifeboat of RRS Sir David Attenborough fell into the sea because the remote control system did not operate in the correct sequence and control of the davit was lost during the launching process. This happened because the winch brake operating arm hydraulic interlock cylinder piston rod was corroded and had not reset after the previous lowering of the lifeboat.
- Without the winch brake operating arm being held in the on position by the interlock cylinder piston rod locking pin, the winch brake released the falls and the lifeboat lowered from the davit head too early in the launching sequence.
- When the lifeboat fell to the deck, the remote control wire tension weight clip supplied by Cammell Laird became jammed in the enlarged gland arrangement. The weight of the lifeboat, when it was on its side, kept the remote control wire under tension and prevented the interruption of the launch sequence.
- The crew inside the lifeboat and on the deck of RRS Sir David Attenborough were unable to stop the lifeboat launch because the remote control wire remained under tension.
- The chrome steel surface finish of the davit’s interlock cylinder piston rod was vulnerable to corrosion and susceptible to seizure when exposed to the marine environment.
- It is likely that the corrosion and degradation of the surface finish on the interlock cylinder piston rod prevented it from automatically resetting after the previous lifeboat launch. Lifeboat post-recovery safety checks were not carried out, and so the seized piston rod went unnoticed.
- Deterioration of the interlock cylinder occurred because it had not been maintained by the shipyard or the manufacturer since the installation of the davits. Subsequently, the PMS davit maintenance tasks had not been completed following the handover of RRS Sir David Attenborough due to the suspension of PMS tasks and the engineering department’s focus on defect rectification.
- Senior officers on board RRS Sir David Attenborough were responsible for scheduling and completing PMS tasks to ensure that safety critical systems complied with classification society, fag state and equipment manufacturer requirements. BAS oversight of the PMS was essential to understand the material state of the vessel.
- The davit installation had not been completed in accordance with the manufacturer’s instructions, specifically the training mode remote control system and deck control station had not been installed. This meant that the davit system did not meet the requirement of the LSA Code and that drills involving dead ship launches could not take place without crew on board the lifeboat. The installation shortcoming went undetected throughout the installation approval and acceptance processes.
- The safety equipment survey conducted by LR was fawed and was not completed in accordance with the relevant SOLAS legislation. By delegating the safety equipment survey to LR, the MCA had removed the independent inspection of the davit system by themselves.
- The crew of RRS Sir David Attenborough were unfamiliar with the davit system operating procedures and the risk assessment was not followed. They had not completed the training recommended by Norsafe, the on board familiarisation training was delivered primarily to members of the deck department with only the C/E present from the engineering department, and time pressure due to the late running of the drills meant that the crew were not briefed on the launch procedure.
- The expectation by BAS headquarters that ship’s staf could have RRS Sir David Attenborough operational according to the published timetable led to overburdening of ship’s staf due to defect rectifcation, deployment preparations and system familiarisation. This prevented routine maintenance on safety systems being conducted and training on emergency systems from being completed.
2. Actions taken
Viking Life-Saving Equipment Ltd has ftted a new tension weight and wire clamp and installed the training mode remote control system to meet the SOLAS
requirement.
British Antarctic Survey has:
- developed checklists for the launch and recovery of the lifeboats.
- revised and republished the SOLAS manual lifeboat operating instructions.
- revised its risk assessment for the launch and recovery of lifeboats.
- modifed its training and drills so that the launch and recovery of lifeboats is conducted without crew embarked.
Cammell Laird Shiprepairers and Shipbuilders Limited has amended its standard procurement terms for newbuild projects to require that original equipment manufacturers must provide a separate annex for any critical planned maintenance or preservation requirements specifc to the period between receipt of goods and handover, including installation and commissioning phases at the shipyard.
Recommendations
The Maritime and Coastguard Agency is recommended to:
- Review its processes for delegating Safety Equipment Surveys to Recognised Organisations and ensure that feedback mechanisms are in place to provide the necessary assurance that the surveys have been carried out efectively and in compliance with SOLAS regulations.
- Review its policy for delegation to consider whether it is appropriate to delegate initial safety equipment surveys for newbuild vessels or those joining the UK register.
