Safety issue

Safety issue description

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.

Issue number MO-2014-002-SI-02
Issue owner Jiangsu Jiaoyan Marine Equipment Company
Transport function Marine: Shipboard operations
Issue status Closed – Adequately addressed
Date issue released 19/05/2015
Issue status justification

The release mechanism design was modified to provide much clearer indication of the hook position with fully reset alignment marks added. 

These modifications, along with warnings in documentation and posted on the lifeboat should reduce the likelihood of inadvertent incomplete resetting of the release hook.

Issue finalisation date 28/11/2024

Safety action

Action type Proactive action
Action number MO-2014-002-NSA-012
Organisation Jiangsu Jiaoyan Marine Equipment Company
Action date 19/05/2015
Action description

All new freefall lifeboats will be supplied with a maintenance pin and instruction plate, which will be mounted on the outside of the lifeboat near the on-load release.

ATSB response

While the maintenance pin reduces the risk of an inadvertent launch during maintenance, leaving the pin in can prevent lifeboat launch in an emergency. The control for this introduced risk is procedural instead of an engineering control.

Action status Released

Safety action

Action type Proactive action
Action number MO-2014-002-NSA-013
Organisation Aquarosa’s managers, V.Ships
Action date 19/05/2015
Action description

An additional pin was fabricated by Aquarosa’s crew so that it could be fitted before entering the lifeboat for any purpose other than launching it.

Shipboard procedures have been implemented which require tool box meetings to be held before entry into the lifeboat to carry out maintenance. These procedures include details of the checks to be made prior to any lifeboat maintenance being carried out. The master’s permission is now required before the lifeboat release system hand pumps are operated and warning signs have been placed at the pump locations stating this requirement.

Aquarosa’s managers have shared the details of the accident within their group and with industry colleagues through safety forums.

ATSB response

While the maintenance pin reduces the risk of an inadvertent launch during maintenance, leaving the pin in can prevent lifeboat launch in an emergency. The control for this introduced risk is procedural instead of an engineering control.

Action status Released

Safety action

Action type Safety advisory notice
Action number MO-2014-002-SAN-005
Organisation Manufacturers of freefall lifeboats and operators of ships fitted with freefall lifeboats
Action date 19/05/2015
Action description

The Australian Transport Safety Bureau advises that all manufacturers of freefall lifeboats and operators of ships fitted with freefall lifeboats should review their on-load release and associated instructions manuals to ensure that crew entering the lifeboat for inspection and maintenance are not exposed to an increased risk due to the removal of the safety pin from the on-load release.

Action status Released

Safety action

Action type Recommendation
Action number MO-2014-002-SR-003
Organisation Jiangsu Jiaoyan Marine Equipment Company
Action date 19/05/2015
Action description

The Australian Transport Safety Bureau recommends that Jiangsu Jiaoyan Marine Equipment Company takes safety action to fully address the issue by providing controls that ensure the freefall lifeboat maintenance pin is replaced by the safety pin after its use.

Action status Released

Safety action

Action type Recommendation
Action number MO-2014-002-SR-004
Organisation V.Ships
Action date 19/05/2015
Action description

The Australian Transport Safety Bureau recommends that V.Ships takes safety action to fully address the issue by providing controls that ensure the freefall lifeboat maintenance pin is replaced by the safety pin after its use.

Action status Released

Safety action

Action type Proactive action
Action number MO-2014-002-PSA-296
Organisation Jiangsu Jiaoyan Marine Equipment Company
Action description

2024—Contact established with Jiangsu Jiaoyan Marine Equipment Company (aka JY Boat) and response received: 

'After checking, regarding to this 5.8m free fall lifeboat, we sent out technical bulletin at that time, pls kindly see attachment.'

The Technical bulletin related to the lifeboat release mechanism system (JX-4) Type JY-FN/FF-5.8. This bulletin included reference to the ATSB report findings of the release mechanism not being fully reset. As a result, changes were made to the release mechanism to include an alignment mark indicator for the locked position and a warning sign posted adjacent to the mechanism.

ATSB response

The release mechanism design was modified to provide much clearer indication of the hook position with fully reset alignment marks added. 

These modifications, along with warnings in documentation and posted on the lifeboat should reduce the likelihood of inadvertent incomplete resetting of the release hook.