Incident Date:

30/06/2006

Summary:

Failure to fully address a change to a lifeboat maintenance routine resulted in part of the lowering mechanism being omitted from system function test.

Incident consequences (potential or actual):

Injury

Cause of accident or incident:

Fall from height

Activity Location:

Any Location Type

Activity Type:

Maintenance

Description:

During routine six monthly lifeboat maintenance work the service engineer noticed that the brake release wire drum would not turn. To establish the cause the drum was dismantled to reveal that its components were heavily rusted. These were cleaned, lubricated and reassembled and when tested the drum operated satisfactorily. Examination of the other boats on the installation revealed the same fault.

Specific Equipment:

TEMPSC Davits

Lessons Learnt:

The root cause of the fault is the result of a change in maintenance policy and routine. Originally the lowering mechanism of the lifeboats was proven by the engineer operating the wire pull release system from within the boat. Due to safety concerns within the industry this practice was stopped and the lowering of the boats was carried out from the winch platform by manually raising the brake release lever. Whilst this proved the disengagement and re-engagement of the brake, it did not exercise the release wire; therefore the deterioration of the drum’s components was not apparent.There seems to have been a lack of appreciation and understanding of the actual purpose and operation of the release system which resulted in it being overlooked as requiring maintenance. The efficiency of the release system would previously have been proven by the full function test, but the use of the brake release lever effectively by passed the release mechanism.Deciding to use the winch brake release lever to lower the boats rather than the wire release system was a significant change to the routine. This event serves to illustrate that even the most innocuous change to a maintenance routine can have potentially serious consequences. This change should have been assessed to establish what impact the change had on the overall operation of the lifeboat launch system. Lifeboat maintenance routines have been amended so they include the brake release system as a separate element ensuring it is inspected and if required, serviced.

Task Description:

Planned Maintenance of the lifeboat system

Recommendations:

It is recommended that other operators who no longer test the brake release system from within the lifeboat check that the brake release wire drum is included in their lifeboat maintenance routine.

Contact Details:

mailto:ahardman@maerskoil.co.uk

Figures:

No figures available.

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