Lifeboat Safety Survey Preliminary Report: Accident Investigators

Transcription

1 Lifeboat Safety Survey Preliminary Report: Accident Investigators

2 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.

3 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 on load 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.

4 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

5 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 vessel 1. Regardless of the validity of that perception the lack of trust in a safety critical 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 davit launched 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 Safety 2, Joint Industry Survey carried out by OCIMF, INTERTANKO and SIGTTO in , and the UK Marine Accident Investigation Branch's Review of lifeboats and launching systems' accidents of and the Maritime & Coastguard Agency's Project 555 report of 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 Perception 6. 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 faceto face and by da77 4e43 b9ca b87afd1d5e c88 989e d3ef1e34a1c

6 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 davit launched lifeboats 7. More recently, following The IMO Intersessional Working Group on Lifeboat Release Hooks (ISWG LRH) in London from 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 on load 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 on load 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 embarkation 10. 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 %20Lifeboat%20accidents%20with%20on loa d %20release%20hooks%20v2.pdf Accessed 1 December _lifeboat_release_hooks.aspx Accessed 1 December GARD seminar on whether lifeboat "onload" release hooks should be banned, 10 Safeships, BP_Shipping_SafeShips.pdf

7 The Survey An 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 Surveymonkey 11, which provides web based 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, Limesurvey 12. 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

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9 Maritime Casualty Investigator Survey Preliminary Report Participation in the Maritime Casualty Investigator Survey was invited on the Maritime Accident Casebook website 13, the Maritime Accident Investigation Group on LinkedIn 14, announcements in the media and s 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 It was estimated that about 40 respondents could be expected and it was initially intended to close the survey on 30 November By 30 November 2010 there had been some 62 participants of which 21, 33.9%, had completed all parts of the survey. Given the higher than expected response it was decided to continue running the survey beyond 30 November but release a preliminary report as soon as possible after 30 November

10 Questions Section 1 What was the profile of respondents? 1. Which is your core industry? Maritime 28 50% Offshore % Both 14 25% Other 05 08% No answer 01 Maritime Offshore Both Other No Answ er

11 2. Current and previous positions Select 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 Coastguar d 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 Private Sector (Insurance/ P&I) In-House Corporate Full-time Independen t consultant 57.1% (4) 28.6% (2) 0.0% (0) 0.0% (0) 14.3% (1) 7 0.0% (0) 0.0% (0) 66.7% (2 0.0% (0) 33.3% (1) % (2) 0.0% (0) 12.5% (1) 62.5% (5) 0.0% (0) % (2) 0.0% (0) 10.0% (1) 10.0% (1) 60.0% (6) 10 Onshore managemen t, noninvestigator 11.1% (1) 0.0% (0) 11.1% (1) 55.6% (5) 22.2% (2) 9 answered question skipped question Former Seafarer Coastguard Public Sector Insurance/P &I In House Independent Consultant On Shore Managemen t

12 Questions Section 2 1. How many lifeboat accidents have you, your company/organisation investigated since 2005 Response Percent Response Count None 29.2% % % % % 2 More 8.3% None One Two Three Four More

13 2. Going from the most recent, which type of lifeboat was involved Freefall Davit launched Other Freefall Davit Other

14 3. What was the level of fatality/ injuries Injuries Fatalities No injuries or fatalities None Injuries Fatalities

15 4. 4. When did the incidents occur? During drill During maintenance During survey During PSC inspection During emergency evacuation During emergency evac During PSC Inspection During Survey During Maintenance During Drills

16 5. Which of the following immediate causes contributed to the incidents hook not set properly hook failure hook design hook maint enance poor Failure of lifeboat structure Lifeboat design Lifeboat quality Lifeboat mainten ance poor Hydrost atic release failure Failure of davit legs Parted falls Jammed falls Jammed Falls Parted Falls Davit legs Hydro release failure L Maintence LB Quality LB Design LB Structure H Maintenance H Design H Failure H Not Set

17 6 In your experience which of the following do you regard as generally true. Yes, generally fit for purpose No, not generally fit for purpose Response Count Life boat design Lifeboat quality Life boat manuals Lifeboat maintenance On Load release design On load release quality Training Drills Onboard maintenance answered question 22 skipped question 40 OnBoard Maintenance Drills Training OLR Quality OLR Design LB Maintenance LB Manuals LB Quality LB Design Fit not Fit

18 7 Which brands of lifeboat were involved in these incidents.? Beiha Hatecke Hyundai MES Nishi Nippon Norsafe Schatt Harding Shigi Titan Viking Watercraft Other Beiha Norsafe Schatt Harding Shigi Titan Viking Other

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20 Analysis Question 1 The 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 core industry as 'Maritime' their core industry as offshore It may be that there is an oversample from the offshore correspondents identified their while 16.1 per cent identified and a quarter answered 'Both'. Maritime Offshore Both Other No Answer representative industry.

21 Question 2 We 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: Public Sector 21 Coastguard 4 Insurance/P&I 9 In House 17 Independent Consultant 19 The majority of respondents were from the public sector (21) followed by independent consultants (19) n House 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 In House Independent Consultant On Shore Management

22 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 None 7 One 7 Two 2 Three 4 Four 2 More 2 incidents since 2005 with two having investigated more than four incidents Question 4 What type of lifeboat was involved? 1 0 None One Two Three Four More Respondents reported 19 incidents involving davit launched lifeboats while 6 freefall lifeboats incidents were reported and one 'other'. Freefall 6 Davit 19 Other 1 The preponderance of incidents involving davit launched 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 Freefall Davit Other The situation may become clearer from other survey modules, whn completed at, for this preliminary report, not firm conclusions are drawn.

23 Question 5 How many injuries/fatalities? Respondents reported two fatalities and 8 injuries, with 16 incidents incurring neither injuries nor fatalities. Injuries None 16 Injuries 8 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 None Injuries Fatalities 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. During Drills 14 During Maintenance During emergency evac 4 During Survey 6 During PSC Inspection During 2 PSC Inspection During emergency evac 0 During Survey The next highest level of incidents occurred during surveys, six, followed by four during maintenance and two during port state control inspections. During Maintenance During Drills 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

24 Question 8 Causes of incidents H Not Set 6 H Failure 2 H Design 8 H Maintenance 8 LB Structure 0 LB Design 5 LB Quality 0 L Maintence 2 Hydro release failure 2 Davit legs 1 Parted Falls 1 Jammed Falls 0 Incidents are usually the product of more then one cause so respondents were able to cite more than one. Jammed Falls Parted Falls Davit legs Hydro release failure L Maintence LB Quality LB Design LB Structure H Maintenance H Design H Failure H Not Set On load 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 on load 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.

25 Question 9 Respondents were asked to rate a variety of aspects as generally Fit for purpose or Not fit for purpose: Fit not Fit LB Design 13 4 LB Quality 16 1 LB Manuals 8 9 LB Maintenance 11 8 OLR Design 8 8 OLR Quality 9 8 Training 5 14 Drills 3 13 OnBoard Maintenance 4 12 OnBoard Maintenance Training OLR Quality OLR Design LB Maintenance LB Manuals LB Quality LB Design Most respondents considered lifeboat design and quality as for for purpose but the equivalent figures for on load 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 on board maintenance of lifeboats. One respondent noted that he had observed an improvement in maintenance since MSC1206. Drills Fit not Fit

26 Question 10 Respondents were asked which brand of lifeboat was involved in the incidents they investigated. Beiha 1 Norsafe 3 Schatt Harding 3 Shigi 1 Titan 1 Viking 2 Other 9 Beiha Norsafe Schatt Harding Shigi Titan Viking Other 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 On Load Release Hooks Were involved? It is, perhaps, surprising given the high level of concern regarding on load hook safety that only one participant was able to provide data. Other modules may provide greater insight.