What happened?
While using the crank handle to manually slack the Rescue Boat davit’s wire rope, the handle suddenly rotated violently, dislodging from its hoisting slot, and striking both the Able Seaman (AB) and Electro-Technical Officer (ETO), resulting in injuries.
How did it happen?
The Bosun and AB attempted to slack the wire from the storage drum using the remote- control unit (see Figure 1). However, contrary to their intention, the wire began hoisting in the opposite direction. They requested ETO to examine the remote control for potential malfunctions.
During the ETO’s inspection and testing the remote control, the AB decided to slack the wire manually using the hand crank. Without warning, the motor began rotating violently without load due to the slack wire, causing the hand crank to slip before striking both AB and ETO. The incident resulted in the AB sustaining a fractured forearm and the ETO suffering a head injury.
Improper Method for Laying Out Rescue Boat Wire Rope
The electric motor of the rescue boat davit is designed for hoisting operations, not for lowering the lifeboat. Instead, rescue boat davits employ a gravity-based lowering system, whereby the rescue boat descends under its own weight, regulated by a brake mechanism. This design specification is clearly documented in the manufacturer's instruction manual.
The incident revealed that the team lacked the requisite seamanship skills, knowledge and experience in operating this mechanism. Furthermore, the preliminary toolbox meeting proved inadequate of risk assessment in establishing and communicating the correct procedure and task to be carried out.
Wrong Type of Remote Control
The remote-control unit in operation featured "Up" and "Down" buttons, which was inappropriate for this system and potentially misleading. This unsuitable control device appears to have been inherited during the management transition, during which time its inherent safety risks went unidentified.
Faulty Limit Switch
Investigation revealed that the limit switch had malfunctioned, failing to perform its critical safety function of interrupting the electrical power supply when the hand crank was engaged with the cranking post.
Improper Work Procedure
Rather than waiting for the ETO’s resolution of the remote control, the AB initiated manual cranking operations. This simultaneous execution of conflicting work processes failed to trigger any safety concerns among the three team members present. This incident highlights a lack of safety awareness within the team.
Conclusion and recommendations
This incident resulted from a combination of technical failures and human factors. The primary contributing factors included improper equipment, mechanical failure (faulty limit switch), inadequate procedural knowledge, and poor safety awareness. The absence of proper safety protocols and insufficient team communication significantly elevated the risk of injury. Most critically, the fundamental misunderstanding of the davit's designed operating principle—using gravity-based lowering rather than motor-powered descent—underpinned the entire sequence of events leading to the accident.
To prevent future incidents, a structured programme of crew training and competency assessment should be established, supported by enhanced safety protocols linked to the machinery / equipment to be used, proper documentation, and regular maintenance schedules, with particular emphasis on the gravity-based lowering system's correct operation.