Replacing equipment without reference to documentation is risky

In the latest issue of its Safety Digest, UK MAIB describes how the bow of a high speed ferry was flipped, because the crewmembers made a mistake fitting the new strops. UK MAIB provides a description of the incident and important lessons learned to prevent similar accidents in the future.

The incident

Whilst alongside, the crew of a high speed ferry changed the lifting strops on the vessel’s port and starboard rescue boats. Needing to prove the boats’ operation and train the crew before the ferry returned to sea, it was decided, in accordance with company procedure, to raise and lower both boats without personnel embarked and with the fall prevention device fitted.

The port rescue boat was lifted first. However, having swung the boat over the ship’s side and then having lowered it a few metres, the boat’s bow suddenly flipped up. Unsure of what was causing the boat to become unbalanced, and keen to determine whether or not it was an issue that affected both boats, the crew repeated the procedure using the starboard boat. Te result was the same.

On further investigation it was found that this class of inflatable rescue boat was fitted with multiple lifting points, and discussions with the senior master of a similar ship revealed that the new lifting strops had been fitted incorrectly. Specifically, the rear pair of strops had been connected to the lifting points on the boats’ decks rather than the boats’ transoms.

The crew reattached the strops to the correct lifting points and both boats were lowered and recovered without incident.

Lessons learned:

1. Replacing or repairing equipment without reference to technical documentation is always fraught with risk. In this instance the crew attached the strops to what they genuinely thought were the correct lifting points, inadvertently creating a dangerous situation. The owner has now addressed this by reviewing the ship’s documentation to ensure that details, such as how to attach the rescue boat strops, are properly recorded. The lifting points within the boat have also been clearly marked.

2. However, whilst the crew made a mistake fitting the new strops, they are to be commended for:

    Their adherence to the safety management system requiring that boats be first lowered and recovered empty during drills, which undoubtedly prevented a more serious accident; and,

    Their swift, open, honest reporting of this incident, which has allowed other personnel operating with similar inflatable rescue boats, to learn from their experience.