On 17 October 2001, GULSER ANA was alongside in Belfast, Ireland.
The previous day the ship had undergone a port state control inspection
and a number of deficiencies were noted, in particular,
that the on-load release hooks on the starboard lifeboat were seized.
At 08:00 the starboard lifeboat was lowered to the water
so two seamen could free up and grease the hooks.
The seamen found in the course of their work
that the operating rod for the after hook had sheared
and so they used some lashing to secure the hook in the closed position.
When they had completed their work,
the lifeboat was hoisted back to the embarkation deck
and the mate boarded the lifeboat to inspect the work.
Approximately 30 seconds to a minute later, the forward hook opened spontaneously
and the lifeboat was left hanging vertically from the after fall.
The two seamen and the mate fell into the water.
The two seamen, who were wearing lifejackets,
managed to bring the mate to the surface
and were picked up a short time later by a pilot launch.
The seamen had both sustained minor injuries and the mate was hospitalised
with more serious injuries.
3. Contributing Factors:
- The release mechanism was poorly maintained and in an unsafe condition.
- The safety pin securing the release lever was missing.
- It is possible that the forward hook was either not fully reset
or that the crew in the lifeboat inadvertently tripped the release lever.
- The crew did not have sufficient training or instructions to safely maintain the system.
- The on-load release manufacturer’s operating and maintenance instructions were not in the language of the crew.
- The ship had no system in place to ensure
that the repair and testing of the hooks was carried out safely and effectively.
- An ISM Code audit carried out on behalf of the Flag Authority did not ensure
that the instructions for the maintenance of the lifeboat release system
were appropriate, comprehensive and easily understood by the crew.
4. Issues Raised/Lessons Learned:
Operations involving the maintenance and operation of lifeboat on-load release systems are inherently risky.
Every ship’s safety management system should include rigorous provisions
for training, maintenance and the operation of these systems.
5. Observations on the Human Element:
The operation and maintenance instructions for the lifeboat on-load release system
were not in the language of the crew and were thus effectively useless to them.