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TAIC CONTINUED … Wire point of failure Wire end fixing only five months earlier had not recognised the potential danger in not inspecting the complete wire," the TAIC said. The safety harness should have stopped the two crewmembers from falling, "but the dynamics of the fall and the effect on the safety harness arrangement would have been difficult to foresee." Fixed wire guide The Commission also found that personal flotation devices would have increased the chances of the second crewmember surviving. He could not swim and was probably dazed and in cold shock after falling into the 16˚ Celsius water. He was unable to hold onto life-rings which were thrown to him. "Had he been wearing a personal flotation device, as he was supposed to, it is more likely that he could have kept his head above water, even in his dazed state." The other man was also probably in cold shock but managed to hold onto a partially empty plastic grease bucket until he was saved. difficult to apply a coating of grease to the wire and to ensure the grease covered the whole circumference of the wire. The other davits on the Volendam were also inspected, and 10 other fall wires were found to be sufficiently corroded to require remedial action. The Transport Accident Investigation Commission listed five key lessons following its investigation into the accident: • a wire rope is only as good as its weakest part. Unless an inspection covers the entire length of the wire, a thorough inspection has not been made • wire ropes in a marine environment require frequent and thorough lubrication to prevent corrosion, otherwise other measures will need to be taken to prevent premature failure of the wire ropes • when selecting a securing point for a safety harness, consideration should be given to its vulnerability in the vent of other catastrophic failures • a personal buoyancy device should always be worn when working outside of a ship's rail, and • robust job hazard analysis can prevent injuries and save lives, but only if the crew follow the procedures. The crew found the easiest way to grease the wires was to extend the lifeboat beyond the hull and stand on the lifeboat's cabin roof. The problem was that this put the wires under tension so they could not be eased out of the guide for inspection or greasing. The state of the wires indicated that part of the wire where it passed around the fixed guides had not been inspected or greased for over four years. "The Commission is surprised that successive 'thorough' inspections by the crew and the manufacturer's representatives It found the safety management system on board the Volendam, which included greasing the lifeboat wires, was robust. If the crew had conformed with the system it would have helped to prevent the death of the crewmember. It also found the toolbox discussion had probably not taken place. "It was a lost opportunity to ensure the crew conducting the task wore buoyancy aids. The crew were aware they were supposed to wear them and had to bear some responsibility for not complying with the instruction." Lastly, it found the lifeboat davit did not allow easy maintenance of the wire fall where it passed around the guidelines on the end of the fixed davit arm and this problem had gone unnoticed or ignored during the 10-year life of the Volendam. It also found the fixed arm of the lifeboat davits bending in and contacting the moveable trolley may have contributed to the wire failure. Following the release of the TAIC's report, Holland America said it had issued a fleet alert on lifeboat davit systems. The parent company, Carnival Corporation & PLC, also issued an advisory notice to each of its subsidiary cruise lines. Three urgent safety recommendations were made to the manufacturer of the davit systems, to: • alert all owners of vessels with the SPTD-150P davit fitted to the Volendam to the circumstances of this accident and issue instructions on what immediate inspections should be carried out • make a technical assessment of other lifeboat davit models it had produced to identify similar safety issues existing with these models, and if so alert owners of these models, and • review the design of the davit to remedy the tendency in this case for the fixed arm davit to flex inwards under load and contact moving parts of the structure. PHONE 09 419 1954 76 Professional Skipper January/February 2012 VIP.S48 VIP.S82