TRANSPORT ACCIDENT INVESTIGATION COMMISSION ACT 1990
The principal purpose of the Transport Accident Investigation Commission shall be to determine the circumstances and causes of accidents and incidents, with a view to avoiding similar occurrences in the future, rather than to ascribe blame to any person.
DEAD CREWMAN IGNORED SAFETY PROCEDURES
F
our of the crew of the cruise ship Volendam were carrying out routine maintenance on the number seven starboard lifeboat in Lyttelton on January 8, 201. A "working aloft" permit was issued and all four crew had signed a "toolbox discussion" form. Two of the crew were standing on the access platform, one greasing the wire falls on the winch drum and other operating the telescopic davit to lower and raise the lifeboat to facilitate greasing the wires.
The other pair were standing on the top of the lifeboat, greasing the wire falls and davit traveller wires. Both men were wearing safety harnesses attached to a line strung between the lifeboat's lifting hooks but were not wearing personal flotation devices.
At about 1355 the two crew on top of the lifeboat requested the crewmember at the controls to lower the lifeboat a short distance from the lifeboat's extreme height against the davit trolley arm, which was fully extended.
PHOTO COURTESY OF HOLLAND-AMERICA LINE
As the winch operator was lowering the lifeboat the for'ard fall wire parted. The lifeboat fell bow down, suspended by the aft fall. The aft hook bent backwards, tearing through the lifeboat's Fibreglass hull. The safety line parted and the two crewmembers on board fell about 16m into the water. A rescue boat and crew picked up one of the crew shortly after, but divers only discovered the second crewmember at 1800, four hours after the accident occurred. The lifeboat was irreparably damaged. The tender launch aft of the lifeboat was also damaged, requiring repairs to the hull before the Volendam could sail.
The 237.9m ship was built by Finantieri Shipyard in Italy in 1998
and owned by the Holland America Line. Her davits were supplied by Navalimpianti Tecnimpianti Group to the shipyard. The lifeboat wire falls were 22mm 6 x 36 wire strand with a minimum certified breaking strain of 390 kilonewtons, supplied in late 2005/early 2006.
Holland America had specified that the falls were to be inspected regularly and replaced every four years. The number seven fall was due for replacement in late November, 2010. But the fleet management had agreed with a request from the
ship's management to defer the replacement until the Volendam entered drydock in March/April 2011, following a visual inspection that the wires appeared to be in good shape. An investigation into the failure mechanism of the for'ard fall wire showed the wire in the failure zone was heavily corroded around the failure. The final failure was due to a tensile fracture of the remaining cross-section of the wire.
Because of the way the davits were designed, it was
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