Marine safety investigations & reports

Independent investigation into the fast rescue boat incident on board the Isle of Man registered liquefied natural gas tanker British Sapphire off Darwin, Northern Territory on 16 May 2010

Investigation number:
275-MO-2010-004
Status: Completed
Investigation completed

Summary

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On 16 May 2010, the chief engineer of British Sapphire was being medically evacuated using the ship's fast rescue boat for the transfer. The fast rescue boat party consisted of the chief mate, second mate and fourth engineer. The chief engineer, second mate and fourth engineer were injured when, during the launch, the ship's fast rescue boat dropped 18 m and impacted the water below.

The investigation determined that, in the process of lowering the rescue boat, the wave compensator mechanism on the fast rescue boat's davit was activated early, before the rescue boat had reached the water. A fail safe interlock device should have prevented this by placing the wave compensator into standby mode, only becoming operational when the fast rescue boat was waterborne. However, the electrical installation of the interlock was incorrect and meant it could not work as designed, allowing the wave compensation unit to always operate and the fast rescue boat to make the uncontrolled descent to the sea.

The investigation identified safety issues relating to the commissioning, maintenance, testing, operating instructions and procedures for the fast rescue boat's wave compensator and its safety interlock system. Further safety issues were identified relating to the job hazard analysis for the use of the fast rescue boat, crew resource management principles and approved training courses for fast rescue boats.

The ATSB is satisfied that the safety action taken by BP Shipping and Davit International addresses these safety issues. The ATSB remains concerned about the adequacy of training in the use of wave compensation units on fast rescue boat davits and has released a safety advisory notice to national and international maritime training institutions about this safety issue.

Download Final Report
[Download  PDF: 1.7MB]
 
 
Alternate: [Download  DOC: 4.84MB]
 

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Safety Issues

Go to MO-2010-004-SI-01 - Go to MO-2010-004-SI-02 - Go to MO-2010-004-SI-03 - Go to MO-2010-004-SI-04 - Go to MO-2010-004-SI-05 - Go to MO-2010-004-SI-06 - Go to MO-2010-004-SI-07 - Go to MO-2010-004-SI-08 - Go to MO-2010-004-SI-09 - Go to MO-2010-004-SI-10 -

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

Safety issue details
Issue number: MO-2010-004-SI-01
Who it affects: All owners operators and managers of ships equipped with Davit International fast rescue craft
Status: Adequately addressed

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

Safety issue details
Issue number: MO-2010-004-SI-02
Who it affects: All owners operators and managers of ships equipped with Davit International fast rescue craft
Status: Adequately addressed

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

Safety issue details
Issue number: MO-2010-004-SI-03
Who it affects: All owners operators and managers of ships equipped with Davit International fast rescue craft
Status: Adequately addressed

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

Safety issue details
Issue number: MO-2010-004-SI-04
Who it affects: All owners operators and managers of ships equipped with Davit International fast rescue craft
Status: Adequately addressed

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

Safety issue details
Issue number: MO-2010-004-SI-05
Who it affects: All owners operators and managers of ships equipped with Davit International fast rescue craft
Status: Adequately addressed

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

Safety issue details
Issue number: MO-2010-004-SI-06
Who it affects: All ship owners, operators, managers and seafarers
Status: Adequately addressed

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

Safety issue details
Issue number: MO-2010-004-SI-07
Who it affects: All owners operators and managers of ships equipped with fast rescue craft
Status: Adequately addressed

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.

Safety issue details
Issue number: MO-2010-004-SI-08
Who it affects: All owners operators and managers of ships equipped with fast rescue craft
Status: Adequately addressed

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.

Safety issue details
Issue number: MO-2010-004-SI-09
Who it affects: All owners operators and managers of ships equipped with fast rescue craft
Status: Adequately addressed

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

Safety issue details
Issue number: MO-2010-004-SI-10
Who it affects: All maritime training organisations
Status: No longer relevant
General details
Date: 16 May 2010   Investigation status: Completed  
Time: 0817 (UTC+9.5)   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): off Darwin    
State: Northern Territory    
Release date: 27 July 2011   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: Serious  

Vessel details

Vessel details
Vessel British Sapphire  
Flag Isle of Man  
IMO 9333618  
Type of operation LNG Tanker  
Damage to vessel Nil  
Departure point Yung An, Taiwan  
Destination Dampier, WA  
Last update 14 November 2018