Nova Bretagne - November 2009

During a routine lifeboat drill, the crew experienced difficulties in getting the boat ready for recovery from the water. Difficulties were experienced with re-setting of the hooks to the locked position but after a number of trial resetting operations, secured in a state that was believed to be safe for hoisting. The lifeboat had been hoisted to the stowed position when the after hook opened unexpectedly. This was followed by a similar opening of the forward hook and the boat fell to the water where it impacted in an inverted attitude. Three seafarers in the boat sustained serious injuries.

It is not possible to eliminate causes down to a simple single failure in equipment or procedures. The danger of doing so would be to miss the many complex elements that can contribute to an accident.

The accident was the direct result of the failure of a number of systems, because of the lack of redundancy of safety systems the situation deteriorated rapidly to a catastrophic conclusion. This was because the suspension system of the boat, which consisted of a double fall arrangement was itself subject to a single point of failure when a single part of that system - the after hook - opened when the craft was almost fully stowed. The boat was then exposed to a fall of approximately 12 metres to the sea surface impeded only by contacts with the davit structure and possibly the deck edge on the boat deck. The forward hook remained connected for a very brief period until it too opened under the much increased load.
The crew of the lifeboat appear to have failed to ensure that the locking Cam Plate of the hooks – both forward and aft – were in the correct position to lock the mechanisms.
The instructions for setting of hook mechanisms do not emphasise forcefully enough particular dangers in failing to operate the system properly.

Irrespective of whether there were failures in the mechanical systems or operational procedures, the boat could not have fallen if Fall Protector Devices (FPDs) had been in place. FPDs would have provided an alternative load path at each of the hook connections or could have involved a secure locking of the same hook closed. These FPDs however were not in place despite the recommendation for their use as outlined in Bahamas Maritime Authority Bulletin 117 (SEE FLAG STATE CIRCULARS) and subsequently  reinforced by IMO MSC Circ. 1327.(SEE IMO CIRCULARS)

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Nova Bretagne - Nov 2009