Investigation number
Occurrence date
Indian Ocean, NW Broome
Report release date
Report status
Investigation level
Investigation type
Occurrence Investigation
Investigation status
Occurrence category
Serious Incident
Highest injury level

Safety summary

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.

Vessel Details
Departure point
Kwinana, WA
Vessel name
Marine vehicle sector
Bulk carrier
Marine occurrence type
Marine Operation Type
Marine shipboard
Vessel Operator
V.Ships (Miami)