WADDENS - Australian Transport Safety Bureau (ATSB) · Navigation Act 1912 Navigation ... master, two mates, a chief engineer, electrician, ... an Advanced Safety Course, dated July

Report No 145

Navigation Act 1912

Navigation (Marine Casualty) Regulations

investigation into a lifeboat accident

and injury to crew

aboard the Antigua & Barbuda flag vessel

WADDENS

at Cairns Harbour

on

14 February 1999

Issued by the

Australian Transport Safety Bureau

October 2000

ISBN 0 642 20033 5

Investigations into marine casualties occurring within the Commonwealth's jurisdiction areconducted under the provisions of the Navigation (Marine Casualty) Regulations, madepursuant to subsections 425 (1) (ea) and 425 (1AAA) of the Navigation Act 1912. TheRegulations provide discretionary powers to the Inspector to investigate incidents asdefined by the Regulations. Where an investigation is undertaken, the Inspector mustsubmit a report to the Executive Director of the Australian Transport Safety Bureau(ATSB).

It is ATSB policy to publish such reports in full as an educational tool to increaseawareness of the causes of marine incidents so as to improve safety at sea and enhance theprotection of the marine enviroment.

To increase the value of the safety material presented in this report, readers are encouragedto copy or reprint the material, in part or in whole, for further distribution, but shouldacknowledge the source. Additional copies of the report can be obtained from:

Inspector of Marine AccidentsAustralian Transport Safety BureauPO Box 967Civic Square 2608 ACT

Phone: 02 6274 6088Fax: 02 6274 6699Email: [email protected] address: www.atsb.gov.au

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Contents

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Sources of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Waddens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Lifeboats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

The incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Comment and analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

The release mechanism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Attempting to re-create the incident . . . . . . . . . . . . . . . . . . . . . . . . . .10

Interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Placement of the release lever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

The manufacturer’s comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

The accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Lifeboat maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Issues of design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Submissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Details of Waddens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Figures1.Waddens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iv

2.Waddens port lifeboat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

3.Lifting hook, cover plate removed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

4.Release lever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

5.Release lever mechanism diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

6.Events and causal factors chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

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SummaryOn 13 February 1999, the motor vesselWaddens was berthed, port side to, at No. 8 wharf in the port of Cairns. Thevessel had been on a voyage from Lihir,Papua New Guinea, to Tauranga, NewZealand, but had diverted to Cairns after itexperienced problems with the mainengine turbocharger.

The master and mate decided that theopportunity should be taken to run thestarboard lifeboat. Permission wasobtained on 14 February from CairnsHarbour Control to lower the boat and runit in the harbour. The boat was lowered tothe water at 0830, manned by the 2nd mateand an able-bodied seaman (AB) andtested for about an hour.

At 0930, the lifeboat was positioned underthe falls for hoisting and connected to thelifting hooks. There was some difficultyexperienced in positioning the boat underthe falls because of a strong tidal flow.The mate, bosun and an AB were standingby on the ship while the falls were beingconnected and the boat was hoisted.

When the boat was ready for hoisting, the2nd mate returned to the aft end of the boat

while the AB remained forward. The boatwas hoisted to a position where the tricingpendants were to be attached and thewinch stopped. At that moment, the fallssuddenly disengaged and the lifeboat fellto the water, landing upright.

The 2nd mate was observed lying on theaft deck just outside the cabin. The AB,who had been at the fore end of the boat,was in the water. The AB who had beenstanding by on board the ship divedoverboard to assist him. Both AB’s thenclimbed aboard the lifeboat and, while oneof them assisted the 2nd mate, the othermanoeuvred the boat to the wharf andmade it fast.

Having informed the master of theincident, the mate called Cairns HarbourControl to request assistance and anambulance. The ambulance arrived atabout 0945 whereupon paramedicsattended to the 2nd mate. The lifeboat wastowed by a coastguard craft to a marinapier from where the 2nd mate was takenashore and transported by ambulance toCairns Base Hospital.

At about 1015 the lifeboat was returned toWaddens. It appeared to be undamagedand was later hoisted and stowed on boardwithout further incident.

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Sources ofinformationThe master, officers and crew of Waddens

Germanischer Lloyd (GL)

Queensland Police Service (Water Police)

Australian Maritime Safety Authority(AMSA)

Transport Accident InvestigationCommission of New Zealand

AcknowledgmentErnst Hatecke GmbH for provision ofmanuals and drawings.

Photograph of Waddens trading as‘Southern Man’; the Director, Cool LineReefers Ltd, agents for the vessel’scharterers, Pacific Tiger Line Ltd.

Narrative

WaddensWaddens is a general cargo vesselregistered in Antigua and Barbuda. Thevessel has a length of 99.5 m, a beam of17.2 m and a gross tonnage of 3 784. Ithas a deadweight of 5 189 tonnes at asummer draught of 6.5 m and is able tocarry 350 twenty-foot containers,including 20 reefer containers. It has onehold and the engine room and accommo-dation are aft.

The ship was built at Oldenburg inGermany in 1984 as the Weser Guide. In1988 the name was changed to ZimKingston and in 1995 to NedlloydTrinidad. Prior to the name change toWaddens, it was known as the Rangiora.Waddens is strengthened for ice and forheavy cargoes and is classed withGermanischer Lloyd.

At the time of the incident, Waddens wasowned by a German company, Baum andCo, and was managed by the timecharterers, Pacific Tiger Line in Auckland,New Zealand.

Waddens is fitted with a MaK 6M551AKsingle acting, diesel main engine of 2 501 kWdriving a controllable pitch propeller,giving the ship a speed of 14 knots. Thevessel has a bow thruster. Navigationequipment includes radar, satellitenavigation and satellite communicationsystems.

The ship’s complement consists of themaster, two mates, a chief engineer,electrician, a bosun and three deck crew, amotor mechanic and a cook. The masterand mate were from New Zealand, thechief engineer was from Germany, the 2nd

mate, electrician and cook were from thePhilippines, the bosun, deck crew and themotor mechanic were from Tuvalu.

The 2nd mate held a chief mate’scertificate of competency issued in thePhilippines. He also held a certificate foran Advanced Safety Course, dated July1997 and had been at sea for 15 years.

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FIGURE 2.Waddens port lifeboat

Lifeboats Waddens is equipped with one lifeboat oneach side stowed in gravity davits, eachwith a capacity of 18 persons. The boats,manufactured by Ernst Hatecke inDrochtersen, Germany, are closed motorboats with a length of 6.6 m, a breadth of2.5 m and a depth of 1.18 m. Both boatshave cabins extending aft for about 3.8 mfrom a short, raised foredeck about 60 cmin length. The after deck extends from theaft end of the enclosed cabin, for just overa metre, to a raised stern (see fig. 2, page 3).

Entrance to the cabin is through a door atthe aft end and through a forward openinghatch at the forward end, the steeringconsole being fitted on the port sideforward. The hoisting hooks (see fig. 3)for the boats are fitted on the foredeck andthe stern.

The boats are fitted with an ‘on load’release mechanism designed so that they

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FIGURE 3.Lifting hook, plate removed

FIGURE 4.Release mechanism

Release lever

Pin

Pawl disengaged

can be released while suspended by thefalls or when being towed under the fallsby a moving ship.

The release mechanism (see fig. 4 & fig.5page 8) consists of a release lever fitted atthe starboard side of the steering console.The release lever is connected by flexiblecables to locking bolts in the hoistinghooks. To release the hooks it is necessaryto unlock the release lever and pull it back.The locking bolts rotate, releasing thehooks and disengaging the falls. There aretwo locking devices for the release lever, asafety pin and a pawl.

The incidentWaddens had sailed from Lihir, PNG, on 7 February 1999 for Tauranga, NewZealand with a cargo of empty containers.The vessel diverted to Cairns after experi-encing main engine turbocharger problemsand berthed at No. 8 Wharf in Cairns at2100 on 13 February.

The weather in far North Queensland atthe time was unsettled. It was the wetseason and cyclone Rona had been in thevicinity on 12 February.

The vessel normally berthed starboard sideto when working cargo. On this occasionWaddens berthed port side to the wharfand the master and mate decided to usethis opportunity to lower the starboardlifeboat and run it in the harbour.Permission was obtained on 14 Februaryfrom Cairns Harbour Control for this. Atabout 0830 the starboard boat was loweredto the water and the 2nd mate and an ABtook the boat for a run in Trinity inlet.

At about 0930, the mate instructed the 2nd

mate by radio to return to the vessel andsecure the lifeboat. The mate, bosun and

an AB stood by on board Waddens at thestarboard boat station.

The 2nd mate experienced difficulty withpositioning the lifeboat under the falls.There was a strong tide running at the timeand the boat had the tide astern. Highwater was at 0822 and the out-going tidewas probably strengthened by localfloodwater.

The 2nd mate made three attempts toposition the boat before he managed tohook on the after falls. The forward fallwas initially hooked on to the tricingpendant eye before being connected,correctly, to the hoisting hook on the boat.The bosun called out to the 2nd mate andthe AB to warn them when he saw thatthey were using the eye for the tricingpendant to attach the forward falls. The2nd mate was aware that the falls had beenincorrectly set up, but the eye for thetricing pendant was convenient as atemporary measure while he tried toposition the boat under the falls in thestrong tide.

When both falls were correctly hooked up,the lifeboat was hoisted. According to the2nd mate and the AB in the boat, therelease lever was secured with the pin andpawl and the hooks were engaged by thelocking bolts before the boat was hoisted.

As the boat was hoisted the 2nd mate wasbehind the cabin near the after fall. TheAB was seated on the tiny area of foredeck with his legs through the forwardopening hatch.

The lifeboat was hoisted almost to theembarkation deck and was about 6 m fromthe water when hoisting was stopped toenable the tricing pendants to be hookedonto the shackles. At that moment the 2nd

mate saw the after hook release. The mate

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and bosun saw the aft end of the boat dipfirst, followed immediately by the forwardend as the forward hook released.

When the boat dropped, the mate, bosunand the AB looked over the side to see thatthe lifeboat had landed upright in thewater. The 2nd mate was lying on the afterdeck, just outside the cabin door,apparently injured.

The 2nd mate had been holding on to agrab rail adjacent to the aft door of thecabin. When the boat dropped and hit thewater, he had been flung against the sidesof the boat and the deck.

The AB who had been in the boat at thebow was seen in the water and the AB atthe starboard boat station dived in to assisthim. The AB in the water was uninjuredand had apparently leaped clear just priorto the boat landing in the water. BothAB’s then climbed into the lifeboat.

The mate, after informing the master ofthe incident, contacted Cairns HarbourControl to notify them of the incident andto request ambulance assistance for the 2nd

mate.

Meanwhile the AB who had been in theboat when it was hoisted, attended to the2nd mate. The other AB manoeuvred theboat forward and it was made fastalongside the wharf.

The ambulance arrived at the wharf atabout 0945 and paramedics attended to the2nd mate. A small coastguard craft towedthe lifeboat to a pier from where the 2nd

mate was taken by ambulance to hospital,accompanied by the mate.

At about 1015 the lifeboat was returned tothe ship. When the mate returned to theship at about 1200, he inspected the davits,the falls, the fall blocks and the liftingeyes. He could find nothing amiss. Healso inspected the boat, the lifting hooksand the release lever. The release leverwas in the locked position with the safetypin fitted and pawl engaged.

At 1335, a senior constable from theCairns Water Police attended the vesseland interviewed the master. The mastercompleted a Queensland Transport marineincident report form on the accident. Thesenior constable arranged for photographsto be taken of the lifeboat and davits toassist with determining whether thehoisting gear was defective.

The lifeboat was inspected and found tohave no apparent damage. It was attachedto the falls once more and hoisted to itsstowed position without incident.

The Australian Maritime Safety Authority(AMSA) surveyor at Cairns was notifiedof the incident the next day and boardedthe vessel at 1030 that day to obtain areport of the incident. He inspected theboat in its stowed position and could seeno signs of damage to the boat. He alsochecked the release mechanism and wasunable to find any reason for amalfunction. He advised the master tocontact the vessel’s classification society,Germanischer Lloyd (GL) and arrange forinspection and testing of the lifeboat fallsand davits. The tests were arranged for0900 the next day.

The AMSA surveyor was then appointedas an investigator by the Inspector ofMarine Accidents to conduct the investi-

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gation on behalf of the Marine IncidentInvestigation Unit (MIIU - later to becomepart of the ATSB).

At 0900 on 16 February 1999, theinvestigator and a surveyor for GLcommenced the tests. The lifeboat waslaunched without incident and aninspection of the release mechanism andhooks was carried out. Then, with theboat just clear of the water, severalattempts were made to induce the release

mechanism to operate, to simulate theincident, but without success.

The lifeboat, davits, falls and brakes weresuccessfully load tested by the GLsurveyor and no defects were found.

The 2nd mate’s injuries, initially reportedas a broken arm and leg, required him tobe admitted to hospital and, subsequently,to be repatriated.

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Comment andanalysis

EvidenceOn 15 February 1999, the investigatorinterviewed the master and others involvedin the incident, except for the 2nd matewho was in hospital. He also obtained astatement from the mate.

The 2nd mate was interviewed thefollowing day and again after his releasefrom hospital.

The investigator’s report with attachmentsincluding the mate’s statement,photographs, a record of interview withthe 2nd mate, the lifeboat manual and thereport from the classification society, wassent to the MIIU.

The manufacturers of the lifeboat, ErnstHatecke of Drochtersen in Germany, wereinformed of the incident and were askedfor comments on the release of the boat.They replied that it must have been humanerror and explained the operation of thelifting hooks in detail. They also supplieddrawings and the manuals for the releasemechanism and for the boat.

On behalf of the MIIU, the TransportAccident Investigation Commission(TAIC) in New Zealand conductedadditional interviews with the master andmate in December 1999 (both live in NewZealand) in an attempt to determine thesequence of events that led to the incident.

Investigators from the MIIU visitedWaddens (now trading as Capitaine Bligh)on 14 December 1999 at Sydney. As thevessel was berthed starboard side to, the

boat could not be lowered, but the hooksand release mechanism were examined ina further attempt to determine the cause ofthe release.

A simplified events and causal factorsdiagram is shown at page 14.

The release mechanismThe manual for the operation of the boatcautions that the hooks may be releasedunder load in any position. The lever forthe release mechanism of the boat issecured by two locking devices, a pin anda pawl. The manufacturer’s manual refers to thepin as a safety pin (see fig. 4, page 4).

The safety pin passes through a bracketthat houses the release lever, preventingthe lever from being moved unless the pinis first withdrawn and the pawl lifted. Thepawl, which engages in a lug on therelease lever, must be lifted clear of thelug to permit movement of the releaselever.

The manual states:

To release the hooks:

1. Turn the safety pin and pull it out.

2. Move up the locking pawl and pull the release lever.

3. After releasing the hooks return the release lever to the original position.

For preparing to hoist the boat, the manualstates:

1. Check the resting position of the hooks and release lever (safety pin in place).

2. Push the long link into the hooks.

The manufacturers confirmed that, afterthe hooks were unlocked, under the weightof the boat, they would open, freeing thefalls and releasing the boat. When the

boat was released, the hooks weredesigned to be returned to an uprightposition by counterweights. When therelease lever was returned to its originalposition, the hooks would be secured oncemore. The hooks would then be ready, ifrequired, for the falls to be hooked upagain after the release lever was secured.

Attempting to re-create theincidentAt 0900 on 16 February, with the boat justclear of the water, the investigator and theclass surveyor made several attempts todetermine the cause of the incident. Theydid this by raising the boat with the releaselever not locked in position and with thehooks not correctly secured by the lockingbolts.

They determined that the boat could behoisted with the release lever housed as itshould be for hoisting, but not locked byeither the safety pin or the pawl. This wascarried out to see if the load on the hookswould induce the release lever to operate.That did not happen.

The boat was then hoisted with the hooksnot locked by the locking bolts but, assoon as the load came onto the hooks, theyrotated and released. This test showed thatif the hooks were not properly locked, theywould release immediately any weightcame on them.

The release mechanism operated as it wassupposed to and there was no indicationthat any mechanical failure might havebeen a factor in the incident.

Interviews None of those interviewed could explainwhy the boat had dropped off the falls.

The master and mate stated that the 2nd

mate and the AB were experienced in thelaunching and recovery of the lifeboat,often working together as they were on theday of the accident.

When the 2nd mate was interviewed, hestated that:

• The falls were properly engaged in thehooks prior to the boat being lifted

• The hooks were correctly locked

• The release lever was in its correctposition and both locking devices wereengaged.

The AB who had been in the boat with the2nd mate agreed that the falls wereproperly engaged and that the hooks werecorrectly locked. He was certain that therelease lever was in its correct positionand that it was locked with both lockingdevices.

The master had examined the boat shortlyafter the incident and the mate furtherexamined the boat at about 1200, abouttwo and a half hours after the incident.Neither the master, nor the mate was ableto find anything wrong with the releasegear or the lifeboat and could onlyconclude that human error had caused theaccident.

The master was again interviewed on 6 December 1999 and described events ashe remembered them. During theinterview, he stated that he had beeninformed that the AB had been on theforedeck of the boat, coiling the rope intothe cabin through the open hatch. Themaster thought that the build up of ropemight have dislodged the release lever andhe seemed sure that there was a

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connection between the coiling of the ropeand the release of the boat.

The mate was again interviewed on 7 December 1999. He stated that, at thetime of the accident, the 2nd mate was inthe cockpit behind the cabin and the ABwas forward, coiling the painter into thecabin through the open forward window.The AB was half in and half out of thewindow while he was coiling the rope.

In the opinion of the mate, in that position,the AB ran the risk of fouling the releaselever either with his leg or with the ropeand, if the securing devices for the releaselever were not in place, the release levercould be accidentally operated.

The mate checked the release lever abouttwo and a half hours after the incident andfound that it was in the locked positionwith both securing devices fitted.However, the nature of the accident led themate to conclude, after tests on the boat bythe investigator and the class surveyor, thatthe release lever must have been operatedto cause the boat to drop and that the leverwas subsequently repositioned and securedbefore he was able to examine it. Therewas sufficient time between the incidentand the mate’s examination of the boat forthis to have been done.

The problem in positioning the boat underthe falls when it returned to the ship andthe initial use of the eye for the tricingpendant to secure the forward fall had nobearing on the accidental release of theboat.

Placement of the release leverThe release lever was located on the righthand side of the steering console. It waspositioned so that looking down from the

(backward sloping) forward window of thecabin, only the lower half of the lever andthe safety pin and pawl could be seen.The upper half of the lever was hiddenfrom view under the backward slope of thecabin front.

With the release lever secured by thesafety pin and pawl, it would not havebeen possible to operate it. If the safetypin and pawl were not in position however,it is conceivable that the lever could bemoved by inadvertent contact with theAB’s foot or leg, although that isconsidered unlikely, due to the lever’sposition. It is also unlikely that the AB,who was reported to be familiar with thesystem, would operate the release lever,when the boat was suspended above thewater.

The mate mentioned that the AB had beencoiling the painter while he was half inand half out of the forward hatch. If thesafety pin and pawl were not in position,or if the AB had removed the pin and thepawl to clear a tangle of rope, it is possiblethat, with the rope and the AB’s legs inclose proximity to the release lever, thelever was fouled and drawn aft, releasingthe boat.

The time taken for the boat to drop 6 mwith an acceleration of 9.81 m/sec/sec iscalculated to have been 1.1 seconds. Inthat time the AB had either leaped over theside into the water or was thrown clear ofthe boat, sustaining bruising only. Thiswould seem to indicate that the AB waseither outside, or was extricating himselffrom the hatch as the hooks released. Itwould also be consistent with the need forthe AB to adjust his position to secure thetricing gear. This was supported by the2nd mate’s statement that the incident

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occurred as the hoisting had stopped andthat both men were preparing to secure thetricing pendants.

Every indication is that the release leverwas operated and, despite the 2nd mate andAB maintaining that the lever was locked,the safety pin and pawl could not havebeen in place.

The manufacturer’s commentsTo assist with analysing the incident, thematter was referred to the manufacturersof the boat for their comments. Themanufacturers responded;

The boats of this ship have been deliveredin February 1984 to Brand Werft inGermany. The boats are equipped with on-load hoisting hooks. Hook bedding andrelease mechanism tests have been carriedout under survey of See-BG. From 1984 upto now we have received no informationregarding these boats, consequently thehoisting hooks have never been maintainedby us.

From the accident report, we have to takethe conclusions regarding this accident thatthe hooks have been released by the releaselever in normal on-load operation by aperson which was not familiar with it.

A disadjustment of the system wouldnormally interfere only with one hook side.As both hooks have been released togetherwe have some doubts regarding adisadjustment.

The accidentThe investigation revealed no evidence ofmechanical failure. To release the hooks,the release lever would need to beunlocked and then pulled back. Themanufacturers also concluded that therelease lever would have been operated inthis instance though they might not becorrect in assuming that the person whocaused the release of the hooks was not

familiar with the system. The master andmate considered that both the 2nd mate andAB were familiar with the system.

The 2nd mate and AB were adamant thatthe release lever was secured by the pinand the pawl. For this accident to haveoccurred, however, they must have beenmistaken.

The issue of the jerk that is oftenexperienced when stopping the hoisting ofa boat was examined as a possiblecontributory cause. However, during thehoisting tests carried out after the incidentby the investigator and the class surveyor,with the release lever in the correctposition but unsecured, no evidence wasrevealed to support this possibility.

Lifeboat maintenance The operation and maintenance manualstated that the hoisting hooks were to becleaned of salt deposits every month and,that every month, all moveable parts of thehoisting hooks and release lever were to belubricated. The manual also stated that acheck for correct functioning of therelease system was to be carried out everymonth. A more recent requirement is thatan operational test under a specified loadis to be carried out every 5 years.

The company was ISM accredited, but theship was not yet required to be accredited.The maintenance records for the boats andfittings were requested by the MIIU, butthe indications were that these records didnot exist.

Issues of designThe MIIU has investigated two otherincidents where lifeboats were releasedinadvertently because release mechanismswere apparently mistaken for engine orsteering controls or were thought to

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operate steering. Both these incidentsinvolved issues of ergonomics and trainingof the crew.

In one instance, a lever at the starboardside of the engine casing operated themechanism for on-load release of the boat(MIIU report no. 71). The lifeboat enginewas being run while the boat was swungout and suspended under the davits, butthe propeller was stationary. In an attemptto put the lifeboat into gear, it is probablethat one of those in the boat pulled therelease lever, releasing the boat. Theinvestigators were struck by the similarityof the lever to the levers for ahead andastern gear for engines on a number oflifeboats.

In another instance, a crewmember wasinstructed, during a Port State Controlinspection, to operate the boat’s rudder.The crewmember turned a radial spokedwheel adjacent to the coxswain’s seat, butthis operated the release mechanismresulting in the lifeboat being launchedover the ship’s stern. The steering wheelwas located on a console in front of thecoxswain’s seat and the report concludedthat one of the main contributing factorswas the crewmember’s lack of knowledgeof free-fall lifeboat controls (MIIU reportno. 128).

In each case, crewmembers sufferedserious injuries requiring hospitalisationand repatriation.

In the case of Waddens, though the boat’screw was said to be familiar with the

release mechanism, the most likelyexplanation for the cause of the incident isthat the release lever was not secured bythe safety pin and pawl.

There was a very small area of foredeckon the boat, 60 cm in length at thecentreline. Most of the space on theforedeck was taken up by the hoistinghook and other fittings. It would require acertain amount of agility to carry out anytasks at the fore end of the boat and itcould be safest to have one’s legs on oneof the steps within the boat. In thatposition, however, the release lever was inclose proximity and there would be thedanger of contact with it. The problemcould be more acute if a crewmember wasstanding on a step next to the release lever,coiling a rope within the boat at the sametime. Space would be at a premium andthis could lead to fouling of the lever.

The position of the lever is such that itinterferes with free movement on the stepsleading to the forward hatch of the boat. Itis also close to the control position for theengine where there is the potential forconfusing the lever with the gear lever forthe engine.

It could not be established exactly whenthe lifeboat engine was taken out of gearor stopped. Even though there is noevidence that the release of the boat wasdue to any ambiguity in design, theInspector considers that the proximity ofthe release lever to the engine controlsillustrates a need for improvedergonomics.

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ConclusionsThese conclusions identify the differentfactors contributing to the incident andshould not be read as apportioning blameor liability to any particular individual ororganisation.

Based on the available evidence, theInspector concludes that:

1. Mechanical failure was not a factor.

2. The locking devices securing the releaselever were not engaged.

3. The release mechanism was operatedinadvertently, possibly by the boat’spainter fouling the release lever.

Contributing to the accident were issues ofpoor ergonomic design:

1. The release lever was fitted at a positionin the boat where it could interfere withfree access to and from the fore deckthrough the cabin window.

2. The location of the release lever meantthat, if unlocked, it might be movedaccidentally to a position at which thehoisting hooks could release.

3. Although there is no evidence that the release lever was mistaken for the gearlever for the engine in this instance, theproximity of the lever to the enginecontrols, in the Inspector’s opinion,increased the possibility of accidentalrelease.

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SubmissionsUnder sub-regulation 16(3) of theNavigation (Marine Casualty)Regulations, if a report, or part of a report,relates to a person’s affairs to a materialextent, the Inspector must, if it isreasonable to do so, give that person acopy of the report or the relevant part ofthe report. Sub-regulation 16(4) providesthat such a person may provide writtencomments or information relating to thereport.

The final draft of the report, or relevantparts thereof, was sent to:

The vessel’s managers

The master, mate, 2nd mate and the AB

Submissions were received from the mateand the 2nd mate and the report wasamended where necessary.

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Details of WaddensIMO No. 8317978

Flag Antigua and Barbuda

Classification Society Germanischer Lloyd

Vessel type General cargo

Owner Baum and Company

Year of build 1984

Builder Brand Schiffswerft, Oldenburg, Germany

Gross tonnage 3 784

Summer deadweight 5 189 tonnes

Length overall 99.5 m

Breadth, extreme 17.2 m

Draught (summer) 6.5 m

Engine 6 cyl. MaK 6M551AK single acting diesel

Engine power 2 501 kW

Service speed 14 knots

Crew 11

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