202042 Premature break release spills two crew into water
Edited from official TSB (Canada) report M18P0257
A roro ferry was at dock with no passengers embarked, and was running various planned boat and fire drills. The original rescue boats delivered with the ship had been replaced with newer models.
Two deckhands prepared rescue boat No. 1 for launch, and were shortly afterwards joined by an engineer. Because there was no deck officer present at this boat, one of the deckhands assumed duties as ‘officer in charge’ while also acting as coxswain. The other deckhand was the bowman and the engineer operated the davit.
The deckhands completed the boat station checklist and checked the brake release line bag, which contained the extra slack of the brake release line. The two deckhands boarded the rescue boat, placing the brake release line bag on the deck of the ferry.
They then signalled the davit operator to raise the boat from its cradle. When the boat had sufficient clearance from the cradle, the coxswain pulled the self-slewing line hanging above the rescue boat to slew the davit arm outboard. Approximately 15 cm of brake release line uncoiled from the storage bag on deck as the arm slewed. Then, the brake release line snagged on a vertical section of the cradle post creating tension on the brake release line.
As the davit arm slewed further outboard, tension on the brake release line increased sufficiently to release the brake. The rescue boat dropped, its hull hitting the raised edge of the outboard deck. It then tilted outboard to such a degree that the two men in the boat fell overboard.
One fell approximately 14 metres into the water below, while the other managed to grab hold of the rescue boat’s painter line four metres above the water, but eventually let go and dropped approximately two metres into the water. The rescue boat reached the water level soon after. The two men were quickly recovered from the water and received first aid before being taken to a local hospital. They were discharged later that day.
Some of the findings of the official report were:
- The new rescue boats that had been installed on the ferry were of a greater height than the original rescue boats. Some of the rescue boat crews had developed an informal practice of removing the rescue boat’s brake release line bag from its on board storage container and leaving it on the deck when the rescue boat was not self-launched.
- When the crew removed the brake release line storage bag from the rescue boat, there was noone available to take the bag from the crew, so it was left unattended on the deck. l Although the coxswain assumed the responsibility of officer in charge of the rescue boat, his ability to supervise the launching operation was limited while he was actively engaged in his duties as coxswain. Lessons learned l Any time you improvise or deviate from established procedures, risks can increase.
- Keep a keen eye for the signs of developing informal practices which insinuate themselves into established routines.