SECTION 4 - Marine Accident Investigation Branch

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SECTION 3 - CONCLUSIONS
3.1 SAFETY ISSUES DIRECTLY CONTRIBUTING TO THE ACCIDENT wHICH
HAVE RESULTED IN RECOMMENDATIONS
1. The first cook’s lack of experience and inadequate understanding of his lifeboat
crew duties resulted in him being unable to operate the forward bowsing gear and to
release the tricing pennant safely when instructed to do so. [2.2], [2.6.5]
2. The method of securing the bowsing tackle rope to the bitts makes the rope
vulnerable to slippage, resulting in slackening of the bowsing tackle if the operator is
not in-line with the bitts to back up the tail of the rope. [2.3], [2.4.2]
3. The tender coach roofs and the open lifeboats’ stem and stern compartment roofs,
which were accessed by the lifeboat teams, were smooth and not finished with a
non-skid application to prevent falling as required by LSA Code and Section 3.10 of
MSN 1676(M). [2.4.1]
4. Requiring a single crewman to secure and hold the bowsing tackle rope and, at the
same time, remove the drop-nosed pin securing the tricing pennant release lever,
and then operate the tricing pennant release lever, risks overloading that person.
[2.4.2]
5. Commercial pressure impacted on the ship’s management team’s focus on
preparing the vessel for its operational role. [2.6.2]
6. The STO’s reporting line by-passed the SO and, despite having the ship’s overall
training responsibility, there was no evidence that the onboard safety management
team provided anything other than a superficial level of training oversight. [2.6.2]
7. There was no evidence that the need to allocate time for training requirements had
been integrated into the refit project management plan. [2.6.3]
8. The quality and management of the lifeboat preparation training was below the
standard necessary for the lifeboats to have been launched safely by the crew
nominated on the muster/emergency plan. [2.6.4]
9. No one formally took control of delivering the lifeboat-related training despite the
master advising the STO to consult with the SO, and the master instructing the SO
to prioritise lifeboat training. [2.6.2], [2.6.4], [2.6.7]
10. Those involved in training management failed to identify the first cook’s lack of
experience and to ensure that he had received sufficient training for his lifeboat crew
role. [2.6.5]
11. The ship’s safety management organisation was weak and ill-prepared for its
operational role in areas of management and oversight of training, risk assessments
and control of PPE. [2.8.1], [2.8.2], [2.8.3], [2.8.4]