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http://maritimeaccident.org Lifeboat Safety Survey Preliminary Report: Accident Investigators
http://maritimeaccident.org
Lifeboat Safety SurveyPreliminary Report: Accident Investigators
Results and conclusions of this preliminary report may differ from the final aggregated report on Lifeboat Safety and should not be considered final.
Nothing in this report is intended to demonstrate fault or liability. It is a condition of access to this report that no part of it may be used in civil or criminal proceedings intended to establish fault or liability.
Summary
More than 60 investigators from the private and public sectors have some far participated in the lifeboat safety survey run by Maritime Accident Casebook. While the full survey, which includes modules from seafarers and offshore workers, shipowners, P&I Clubs and lifesaving appliance manufacturers, will not be closed until late 2011it was felt beneficial to provide a preliminary report on the maritime investigators survey module.
While respondents from the public sector were the largest single group a wide variety of other investigators participated. Most specialised in the maritme industry but there was high representation from those in the offshore industries. Former seafarers dominated the sample.
Not all respondents answered all questions and it was somewhat surprising given the high level of attention paid to the hazards of onload release hooks that only one respondent was able to name those from incidents he had investigated – too few to be significant.
17 Respondents reported one or more incidents since 2005 with two reporting more than four incidents.
Of 26 incidents, 19 involved davit launched lifeboats, 9 involved freefall lifeboats with one incident outside these two categories. About one third of incidents cited, therefore, involved freefall lifeboats, which intuitively seems to be a surprisingly high figure. Other survey modules may provide greater insight in due course.
These incidents resulted in two fatalities and 8 injured persons.
While figures to date confirm some common assumptions – accidents during drills dominated the figures – accidents during survey accounted for the second highest number. Given the far greater frequency of drills and, we hope, lifeboat maintenance (the third highest situation in which incidents occurred), incident during survey may deserve closer examination.
Dominating causes of incidents were onload release hook design and maintenance, both cited eight times. These issues are connected, as is 'hook not set' which was in third place.
Lifeboat design was cited five times, to be the fourth most common cause.
Respondents overwhelmingly agreed that lifeboat quality and design were generally considered fit for purpose and that training, drills and onboard maintenance (of lifeboats) were generally considered not fit for purpose and therefore more attention needs to be paid to these latter issues.
There was a more even split on other significant issues: about half the respondents considered lifeboat manuals to be not fit for purpose, with the same split on onload release design and onload release quality.
Data was gathered on lifeboat brands but was not sufficient for conclusions to be safely drawn.
Only one respondent answered a question regarding makes of onload release hook and the data is not significant at this time.
This survey will close on 31 March 2011
Background
For the past two decades the maritime industry has expressed increasing concern regarding the safety of lifeboats and the measures required to ensure that lifeboats are as safe as reasonably practicable. In recent years meetings of the International Maritime Organisation, IMO, have sought to address the issue, however, the urgency of addressing the problem has failed to be understood by sufficient members of the IMO for effective mandates to be introduced in a timely manner.
The unproven claim that more seafarers have been killed by lifeboats than have been saved by them is common currency. It is certainly true that a number of masters have falsified records of lifeboat drills because they feared for the safety of their crew and the deleterious effect that such an incident may have on the functioning of their vessel1.
Regardless of the validity of that perception the lack of trust in a safetycritical piece of equipment in which seafarers should have confidence must inevitably have a deleterious effect on the seafarer's ability to operate lifeboats in a crisis.
Drills are intended to provide seafarers with experience in launching lifeboats – including 'muscle memory', in being launched in lifeboats, and ensure that critical equipment is in working order. Every step away from realism reduces the effectiveness of drills.
Given the current concerns regarding lifeboat safety, however, it is considered at least unwise, if not foolhardy, to launch a davitlaunched lifeboat with crew aboard.
While there is qualitative evidence regarding the causes of lifeboat incidents there is little quantitative research. Outstanding exceptions are the OCIMF study of 1994, Results of a Survey into Lifeboat Safety2, Joint Industry Survey carried out by OCIMF, INTERTANKO and SIGTTO in 20003, and the UK Marine Accident Investigation Branch's Review of lifeboats and launching systems' accidents of 20014 and the Maritime & Coastguard Agency's Project 555 report of 20065.
To these may be added the thesis by Trevor Ross in support of his MSc in Environmental & Occupational Health and Safety Management, Ship’s Lifeboats: Analysis of Accident Cause and Effect and its Relationship to Seafarers’ Hazard Perception6.
The IMO's GISIS contains too little information on lifeboat accidents to make a contribution to current knowledge of the issue.
No comparable studies have been made available by lifeboat manufacturers or their trade organisations and we are therefore unable to make reference to them.
1 For obvious reasons it is not possible to give published references. Confidential discussions with masters both facetoface and by email.2 http://www.ocimf.com/mf.ashx?ID=cabb62f0da774e43b9cab87afd1d5e393 http://www.ocimf.com/mf.ashx?ID=bad5fa6543804c88989ed3ef1e34a1c94 http://www.maib.gov.uk/cms_resources/Review_of_%20lifeboat_and_launching_systems_accidents.pdf5 http://www.mcga.gov.uk/c4mca/research_report_555.pdf 6 http://www.msc1206.com/trevor_w_ross_report.pdf
In 2008, P&I Club Gard said: “The number of accidents and the number of people killed or injured runs into the hundreds. However, there are no official records for the total numbers and the lack of such records may be one of the reasons why the regulators have not managed to change the situation. The end result is reduced confidence in davitlaunched lifeboats”7.
More recently, following The IMO Intersessional Working Group on Lifeboat Release Hooks (ISWG LRH) in London from 2022 October 2010, BIMCO said: “The fact that no international statistics were available made BIMCO feel that there was a need for more detailed knowledge about accidents with onload release hooks on lifeboats and the use of fall preventer devices (FPDs).”8
In 2007 Gard Norway held a seminar to discuss whether or not onload release hooks should be abandoned. An attendee from the International Group of P&I Clubs said Its statistics showed that as many as 13 seafarers die every year due to accidents with lifeboats. Relevant to our discussion is the observation: “One of the dilemmas for the seminar was that since "onload" release hooks were introduced, some said that the number of accidents had increased, while some said the opposite. It was difficult to reach a consensus because of the lack of available data and statistics”9.
BP Shipping is one of the few companies to make accident statistics available. In a review of injuries in 2006 four percent of all injuries occurred during lifeboat embarkation10. Says BP Shipping: “Statistics are not the ‘be all and end all’ of safety performance and today as much attention is paid by specialists to behaviour and attitude as to procedures and processes. But numbers still matter – not least in the way they can detect a developing trend”.
Reviewing the available data Maritime Accident Casebook concluded that the lack of statistical data involving all industry stakeholders hampered the development of regulatory, technical and human element solutions.
A series of confidential, independent surveys was therefore designed which would enable all stakeholders at all levels to participate and contribute experience and opinion to core knowledge within specific sectors which together can provide an holistic overview.
7 http://www.gard.no/ikbViewer/Content/8085/No%200208%20Lifeboat%20accidents%20with%20onloa d %20release%20hooks%20v2.pdf Accessed 1 December 20108 https://www.bimco.org//Home/Members/News/2010/2010/10/27_IMO__lifeboat_release_hooks.aspx Accessed 1 December 20109 GARD seminar on whether lifeboat "onload" release hooks should be banned ,
http://www.intertanko.com/templates/Page.aspx?id=4289410 Safeships, http://www.bp.com/liveassets/bp_internet/bp_shipping/bp_shipping_english/STAGING/local_assets/downloads_pdfs/b/BP_Shipping_SafeShips.pdf
The SurveyAn initial decision was made to fund the survey using inhouse resources rather than seek sponsorship.
The first survey, the subject of this preliminary report, was hosted on Surveymonkey11, which provides webbased survey forms. A limited service is available at no cost. Exporting data is not available with this service nevertheless it provided valuable experience in the preparation of online surveys.
Subsequent surveys were hosted inhouse using an opensource platform, Limesurvey12. This provided greater control, a potentially higher level of security and exportable data at low cost.
Since accident/casualty investigators are likely to have daily access to the internet it was not considered necessary to provide alternative versions in hardcopy.
Questions were designed following consultation with investigators and mariners at all levels.
To attempt to capture the maximum amount of data, and recognising the need for confidentiality, the identity of participants was not captured. While IP addresses were recorded to prevent multiple submissions intended to affect the statistical validity of the online survey, the IP addresses were not associated with individual responses.
As far as possible questions were optional.
Further data will be provided in the final report.
11 www.surveymonkey.com12 www.limesurvey.org
Maritime Casualty Investigator Survey Preliminary ReportParticipation in the Maritime Casualty Investigator Survey was invited on the Maritime Accident Casebook website13, the Maritime Accident Investigation Group on LinkedIn14, announcements in the media and emails to P&I clubs, class societies and members of the Maritime Accident Investigators International Forum, MAIIF, and International Association of Safety and Survival Trainers, IASST.
The survey was published using the Surveymonkey platform on 23 September 2010. It was estimated that about 40 respondents could be expected and it was initially intended to close the survey on 30 November 2010.
By 30 November 2010 there had been some 62 participants of which 21, 33.9%, had completed all parts of the survey.
Given the higherthanexpected response it was decided to continue running the survey beyond 30 November but release a preliminary report as soon as possible after 30 November.
13 http://maritimeaccident.org14 http://www.linkedin.com/groups?home=&gid=2155356&trk=anet_ug_hm
Questions Section 1
What was the profile of respondents?
1. Which is your core industry?
Maritime 28 50%Offshore 09 16.1 %Both 14 25%Other 05 08%No answer 01
MaritimeOffshoreBothOtherNo Answ er
2. Current and previous positionsSelect the best description for your current position on the top row and your previous positions from those in the leftmost column, clicking the button where the columns/rows meet. You may select more than one previous position.
Public Sector
Government
Coastguard
Private Sector(Insurance/P&I
)
In-House Corporate Full-time
Independent consultant Response
Count
Former seafarer
36.7% (11) 6.7% (2) 10.0% (3) 16.7% (5) 30.0% (9) 30
Coastguard 33.3% (1) 0.0% (0) 33.3% (1) 33.3% (1) 0.0% (0) 3
Public Sector Government
57.1% (4) 28.6% (2) 0.0% (0) 0.0% (0) 14.3% (1) 7
Private Sector (Insurance/P&I)
0.0% (0) 0.0% (0) 66.7% (2 0.0% (0) 33.3% (1) 3
In-House Corporate Full-time
25.0% (2) 0.0% (0) 12.5% (1) 62.5% (5) 0.0% (0) 8
Independent consultant
20.0% (2) 0.0% (0) 10.0% (1) 10.0% (1) 60.0% (6) 10
Onshore management,non-investigator
11.1% (1) 0.0% (0) 11.1% (1) 55.6% (5) 22.2% (2) 9
answered question skipped question
4715
Former Seafarer
Coastguard
Public Sector
Insurance/P&I
InHouse
Independent Consultant
OnShore Management
Questions Section 21. How many lifeboat accidents have you, your company/organisation investigated since 2005
ResponsePercent
ResponseCount
None 29.2% 7
1 29.2% 7
2 8.3% 2
3 16.7% 4
4 8.3% 2
More 8.3% 2
24
None One Two Three Four More
0
1
2
3
4
5
6
7
8
2. Going from the most recent, which type of lifeboat was involvedFreefall Davit launched Other
1 9 1
1 4 0
2 4 0
1 1 0
1 0 0
0 1 0
6 19 1
Freefall
Davit
Other
3. What was the level of fatality/ injuriesInjuries Fatalities No injuries or fatalities
4 1 8
1 1 2
3 0 2
0 0 2
0 0 1
0 0 1
8 2 16
None
Injuries
Fatalities
4.4. When did the incidents occur?
Duringdrill
Duringmaintenance
Duringsurvey
DuringPSC
inspection
Duringemergencyevacuation
8 2 3 1 0
3 0 0 0 0
2 2 1 0 0
0 0 2 0 0
0 0 0 1 0
1 0 0 0 0
14 4 6 2 0
During Drills
During Maintenance
During Survey
During PSC Inspection
During emergency evac
0 5 10 15
5. Which of the following immediate causes contributed to the incidents
hooknot set
properly
hookfailure
hookdesign
hookmaint
enance poor
Failureof
lifeboatstructure
Lifeboatdesign
Lifeboatquality
Lifeboatmainten
ancepoor
Hydrostatic
releasefailure
Failureof
davitlegs
Partedfalls
Jammedfalls
2 1 1 2 0 1 0 1 1 1 1 0
0 1 1 1 0 1 0 0 1 0 0 0
1 0 2 3 0 1 0 1 0 0 0 0
2 0 2 1 0 1 0 0 0 0 0 0
1 0 1 0 0 0 0 0 0 0 0 0
0 0 1 1 0 1 0 0 0 0 0 0
6 2 8 8 0 5 0 2 2 1 1 0
H Not Set
H Failure
H Design
H Maintenance
LB Structure
LB Design
LB Quality
L Maintence
Hydro release failure
Davit legs
Parted Falls
Jammed Falls
0 1 2 3 4 5 6 7 8 9
6 In your experience which of the following do you regard as generally true.
Yes, generally fit for purpose
No, notgenerallyfit forpurpose
ResponseCount
Life boat design 13 4 17
Lifeboat quality 16 1 17
Life boat manuals 8 9 17
Lifeboat maintenance 11 8 19
OnLoad release design 8 8 16
Onload release quality 9 8 17
Training 5 14 19
Drills 3 13 16
Onboard maintenance 4 12 16
answered question 22
skipped question 40
LB Design
LB Quality
LB Manuals
LB Maintenance
OLR Design
OLR Quality
Training
Drills
OnBoard Maintenance
0 2 4 6 8 10 12 14 16 18
Fit not Fit
7 Which brands of lifeboat were involved in these incidents.?
Beiha 1 0 0 0 0 0
Hatecke 0 0 0 0 0
Hyundai 0 0 0 0 0 0
MES 0 0 0 0 0 0
Nishi Nippon
0 0 0 0 0 0
Norsafe 2 0 1 0 0 0
SchattHarding
1 1 0 1 0 0
Shigi 1 0 0 0 0
Titan 0 1 0 0 0 0
Viking 1 1 0 0 0 0
Watercraft 0 0 0 0 0 0
Other 4 2 2 1 0 0
Beiha
Norsafe
SchattHarding
Shigi
Titan
Viking
Other
Analysis
Question 1The core industry of the respondent can introduce a statistical bias. Some classes of lifeboats are more common in the offshore industry than the maritime industry such as freefall lifeboats.
The offshore industry is younger than the maritime industry and one would expect older lifeboat designs to be more common in the latter than the former. Also, the impact of the Pipe Alpha tragedy had led to wider installation of freefall lifeboats, in percentage terms, than on ships.
The preliminary survey suggests that it succeeded in attracting a broad spectrum of those involved in accident investigation.
Some 50 per cent of correspondents identified their core industry as 'Maritime' while 16.1 per cent identified their core industry as offshore and a quarter answered 'Both'.
It may be that there is an over representative sample from the offshore industry. Maritime
Offshore
Both
Other
No Answer
Question 2We sought to assess the experience of respondents. There are no internationally
prescribed assessable competencies for maritime investigators and investigative techniques vary widely. For that reason it was not felt to be constructive to include related questions in this survey.
Respondents by current position:
The majority of respondents were from the public sector (21) followed by independent consultants (19) nHouse investigators (17) and Coastguard personnel (4)
30 respondents were former seafarers, who can be assumed to have direct knowledge of lifeboat operations, as can coastguard personnel.
Former Seafarer
Coastguard
Public Sector
Insurance/P&I
InHouse
Independent Consultant
OnShore Management
Public Sector 21Coastguard 4Insurance/P&I 9InHouse 17Independent Consultant 19
Question 3
How many incidents have the respondents investigated since 2005?
Seven respondents reported having investigated no lifeboat incidents during that time period.
In total, 17 respondents had investigated one or more incidents since 2005 with two having investigated more than four incidents.
Question 4
What type of lifeboat was involved?
Respondents reported 19 incidents involving davitlaunched lifeboats while 6 freefall lifeboats incidents were reported and one 'other'.
The preponderance of incidents involving davitlaunched lifeboats is to expected, given their relatively greater complexity,
That about one in four lifeboat incidents reported by respondents involved freefall lifeboats seems higher than one would intuitively expect.
The situation may become clearer from other survey modules, whn completed at, for this preliminary report, not firm conclusions are drawn.
None One Two Three Four More
0
1
2
3
4
5
6
7
8
None 7One 7Two 2Three 4Four 2More 2
Freefall 6Davit 19Other 1
Freefall Davit Other
0
2
4
6
8
10
12
14
16
18
20
Question 5How many injuries/Fatalities?
Respondents reported two fatalities and 8 injuries, with 16 incidents incurring neither injuries nor fatalities.
This suggested that a relatively small number of incidents investigated by respondents have produce injuries and/or fatalities.
Further clarification may be available once other lifeboat safety survey modules are completed.
One suspects that the promotion of the use of fall preventors since 2005 may have an influence on these figures.
Question 6
When did the incidents occur?
Given current knowledge it is no surprise that drills produced the greatest number of incidents, 14 out of 26, accounting for almost half.
The next highest level of incidents occurred during surveys, six, followed by four during maintenance and two during port state control inspections.
Given the far lower frequency of surveys compared to drills and maintenance there may be a justifiable cause for concern. If adjusted for frequency, the chances of an incident occurring during a survey is higher than during drills.
InjuriesNone 16Injuries 8Fatalities 2
None Injuries Fatalities
0
2
4
6
8
10
12
14
16
18
During Drills 14During Maintenance 4During Survey 6During PSC Inspection 2During emergency evac 0
During Drills
During Maintenance
During Survey
During PSC Inspection
During emergency evac
0 5 10 15
Question 8
Causes of incidents
Incidents are usually the product of more then one cause so respondents were able to cite more than one.
Onload hook design and maintenance together came top of the list cited in eight incidents each. Design and maintenance may well be linked issues in that a badly designed hook may be difficult to maintain. A good onload release hook design will be easier to maintain.
“Hook not set” was cited in six instances. A variety of conditions may lead to a hook not being set properly, among them in inability simply and unambiguously determine the status of the hook.
Lifeboat design scored higher than lifeboat maintenance, five instances compared to two. This is not an intuitive result since it exceeds other causes as well.
H Not Set
H Failure
H Design
H Maintenance
LB Structure
LB Design
LB Quality
L Maintence
Hydro release failure
Davit legs
Parted Falls
Jammed Falls
0 1 2 3 4 5 6 7 8 9
H Not Set 6H Failure 2H Design 8H Maintenance 8LB Structure 0LB Design 5LB Quality 0L Maintence 2Hydro release failure 2Davit legs 1Parted Falls 1Jammed Falls 0
Question 9
Respondents were asked to rate a variety of aspects as generally Fit for purpose or Not fit for purpose:
Most respondents considered lifeboat design and quality as for for purpose but the equivalent figures for onload release hooks were about evenly split. Slightly fewer felt that lifeboat manuals were fit for purpose than not fit for purpose.
There was greater agreement regarding training, drills and onboard maintenance of lifeboats. One respondent noted that he had observed an improvement in maintenance since MSC1206.
Fit not FitLB Design 13 4LB Quality 16 1LB Manuals 8 9LB Maintenance 11 8OLR Design 8 8OLR Quality 9 8Training 5 14Drills 3 13OnBoard Maintenance 4 12
LB Design
LB Quality
LB Manuals
LB Maintenance
OLR Design
OLR Quality
Training
Drills
OnBoard Maintenance
0 5 10 15 20
Fit
not Fit
Question 10
Respondents were asked which brand of lifeboat was involved in the incidents they investigated.
Respondents cited 21 incidents, the largest portion being those not specifically identified in the selection, 9 instances. At this stage no firm conclusions can safely be drawn from these figures. Comparison with information provided in other lifeboat safety survey modules may take knowledge further.
Question 11
Which OnLoad Release Hooks Were involved?
It is, perhaps, surprising given the high level of concern regarding onload hook safety that only one participant was able to provide data. Other modules may provide greater insight.
Beiha 1Norsafe 3SchattHarding 3Shigi 1Titan 1Viking 2Other 9
Beiha
Norsafe
SchattHarding
Shigi
Titan
Viking
Other
