Lifeboat incident and injury on board Kayax

Summary

At about 1100 on 9 August 1994, the Panama flag bulk carrier Kayax was alongside in the port of Portland, Victoria, to load a full cargo of grain.

A Surveyor from the Australian Maritime Safety Authority boarded the vessel to undertake a grain loading inspection and a port state control inspection.

As part of the port state control inspection, the port lifeboat was lowered to the boat deck and then recovered to its embarkation position at the davit head. In this position the surveyor asked to see the lifeboat engine run ahead and astern. After some minutes, with the engine running but the shaft in neutral, the boat suddenly became detached from the lifeboat falls and fell to the water, a distance of a little under 20m.

In the boat were the Second Mate and two ratings. The Master was just getting in when the boat fell. The four men were admitted to hospital with significant injuries, the Second Mate suffering serious head and spine injuries requiring prolonged hospital care and rehabilitation.

The boat was recovered from the water and an investigation initiated into the circumstances and causes of the incident.

Conclusions

These conclusions identify the different factors contributing to the accident and should not be read as apportioning blame or liability to any particular organisation or individual.

1. The boat was released by the operation of the releasing handle by one of three people actually in the boat.
2. The port lifeboat on-load release mechanism safety pin preventing movement of the quadrant was not in position and the release system was in the "armed" condition.
3. Although the boats were swung out at regular intervals and the general maintenance ensured the boats were in good working order, the vessel's crew were insufficiently practiced in using the on-load release gear.
4. None of the three people in the boat understood how the on-load release mechanism operated.
5. The two languages used in the instruction manual and on notices inside the boats were inappropriate, given the nationalities of those involved, and the instruction diagrams were not fully understandable without a good knowledge of either Japanese or English.
6. Difficulties in communication through the differing nationalities was a factor in understanding the release mechanism and in passing instructions covering non-standard operations.
7. The incident could have been prevented by the fitting of an operational interlock designed to ensure a two-stage release.