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What happened

On 1 March 2014, Aquarosa was transiting the Indian Ocean en route to Fremantle, Western Australia, when its freefall lifeboat was inadvertently released during a routine inspection. A ship’s engineer, the only person in the lifeboat at the time, was seriously injured in the accident.

About 5 hours after its release, the ship’s crew recovered the lifeboat and resumed the voyage. On 8 March, the ship berthed in Kwinana, near Fremantle, and the injured engineer was transferred to hospital.

What the ATSB found

The ATSB found that when the lifeboat on-load release was last operated before the accident, it was not correctly reset. Consequently, when the engineer operated the manual release pump to inspect the equipment, the incorrectly-reset release tripped unexpectedly. The simulation wires, designed to hold the lifeboat during a simulated release, failed and the lifeboat launched.

The investigation found that although there was an indicator to show that the hook was in the correct position, there was nothing to indicate that the tripping mechanism was correctly reset. It was also found that the design and approval process for the lifeboat’s simulated release system had not taken into account effects of shock loading on the simulation wires.

What's been done as a result

Aquarosa’s shipboard procedures were revised shortly after the accident. Changes included the introduction of a requirement to notify the officer of the watch before entering the lifeboat. Notices were posted at the on-load release hydraulic pump positions, stating that the pumps must not be operated without the master’s permission.

Via a circular, Aquarosa’s managers, V.Ships, notified all ships in its fleet of the accident and its internal investigation findings. The circular also required the masters of all ships fitted with the same type of on-load release, to similarly revise the instructions for its operation and resetting. In addition, masters were required to review the simulation wire maintenance and inspection regime.

On 17 March 2014, the ATSB contacted V.Ships, the ship’s flag State (Malta), Bureau Veritas, the lifeboat manufacturer, the International Association of Classification Societies and the Australian Maritime Safety Authority (AMSA) and advised them of the ATSB’s preliminary findings. The parties were asked to identify ships equipped with similar freefall lifeboat arrangements and to advise operators of those ships to take safety action to prevent a similar accident.

In response, AMSA informed its surveyors of the accident and the ATSB’s preliminary findings, and asked them to pay particular attention to these issues during flag and Port State inspections.

Safety action by the manufacturer included placing alignment marks on the release segment of new on-load releases mechanisms, to indicate when they are correctly reset. A lock-out ‘maintenance pin’ is also being provided for all new on-load releases to ensure the release cannot trip while maintenance is being performed.

Safety message

When designing and certifying equipment such as on-load release systems for lifeboats, all facets of the equipment’s possible operation, use and environment must be taken into account and allowed for. Only then can fully comprehensive instructions be documented, enabling seafarers and others to safely use and maintain the equipment under all conditions.

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Preliminary report released 31 March 2014

What happened

On 1 March 2014, the 190 m Maltese registered bulk carrier Aquarosa was on a voyage from Singapore to Kwinana, Western Australia, when its freefall lifeboat was inadvertently released during a routine inspection.

A ship’s engineer, who was in the lifeboat at the time of its release, sustained serious injuries. The lifeboat was retrieved on board the ship about 5 hours after its release and the voyage to Kwinana was resumed.

What the ATSB found

The ATSB’s initial analysis of the incident indicates that the lifeboat release mechanism was not fully and correctly reset after it was last exercised and that the hook was released when the engineer topped up the release system hydraulic oil reservoir and manually operated the pump to pressurise the system.

Initial analysis also indicates that the two simulation wires, which were designed to hold the lifeboat when the hook was released during a simulated release, failed at a load significantly below their rated safe working load.

What's been done as a result

On 17 March 2014, the ATSB contacted Aquarosa’s managers, the lifeboat manufacturer, Bureau Veritas, the International Association of Classification Societies, the Malta Merchant Shipping Directorate and the Australian Maritime Safety Authority. These organisations were advised of the incident and the initial findings of the ATSB safety investigation. They were also urged to identify ships fitted with similar freefall lifeboats and to advise operators of those ships to take appropriate safety action to prevent similar accidents from occurring.

Investigation direction

The investigation is ongoing and will focus on determining how the lifeboat release mechanism could be reset incorrectly without an obvious visual indication and why the simulation wires failed.

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Safety issues

MO-2014-002-SI-01 - MO-2014-002-SI-02 - MO-2014-002-SI-03 - MO-2014-002-SI-04 -  

Lack of visual indication for the resetting of the release segment

While the design of the on-load release system allowed the reset position of the hook to be visually confirmed, it did not allow for visual confirmation that the release segment and mechanism had been correctly reset. Consequently, the hook device could appear to be properly reset when it was not.

Safety issue details
Issue number:MO-2014-002-SI-01
Who it affects:All ships with this type of on-load release arrangement
Status:Adequately addressed


 

On-load release safety pin

An equivalent, alternative arrangement to the safety pin had not been provided to prevent inadvertent tripping of the freefall lifeboat’s on-load release during routine operations, such as inspections and maintenance.

Safety issue details
Issue number:MO-2014-002-SI-02
Who it affects:All ships with this type of on-load release arrangement
Status:Safety action pending


 

Simulation wire calculation

The manufacturer’s calculations did not take into account the shock load imposed on the simulation wires or the lifeboat and launching frame mounting points.

Safety issue details
Issue number:MO-2014-002-SI-03
Who it affects:All ships with this type of launch simulation system
Status:Safety action pending


 

Simulation wire approval by a recognized organization

The Recognized Organization’s process for the approval of the simulation wires for ‘maintenance and testing’ had not taken into account the shock loading that would be experienced during testing.

Safety issue details
Issue number:MO-2014-002-SI-04
Who it affects:All ships with this type of launch simulation system
Status:Safety action pending

 
General details
Date: 01 Mar 2014 Investigation status: Completed 
Time: 1118 UTC +8 Investigation type: Occurrence Investigation 
Location   (show map):Indian Ocean, NW Broome  
State: International  
Release date: 20 May 2015 Occurrence category: Serious Incident 
Report status: Final Highest injury level: Serious 
 
Vessel details
Operator: V.Ships (Miami) 
Vessel: Aquarosa 
Flag: Malta 
IMO: 9506708 
Sector: Bulk carrier 
Type of Operation: Marine shipboard 
Damage to Vessel: Minor 
Departure point:Singapore
Destination:Kwinana, WA
 
 
 
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Last update 20 May 2015