Cause & Consequence
- Handling, lifting or carrying
Lifting, crane, rigging, deck operations
WHAT CAUSED IT:
- The hazard created by the high wind was not fully recognized, and the opportunity to call a time out was not taken. The potential to snag the lifeboat release wire had not been recognized during the risk assessment.
- Although the tag lines in use were of the tangle free type, the textile covering on the upper body of the line had become loose and retracted causing a snagging point to occur. This caught the release line and activated the lifeboat brake.
- When the brake drum was opened for inspection, a large amount of oil residue was found on the brake lining. The oil sump had been overfilled above the manufacturer’s recommendations allowing oil to seep through the seals into the brake area. The oil on the brake linings reduced the ability and efficiency of the brake to reset when the counterweight was reapplied.
CORRECTIVE ACTIONS: To address this incident, this company did the following:
Crews were reminded to discuss at their earliest opportunity, the hazards that led to this operational event.
All employees were reminded to consider the following:
- Take into account all conditions during the risk assessment. (i.e., How did the controls to manage the steel plate introduce other hazards in this event?)
- Were the tag lines really inspected and fit for purpose?
- Was the condition of the lifeboat brake with oil contamination an incident waiting to happen?
Supervisors should ask themselves: “What are your expectations of your people to properly risk assess the conditions of the environment they work in and the tools they use?” and “Is maintenance being monitored for quality according to the manufacturer’s procedures?”
All crews were instructed to ensure all tag lines are fit for purpose and sufficient replacement stock is held onboard.
The crews were reminded to review lifeboat maintenance procedures to ensure that the gravity brake is tested by use of the wire release and not by lifting the counter weight.
Maintenance personnel were instructed to check that the lifeboat oil sump levels are correct and that personnel understand the use of level plugs.