Incorrect wiring of the interlock

It was found that the safety interlocks on the wave compensator systems on board British Sapphire, British Emerald and British Ruby had been electrically by-passed thereby preventing the safety interlocks from functioning.. As a result, the wave compensators on board all three ships could be engaged regardless of whether the fast rescue boats were waterborne or suspended from the fall wire

Crew training for wave compensator

The training provided to the crew did not ensure they were familiar with the function or operation of the wave compensator or its safety interlock

Manufacturers Manuals and procedures for wave compensator

Davit International’s fast rescue boat davit manual did not provide sufficient guidance for the crew in the operation of the wave compensator and its safety interlock

Ship's manuals and procedures for wave compensator

British Sapphire’s fast rescue boat davit procedures did not provide sufficient guidance for the crew in the operation of the wave compensator

Job hazard analysis

The job hazard analysis for the operation of the fast rescue boat was incomplete and did not include an assessment of the hazards associated with the operation of the wave compensator

Team resource management

The crew did not use resource management principles to ensure that they had a shared mental model of the task that they were carrying out. As a result there was confusion amongst the various crew members as to their roles and responsibilities at the time of the incident

Installation and acceptance

There was no evidence to indicate that the operation of British Sapphire's (or its sister ships) fast rescue boat davit’s wave compensator and safety interlock had been sufficiently tested at the time of the ship's delivery to ensure safe operation

On board maintenance of wave compensator

The planned maintenance system on board British Sapphire did not include a specific requirement to maintain or test the wave compensator or its safety interlock on the fast rescue boat davit. As a result, the crew had not identified the issue with the wave compensator safety interlock during periodic maintenance.

On board return to service

The planned maintenance system on board British Sapphire did not detail a procedure for a recommissioning test following maintenance on the fast rescue boat davit. As a result, any recommissioning test that was done after on board maintenance had not identified the issue with the wave compensator safety interlock prior to the incident.

STCW training for wave compensator

Training institutions delivering approved STCW courses are not keeping up to date with the introduction of wave compensation units to ensure their courses provide students with the required knowledge to safely operate these units