MARINE SAFETY INVESTIGATION

REPORT 164

Independent investigation into the lifeboatincident on board the Maltese flag bulk carrier

at Geelong, Victoria on 24 January 2001

Alianthos

Department of Transport and Regional Services

Australian Transport Safety Bureau

Navigation Act 1912Navigation (Marine Casualty) Regulations

investigation into the lifeboat incident on board the Maltese flag bulk carrier

Alianthosat Geelong, Victoria on 24 January 2001

Report No 164

December 2002

ISSN 1447-087XISBN 1 877071 19 6

Investigations into marine casualties occurring within the Commonwealth's jurisdiction are conductedunder the provisions of the Navigation (Marine Casualty) Regulations, made pursuant to subsections425 (1) (ea) and 425 (1AAA) of the Navigation Act 1912. The Regulations provide discretionarypowers to the Inspector to investigate incidents as defined by the Regulations. Where an investigationis undertaken, the Inspector must submit a report to the Executive Director of the Australian TransportSafety Bureau (ATSB).

It is ATSB policy to publish such reports in full as an educational tool to increase awareness of thecauses of marine incidents so as to improve safety at sea and enhance the protection of the marineenvironment.

To increase the value of the safety material presented in this report, readers are encouraged to copy orreprint the material, in part or in whole, for further distribution, but should acknowledge the source.Additional copies of the report can be downloaded from the Bureau’s website www.atsb.gov.au

Australian Transport Safety BureauPO Box 967Civic Square ACT 2608 AUSTRALIA

Phone: 02 6274 64781800 621 372

Fax: 02 6274 6699E-mail: marine@atsb.gov.au

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Contents

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Sources of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Alianthos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Lifeboats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

The on-load release system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

The davits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

The incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Comment and analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Initial inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Further examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Examination conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Sequence of events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Operation of the davit winch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Past incidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

On-load release design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Lost motion in the operating cable system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

SOLAS requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Hook indicator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Operation and maintenance of the on-load release system . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Submissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Alianthos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

Figures

1. Alianthos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iv

2. Operating mechanism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

3. Hook mechanism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

4. Operating cable system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

5. Alianthos’ starboard lifeboat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

6. Damage to port lifeboat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

7. Damage to port lifeboat davit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

8. After hook as found . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

9. Forward hook as found . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

10. After hook operating cable system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

11. Alianthos: Events and causal factors chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

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FIGURE 1:Alianthos alongside in Geelong

SummaryOn 20 January 2001, the Maltese flag, panamaxbulk cargo carrier Alianthos arrived at theanchorage in Corio Bay, Geelong, after anuneventful voyage from Shanghai, China. Theship was in ballast and intending to load a fullcargo of grain at the Geelong grain loader.

On 23 January, the master made the decision toconduct an ‘abandon ship’ drill while the vesselwas at anchor waiting to berth. The drillcommenced at 1018 and was completed by1140. The master was not satisfied with someaspects of the crew’s performance during thedrill. He ordered that all crew were to receivefurther instruction, and complete another‘abandon ship’ drill, the following day.

The ‘abandon ship’ drill commenced at 1700 thefollowing day. Both port and starboard lifeboatswere prepared, lowered to the water and takenaway from the ship by crews who had not beenin one of the boats the previous day. The thirdmate was assigned as the officer in charge of theport lifeboat.

When the port lifeboat returned to the ship,there was some delay in reconnecting the fallsto the boat’s on-load release hooks. After sometime, the third mate gave the order to raise theboat from the water. The crew then disembarkedat the embarkation deck and the boat was raisedand secured at the head of the davit.

At the master’s request, the mate continued toinstruct members of the ship’s catering and

engineering staff who were not conversant withsome aspects of the operation of the lifeboats.Once the mate had finished instructing the crew,they prepared the empty port lifeboat forlowering to the embarkation deck.

At 1742, one of the motormen was instructed tooperate the davit winch to lower the portlifeboat. The motorman, who had not operatedthe davit before, lifted the winch brake handleand started to lower the boat. The boat movedmore quickly than usual down from the housedposition, resulting in the davit cradles coming toan abrupt stop as they reached deck level.

When the davit cradles hit their stops, the boatwas seen to jerk sharply. At this instant, the afterfall released from its on-load release hook. Thestern of the lifeboat fell, swinging on theremaining forward fall. As the weight of thewhole boat came onto the forward davit cradle itbuckled and the boat made hard contact with theside of the ship. The starboard side of thelifeboat was cracked and holed by the contact.The forward fall and hook continued to hold theweight of the lifeboat, which had come to restwith its stern above the port gangway. Therewere no crew inside the lifeboat andconsequently no injuries as a result of theincident.

After assessing the damage to the lifeboat andits davit, the master instructed the crew to usethe after stores crane to raise the stern of thelifeboat and secure it alongside the ship.Alianthos berthed on the morning of 26 Januarywith the lifeboat still suspended in this fashion.

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Sources ofinformationThe master and crew of Alianthos

Shigi Shipbuilding Company Ltd

Australian Maritime Safety Authority

Marine Accident Investigation Branch, UnitedKingdom

Transportation Safety Board, Canada

ReferencesSafety of Life at Sea Convention (SOLAS),International Maritime Organization

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Narrative

AlianthosAlianthos (formerly Young Senator, RubinElegant, CS Elegant) is a Maltese flag bulkcarrier of 65 850 deadweight tonnes at itssummer draught of 12.822 m (figure 1). Thevessel is owned by the Alianthos ShippingCompany and has undergone a number of nameand management changes since entering service.The most recent was in November 1999 whenthe management was passed from Mitsui OSKto Acomarit (U.K.) with a change of flag Statefrom Panama to Malta. The ship is classed withNippon Kaiji Kyokai (Class NK) as a BulkCarrier, Strengthened for Heavy Cargos, ESP1.

Alianthos was built in 1989 by NamuraShipbuilding Company at Imari in Japan. Theship has an overall length of 225.78 m, amoulded breadth of 32.2 m and a mouldeddepth of 17.8 m. Propulsive power is providedby a 6-cylinder Mitsubishi-Sulzer 6RTA62,single acting, direct reversing 2-stroke dieselengine of 7 838 kW. The main engine drives asingle fixed-pitch propeller, which gives theship a service speed of 14.0 knots.

The ship is of standard bulk carrier design withseven cargo holds located forward of theaccommodation superstructure.

At the time of the incident, Alianthos had acrew of 19, comprising a master and threemates, chief and three engineers, boatswain andfive deck ratings, three engine room ratings andtwo catering staff. The master held a foreign-going master’s certificate of competency andhad 37 years experience at sea, the last 12 incommand. He had previously completed a sixmonth contract on the vessel and was two and ahalf months through his current contract. Thethird mate had been at sea for three years and on

the vessel for the previous three months. All ofthe crew were Ukrainian nationals.

Lifeboats Alianthos is equipped with two 27-man totallyenclosed lifeboats. The lifeboats are both typeSZ-65BR constructed by Shigi ShipbuildingCompany in Osaka, Japan. Each lifeboat isstowed in a gravity davit on the port andstarboard sides of ‘A’ deck, the first deck ofaccommodation above the main deck. The portlifeboat is the designated rescue boat.

The lifeboats are constructed of fibre-reinforcedplastic and each boat is 6.5 m in length, has abreadth of 2.6 m and a depth of 1.1 m. Theunladen weight of each boat is 2 380 kg with afully laden design weight of 4 640 kg. Theirinternal configuration is typical of manymodern totally enclosed lifeboats. Thecoxswain’s thwart is located at the stern and israised to allow all-round vision from a small‘conning’ bubble in the top of the canopy. All ofthe lifeboat’s controls are accessible from thisposition, including the davit winch brake remoterelease cable and the on-load hook release lever.Seating for the rest of the crew is providedaround the periphery of the boat with someseating also provided along the centre-lineforward of the coxswain’s position. There arehatches located midships on the inboard side ofeach boat for boarding the crew and additionalhatches at the forward and after ends of thecabin to allow the crew access to the on-loadrelease hooks.

Propulsive power is provided by a DaihatsuCLMD-25 4-stroke diesel engine, which giveseach boat a fully laden speed of 6.23 knots.

The on-load release system Both of Alianthos’ lifeboats are fitted with anSZK-5 on-load fall release system designed andmanufactured by the lifeboat builder, ShigiShipbuilding Company. The system is designed

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1Enhanced Survey Programme

to be operable by one person with thesimultaneous release of both hooks occurringwhen actuated. The system is not fitted with anhydrostatic interlock.

The main components of the SZK-5 on-loadrelease system are the operating mechanismlocated on the starboard side of the enginehousing, the forward and after hooks and theirassociated locking mechanisms, and flexiblecables which connect the operating mechanismto the two hooks.

The operating mechanism is shown in figure 2.It is depicted in both states ie. the tripped andreset positions. The main components are theoperating lever, the quadrant plate, safety pinsand the operating quadrants. The procedure totrip the hooks is sequential and involvesremoving the operating lever safety pin, raisingthe operating lever and engaging the socket. Thesafety pin in the quadrant plate is then removedand the operating lever is moved aft whichmoves the after hook’s operating quadrantforward. At the same time the forward hook’soperating quadrant, which is driven by the gearattached to the quadrant plate, also moves aft.

Resetting the system involves inserting thesafety pin in the resetting pin hole and thenmoving the operating lever back to its originalposition. This action causes each hook operatingquadrant to move towards its respective hookuntil it reaches the original position. The safetypin is then returned to the original positionwhich locks the quadrant plate, the lever is thenfolded and its safety pin inserted.

The main components of each hook mechanism(figure 3) are the hook, link stopper, side plates,base plate, bracket and the no. 1, no. 2 and no. 3hook bearers.

When the operating lever is moved to trip thesystem, each operating quadrant moves awayfrom its respective hook. The teleflex cabletransmits this motion to each hook mechanismrotating the no.3 hook bearer cam downward.The no.2 hook bearer moves down as the no.3hook bearer cam rotates, which allows the no.1hook bearer to also rotate downward. Once theno.1 hook bearer has rotated sufficiently, the toeof the hook is freed, the hook opens and the fallsuspension ring is released.

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FIGURE 2:Operating mechanism

Lever motion to trip hooksLever motion to reset system

Operating lever

Lever safety pin

Gearing

Forward hook operating quadrant

Operating cable turnbuckle clevis

Resetting pin hole

After hook operating quadrant

Quadrant plate

Safety pin

Lever socket

FORWARDAFT

Operating cable turnbuckle clevis

During a resetting operation, movement of theoperating lever causes the operating mechanismquadrants to move toward their respectivehooks. This motion is transmitted by eachteleflex cable so that each end rod movesupward to rotate the no.3 hook bearer. As thecam on the no.3 hook bearer rotates, it movesthe no.2 hook bearer upward, which in turnrotates the no.1 hook bearer into a position tolock the toe of each hook. The hooks must beheld in the closed position by a crew memberduring the resetting operation.

To be fully reset (locked) the no.3 hook bearercam must be rotated past the centre-line of theno.2 hook bearer. If the cam is not rotated intothis position, the design of the mechanism willallow limited load to be carried on the hook,however, in this condition the mechanism is

subjected to a tripping force and if the load ishigh enough, the hook will trip open.

The cable system, which operates each of thehook mechanisms, consists of a teleflex cableattached to the quadrants of the operatingmechanism via a turnbuckle (figure 4). Thecable system is designed to transmit the fullmotion of the quadrants to each hookmechanism. When the hooks are being trippedthe cable is in tension and when the hookmechanisms are being reset the cables are incompression.

The teleflex cables consist of an outerpolyethylene sheath over an inner steel flexiblecable. The inner cable is designed to slide freelyinside the outer sheath. There is a short rodattached to both ends of the inner cable which

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Side plate

Side plate

Link stopper

Base plate

Bracket

Teleflex operating cable

No.3 hook bearer (cam plate)

No.2 hook bearer

No.1 hook bearer

Hook

B

A

C

FIGURE 3:Hook mechanism

slides through a gland fitted on each end of theouter sheath. The gland provides a seal betweenthe rod and outer sheath to prevent dirt andwater ingress into the core of the cable.Lubrication for the sliding inner cable and rodsis applied when the cables are manufactured andno further lubrication should be required whenthe cables are in service.

The turnbuckle, which connects each teleflexcable to its quadrant, consists of a threadedcentre section, (one half left-hand and the otherright-hand thread) with a clevis and lock nutscrewed to each end. One clevis is pinned to theend of the operating cable and the other ispinned to the quadrant. The turnbuckles allowthe length of each operating cable to beadjusted.

A single clamp secures the end of each teleflexcable to a fixed point in the boat adjacent to theoperating mechanism. The clamps are fitted tothe outer sheath of each cable, adjacent to the

gland, and secure the end of the cable inalignment with each operating quadrant. Theclamps have a swivel mount to allow the end ofthe teleflex cable to swing through a small arcin order to maintain the correct alignment whenthe quadrants are actuated.

The davitsAlianthos’ lifeboat davits consist of a frame,winch, falls, cradles, boarding platform, forwardand aft suspension blocks and cradle stoppersused to secure the boats when stowed (the davitsare shown in figure 5). Each boat is suspendedin its cradles by the suspension blocks, with thefall wires running from each suspension blockto the davit winch. The davit cradles are pinnedforward and aft at the base of the davit frame.Each cradle is free to pivot on the pin androtates, outboard initially when lowering alifeboat and inboard at the final stage of raisingthe boat. Each davit cradle is fitted with a stop,which limits the outboard rotation of the cradle

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FIGURE 4:Operating cable system

Operating quadrant

Clevis

Turnbuckle adjuster

RodGland

Inner cableOuter sheath

Clevis

Cable clamp with swivelmounting attached toengine casing

To hookmechanism

FIGURE 5:Alianthos’ starboard lifeboat

when the lifeboat is being lowered. The davitsare also equipped with a wire-operated remoterelease for the winch. The remote release allowsthe crew inside the lifeboat to lower it from thestowed position. The davit and lifeboat aredesigned so that boarding of the crew may takeplace with the boat either in the stowed positionor from the embarkation deck (A deck).

Each crew member on Alianthos is allocated aposition in either the port or starboard boat. Themate is the designated officer in charge of theport boat and the second mate is the officer incharge of the starboard boat.

The incident On 20 January 2001, Alianthos arrived at theanchorage in Corio Bay, Geelong, after anuneventful voyage from Shanghai, China. Theship was in ballast and intending to load a fullcargo of grain at the Geelong grain loader.

On 23 January, the master decided to conduct an‘abandon ship’ drill while the vessel was atanchor waiting to go alongside. The drillcommenced at 1018 and involved both the portand starboard lifeboats. The boats wereprepared, then lowered to the water and takenaway from the ship by their respective crews.The drills were completed without incident withboth boats rehoused in their davits by 1140.During the post drill debrief, the masterexpressed his dissatisfaction with some aspectsof the lifeboat drill. He ordered that all crewwere to receive further instruction and tocomplete another ‘abandon ship’ drill thefollowing day.

The following day the ‘abandon ship’ drillcommenced at 1700. Initially the crew weremustered at their boat stations and giveninstruction by the mate and second mate on theoperation of the davit, lifeboat engine and on-load hook release mechanism. The boats werethen lowered to the water and taken away fromthe ship by crews who had not been in one ofthe boats the previous day. The third mate wasassigned as the officer in charge of the port

lifeboat with the second engineer, a deck ratingand an engine room rating making up the rest ofits crew.

When the port lifeboat returned to the ship,there was some delay in reconnecting the fallsto the boat’s on-load release hooks. After sometime, the third mate gave the order to raise theboat from the water. When the boat had beenlifted approximately one metre, the third mateasked for the boat to be lowered back into thewater where he released the falls from the on-load release hooks. This was the first time thatthe third mate had actually operated this type ofon-load release system. After resetting the hooksa second time, the falls were reconnected andthe boat was raised from the water. The crewthen disembarked at the embarkation deck andthe boat was raised and secured at the head ofthe davit.

After the boat was housed, at the master’srequest, the mate continued to instruct membersof the ship’s catering and engineering staff whowere not fully conversant with some aspects ofthe operation of the lifeboats. His instructionincluded the preparation of the boat for loweringand the operation of the on-load release systemfor the falls. During this time he took some ofthe crew into the port lifeboat to show them theprocedure for operating the on-load releasesystem. While he was in the boat he noted thatboth hooks appeared to be in a reset position.

At 1742, the mate finished instructing the crewand the crew left the boat and mustered on deck.They prepared the port lifeboat for lowering tothe embarkation deck, this time empty. The mateinstructed one of the motormen to operate thedavit winch to lower the boat. The motorman,who had not operated the davit before, lifted thewinch brake handle and started to lower theboat. The boat moved quickly out and downfrom the housed position as the davit cradlespivoted outboard from their vertical, housed,positions. The master, who was on the portbridge wing, saw that the boat was beinglowered too quickly and shouted to the

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motorman to slow down. At the same time themate also shouted to the motorman to stoplowering. However, at this point, the davitcradles came to an abrupt halt as they madecontact with their stops at deck level.

When the davit cradles hit their stops, the boatwas seen to jerk sharply. At this instant, the afterfall was released from its hook. The stern of thelifeboat fell, suspended only by the remainingforward fall. As the weight of the whole boatcame onto the forward davit cradle it buckledand the boat fell further, making hard contactwith the side of the ship. The starboard side ofthe lifeboat was cracked and holed by thecontact. The forward fall and hook continued tohold the weight of the lifeboat, which had cometo rest with its stern just above the portgangway.

After assessing the damage to the lifeboat anddavit, the master realised his priority was toensure that the lifeboat was adequately securedin case the forward hook should fail and allow itto fall to the water. He instructed the mate tosecure the forward end of the boat using a wiresling rigged between a shackle on the boat’sforward hook unit and an eye welded on thelifeboat deck. Once the forward end of thelifeboat was secure, the ship’s port stores cranewas used to lift the stern of the boat using ashackle attached to the after hook unit. Whenthe lifeboat was horizontal, another wire slingwas used to secure the stern of the boat to theafter davit cradle. The lifeboat was left securedalongside the ship in this fashion until Alianthosberthed on the morning of 26 January.

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Comment andanalysisA marine investigator from the AustralianTransport Safety Bureau attended Alianthos onthe morning of 26 January to conduct an investi-gation of the incident. The master, mate andthird mate were interviewed and provideddetailed accounts of the incident. Copies ofrelevant ship’s documents were obtained,including the lifeboat davit and on-load releaseinstruction manuals, lifeboat certificates ofsurvey and lifeboat maintenance instructions.There were no records on board relating to pastmaintenance on the lifeboats. The master,however, indicated that the on-load releasesystems in both lifeboats had been overhauledby the crew in November 1999, when the ship’smanagement had changed.

The primary aim of the investigation was toestablish the sequence of events with a view todetermining how the after fall became detachedfrom the lifeboat and the factors that may havecontributed to the incident. Although there wasno loss of life or serious injury, the incident was

significant as there have been a number offailures involving lifeboat on-load releasesystems in recent years.

DamageThe port lifeboat and davit were both damagedas a result of the after fall being released. Thedamage to the port lifeboat consisted of a smallhole and several cracks on the rubbing strake onthe starboard side where the canopy joins thehull (figure 6). The rubber fender was alsodamaged in way of the hole. The damage wasconsistent with the boat making hard contactwith the side of the ship as a result of the afterfall releasing and the subsequent failure of theforward davit cradle.

Damage to the port lifeboat davit was extensive(figure 7). The forward cradle was severelydamaged and bent down and aft at approxi-mately 90°, halfway along its length. The davitframe supporting the forward cradle was twistedapproximately 5° in the same direction (aft).From the damage it was apparent that the davithad experienced a large load mostly in a verticalplane but with a lateral component directed aft.The damage was consistent with the effect ofthe large dynamic loading of the swinginglifeboat when the after fall released.

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FIGURE 6:Damage to port lifeboat

The on-load release system

Initial inspection

An examination of the on-load release systemwas conducted to establish how the after fallbecame detached from its hook when the boatwas being lowered. The system was initiallyinspected while the boat was still suspendedoutboard of the main deck. The master and mateboth stated that the on-load release system inthe boat had not been operated, adjusted or resetin the time between the incident and theinspection.

The after hook was found to be in a tripped, oropen, condition (figure 8). The hook lockingmechanism was in a partially reset positionindicated by the position of the cam plate on theno.3 hook bearer (refer to figure 3). The linkstopper on the hook was undamaged with nowitness marks to suggest that the suspensionring may have been forced past the stopper andoff the hook. The disposition and condition ofthe various components of the after hook

mechanism indicated that the hook had beenforced open under load.

The forward hook was found to be in anuntripped, or closed, condition. Its lockingmechanism was also found to be in a partiallyreset position, indicated by the position of thecam plate on its no.3 hook bearer but closer tothe fully reset position than was the after hookmechanism (figure 9).

The operating mechanism was found to be inthe secured position with the safety pins fittedto both the release lever and the quadrant plate.

Various measurements were taken of theforward and aft hook mechanisms. Initially thedistance between the bottom of the no.2 hookbearer and the bottom of the slot in the adjacentbracket (‘A’ on figure 3) was measured toreveal: 30 mm for the forward hook, 18 mm forthe after hook. As a reference for thismeasurement, the distance between the point ofcontact between the no.1 and no.2 hook bearersand the hook base plate (‘B’) was also measured

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FIGURE 7:Damage to port lifeboat davit

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FIGURE 8:After hook as found

FIGURE 9:Forward hook as found

to reveal: 45 mm for the forward hook and 35mm for the after hook. According to thesemeasurements the forward hook’s no.2 hookbearer was 10 mm higher (more reset) than theafter hook.

The travel of each teleflex cable (indicated bythe grease marks on the rods attached to theno.3 hook bearer, (‘C’) was measured: forwardhook 72 mm, after hook 35 mm. Thesemeasurements indicate that the teleflex cableoperating the forward hook mechanism wasextended 37 mm more in the resetting directionthan the after hook.

Further examinationSeveral tests were performed on the on-loadrelease system after the lifeboat had been liftedonto the ship’s poop deck using the stores crane.Initially, both hooks were tripped and then resetusing the procedure described in themanufacturer’s instructions. After resetting thesystem the forward and after hook lockingmechanisms were closely inspected and morecomparative measurements were taken. Themeasurements and inspection revealed thatneither hook mechanism had moved to the fullyreset position, with the after hook mechanismstill substantially less reset than the forward one.The procedure was repeated several times untilit became apparent that neither hook could befully reset using the procedure prescribed in theinstruction manual.

Closer examination of the operating unitmechanism and the after hook mechanismrevealed that there appeared to be some lostmotion in the operating cable connecting thetwo. To allow an inspection of the cable systemoperating the after hook, the screws securing thefootplate under the operating mechanism wereremoved and the footplate lifted.

With the after operating cable system exposed,the operating lever was actuated several moretimes. When the operating lever was moved toreset the hooks the end of the teleflex cable wasdeflecting downward, so that the turnbuckleclevis attaching it to the operating lever wasmaking contact with the bottom of the boat.Thus, each time the operating lever was movedto reset the after hook, instead of sliding the rodlongitudinally inside the outer sheath of theteleflex cable, the end of the cable was beingforced down in a ‘bend’ to touch the bottom ofthe boat. The motion lost as a result of thisdeflection was at least 60 mm in the resettingdirection. Where the clevis attached to the endof the teleflex cable had been making contactwith the bottom of the boat the paint had beenworn away (figure 10). This indicated that theafter hook operating cable had been deflectingin this fashion for a lengthy period of time.

The rod on the teleflex cable at the operatingmechanism end was dry indicating a lack oflubrication. The swivel bracket securing the endof the teleflex cable to the side of the enginecasing, although securely fastened to both thecable and the casing, was worn enough to allowthe end of the cable to swing relatively freely.The after hook could only be fully reset bymanually supporting the operating cable, at theunion between the end of the rod and theturnbuckle, to prevent it deflecting when theoperating lever was actuated. When resetting theafter hook in this fashion, a higher than normalforce was required to move the resetting leverthe last portion of its throw. This stiffness in thesystem was apparently due to some bindingwithin the teleflex cables.

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FIGURE 10:After hook operating cable system

Paint worn away due to contactwith operating cable

The cable system operating the forward hookwas also inspected. There was no significant lostmotion found in the system. It appeared that theforward hook was not moving to a fully resetposition as a result of incorrect adjustment ofthe turnbuckle.

A limited load test was next applied to the afterhook. First the hook was reset using only thefull travel of the operating lever ie. to thepartially reset position allowed by the deflectionin the operating cable. Inspection revealed thatthe hook locking mechanism had moved to thesame position as found after the incident, that isa distance of 18 mm measured at position ‘A’. Alimited load was then applied to the hook (usinga length of steel pipe as a lever on the hook)with the intention of ‘breaking’ the hook open.The hook remained closed under this test whichverified that the hook was able take a limitedload in the partially reset position.

The whole system showed surface corrosion andflaking paint on all external components. Thegrease on both the hook and operatingmechanisms was old, hard and contaminated. Abuild up of paint and rust flakes 3–4 mm thickwas found on the mating surface between theno.1 hook bearer and the toe of the after hook.As a final test, this debris was removed and theoperating cable was supported with a piece oftimber to prevent it deflecting during theresetting operation. The after hook was againreset with measurements at position ‘A’revealing that the no.2 hook bearer’s travel hadincreased from 18 mm to 42 mm.

Examination conclusionsThe following conclusions were drawn from theinspection and testing of the on-load releasesystem fitted to Alianthos’ port lifeboat:

• neither the forward or after hook could befully reset using the prescribed method. Theforward hook operating cable system wasincorrectly adjusted and there was a largeamount of lost motion in the cable systemwhich operates the after hook mechanism;

• marks where the turnbuckle clevis had beenin contact with the bottom of the boatindicate that there had been lost motion (inthe resetting direction) in the cable systemwhich operated the after on-load release hookmechanism for a lengthy period of time;

• the crew of the vessel were not aware thatthere was lost motion in the cable systemoperating the after hook as it was covered bya section of plate, screwed to the deck, andthus not visible to the operators of thesystem;

• the crew had not been checking the positionof the cam plates on the no.3 hook bearers assuch an inspection, carried out correctly,would have revealed that neither hookmechanism was resetting fully;

• its general condition and the long standingproblem with the after hook operating cable,indicates that maintenance of the system hadbeen inadequate.

Sequence of eventsConsidering the statements of the witnesses andthe physical evidence in the form of the damageto the port lifeboat and davit, together with thecondition of the on-load release system as foundafter the incident and analysis of the design ofthe system, the sequence of events appears tohave been:

• the port lifeboat’s hooks were not fully resetwhen the lifeboat returned to the ship andwas recovered on the afternoon of 24 January;

• the speed of lowering the lifeboat to theembarkation deck resulted in the davitcradles making hard contact with their stopsat deck level;

• the partially reset locking mechanisms onboth hooks were subjected to a relativelyhigh dynamic load as a result of the boatbeing brought to an abrupt halt by the davitcradle stops,

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• the dynamic load when the davit cradlesmade contact with their stops, was sufficientto cause the after hook to release,

• once the stern of the lifeboat was discon-nected from its fall, it started to swingforward applying a greatly increaseddynamic load to the forward davit cradlewith a component of the load directedlaterally and aft,

• the forward davit structure was insufficientlystiff in a lateral plane to carry the load of theswinging boat and so failed. The failureoccurred at the weakest point in the davitcradle ie. at the bend midway along itslength, with sufficient force beingtransmitted through the cradle pinion to twistthe frame,

• the lifeboat continued to fall until it wasvertical, impacting on the side of the shipshortly after the forward cradle failed,

• damage to the boat was sustained on impact.

Operation of the davit winch It was the usual practice on the vessel for thecrew member operating the lifeboat davit winchbrake to control the initial speed of lowering toensure that the davit cradles made relativelygentle contact with their stops at deck level. Onthis occasion the motorman controlling thewinch brake was not experienced with theoperation of the davit and did not control thespeed of lowering. The relatively hard contactwhen the davit cradles hit their stops caused ahigher than usual load on the on-load releasehooks and caused the partially reset after hook totrip open. However, the actions of the motormanare not considered to have contributed to thefailure as the after hook would not have trippedopen if the on-load release system had been fullyreset. If anything, his actions may have beenfortuitous as there was the potential for a seriousaccident if the hook had failed during the nextabandon ship drill when the lifeboat would havebeen occupied.

The lifeboat launching system is designed toallow the coxswain to lower the boat using theremote winch brake release cable inside theboat. It is not reasonable, particularly in anemergency, to require the coxswain to controlthe rate of descent using this system and so thedavit and lifeboat design must allow for thedavit cradles making contact with their stops atthe maximum rate of lowering allowed by thecentrifugal brake in the davit winch. Indeed, therelevant statutory and classification societyrequirements dictate that the on-load releasehooks are to be tested to six times their designload.

Past incidentsIn the last nine years there have been severalinvestigations into incidents around the worldinvolving the on-load release systems in Shigilifeboats. These include; the investigation of anincident on board the bulk carrier Kayax in1994 (ATSB report number 71), the UnitedKingdom’s Marine Accident InvestigationBranch’s investigation of an incident on IvoryAce in 1993 and the Canadian TransportationSafety Board’s (TSB’s) investigation of anincident on Iolcos Grace in 1998. These investi-gations revealed factors common to the incidentwhich occurred on Alianthos. The Iolcos Graceincident, in particular, being very similar.

On 9 November 1998, in Vancouver harbour, theforward on-load release hook on the portlifeboat of the bulk carrier Iolcos Grace openedunder load during a drill. As a result, thelifeboat fell seven metres to the water with sixcrew on board. One crew member was killedand the five others were all injured to varyingdegrees. The subsequent investigation found thatthe forward hook had not been fully reset afterthe previous drill and had opened when the boatwas being lowered. The investigation found,among other things, that the operating cablesconnecting the forward and aft hookmechanisms to the release mechanism wereincorrectly adjusted.

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The TSB’s investigation also found that the crewhad repaired a hole in the bottom of the lifeboatsome time before the incident. An operatingcable turnbuckle on the boat’s on-load releasesystem had made the hole when it had deflectedin exactly the same manner as found onAlianthos’ lifeboat.

These three investigations revealed that the crewof each ship were insufficiently conversant withthe operation of the on-load release system andthat they had difficulty understanding thelifeboat manufacturer’s operating instructions.

In August 1997, Shigi Shipbuilding Companyresponded to several incidents involving on-loadrelease systems on their lifeboats by distributinga circular to each ship fitted with a Shigilifeboat. The circular contained warningsrelating to the resetting of the hooks, upgradedinstructions for testing and maintaining the on-load release equipment and some newinstruction and warning plaques. Of particularrelevance was a new warning plaque to be fittedinside each lifeboat which advised the operatorsto check the position of the cam plate on theno.3 hook bearer to ensure that the hooks arefully reset.

On 1 February 2001, the ATSB provided ShigiShipbuilding Company with details of theAlianthos incident and requested the designspecification, load testing and certification ofthe on-load release system. These documentswere subsequently provided to the investigationin addition to a copy of the 1997 circular, whichthe company indicated had been sent to the ship,(C.S. Elegant at the time). Inspection ofAlianthos’ documentation relating to thelifeboats revealed that the ship had received thecircular, however the warning plaque relating tothe position of the cam plate on the no.3 hookbearer was notably absent in the documentationand had not been fitted inside the lifeboat.

On-load release design The Shigi SZK-5 on-load release system wasdesigned to meet the requirements of the 1974International Convention for the Safety of Lifeat Sea (SOLAS) and 1983 amendments. Thedesign has been in use since 1988 and isapproved by various classification societiesincluding Lloyd’s Register and Nippon KaijiKyokai.

The design of the on-load release system hassome aspects that may have contributed toincident on board Alianthos. The cable systemoperating the hooks exhibits designinadequacies which make it prone to acquiringthe ‘lost motion’ found in the port lifeboat’safter hook cable. The design of the hookmechanism is also of concern as it allows loadto be taken by a partially reset hook, which maytrip open under conditions of higher thannormal sustained or transient load. As such, it isdebatable whether the on-load release systemcomplies with the intent of the applicableSOLAS requirements.

Another significant factor in the incident wasthe lack of a ‘telltale’ or mark to readily indicateto the crew whether or not the hooks are in thefully reset position.

Lost motion in the operatingcable system After a period of time in service, teleflex cablesinevitably become stiffer to operate. Frictionbetween the inner cable and outer sheath, andbetween the rods and glands increases with theaging of the internal lubricant, hardening ofgland seals, ingress of dirt and/or water,corrosion, and infrequent operation. Thesecables are not designed to be maintained onboard ships and so must be renewed periodicallywhen their condition deteriorates. In practicethey are infrequently replaced as sourcing thecorrect replacement cables is difficult and

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expensive with few crews sufficiently trained orconfident to perform the maintenance work.

Alianthos had been in service for about 12 yearswith no evidence that the lifeboat teleflex cableshad ever been replaced. Over this period oftime, the cables had become progressivelystiffer. In the case of the after hook in the portlifeboat, as the cable stiffness increased, theswivel mounting on the cable clamp adjacent tothe operating mechanism would have beenrequired to react with progressively more forcein both the tripping and resetting operations.Eventually the swivel mount on the clamp hadworn to the point where it was not maintainingthe alignment of the cable end with theoperating quadrant. Once there was sufficientmisalignment the end of the cable was relativelyfree to deflect during each resetting operation,pivoting about the clevis pins in the turnbuckle.With both turnbuckle clevises aligned, there wasan easy degree of freedom for the cable end todeflect in the vertical plane, in this casedownwards, until it was in contact with thebottom of the boat.

The design of the on-load release system wasnot tolerant of the increasing compressive forcesrequired to reset the hooks as the movement ofthe teleflex cables became stiffer with age. Theswivel mount clamps did not adequatelymaintain the alignment of the cable ends withthe operating quadrants and there was too muchfreedom in the vertical plane as a result of theturnbuckle clevises being aligned in the samedirection.

SOLAS requirementsChapter III regulation 41.7.6 of SOLAS 74 (asamended in 1983) contains the requirements forlifeboat on-load release systems applicable atthe time Shigi Shipbuilding developed the SZK-5 system.

Regulation 41.7.6.2.2 states with respect to theon-load release capability:

…This release capability shall be adequatelyprotected against accidental release or prematureuse.

The design of the on-load system doesincorporate measures for preventing accidentalrelease, including the two safety pins in theoperating mechanism. However the number ofincidents involving this particular type ofrelease equipment, where partially reset hookshave opened under load, demonstrates that thesemeasures are inadequate. In the Inspector’sopinion the design of the system fails to complywith the SOLAS provisions against accidentalrelease. Subsequent International MaritimeOrganization (IMO) resolutions have clarifiedand amended the relevant SOLAS requirements.

IMO Resolution MSC.48 (66) adopted theInternational Life-Saving Appliance Code(LSA) on 4 June 1996, effectively amendingChapter III of SOLAS on life-saving appliancesand arrangements. To reduce the chances of anaccidental release of hooks while on load, theCode requires ‘special mechanical protection’,an improvement over the previous requirementfor ‘adequate protection’. To satisfy thisrequirement, a number of designs, includinglater Shigi models, have incorporated anhydrostatic interlock.

SOLAS 1997, Chapter III, 41, 7.6.2.2 nowcontains a clarification with regard to theoperation of lifeboat on-load release systeminterlocks:

To prevent an accidental release during recoveryof the boat, the mechanical protection (interlock)should only engage once the release mechanismis properly and completely reset.

Such an arrangement, designed to engage onlywhen both hooks were fully reset, if fitted to

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Alianthos’ lifeboats, would have greatly reducedthe chances of the incident occurring

Hook indicatorThe absence of a clear indication that the hookmechanisms were not fully resetting was afactor in the incident. Such an indication wouldhave provided positive information as towhether the hooks were fully engaged or notand would have prompted the crew toinvestigate the on-load release system. Thiswould have given them the opportunity to findand rectify the problems with the operatingcables.

The bottom of the no.2 hook bearer is arectangular plate which has the dual function of;providing a bearing surface for the no.3 hookbearer (cam plate) which drives it, and locatingthe no.2 hook bearer in the adjacent slottedbracket (preventing it from rotating or fallingout). The vertical position of the plate withrespect to the slot in the bracket provides aneasily visible indication of the status of thehook.

Once the on-load release system has beeninstalled, and the length of the release cables hasbeen properly adjusted, the final or fully lockedposition of the no.2 hook bearer with respect tothe bracket should not change. A simple paintedor engraved mark on the bracket would providean easily-seen gauge for the status of each hook.Such an indication would not negate the need toinspect the position of the cam plate on the no.3hook bearer, which must be rotated past thecentre line of the no.2 hook bearer to ensurepositive locking of the hook mechanism.However it would prevent the situation whichoccurred on Alianthos where neither hook wasbeing fully reset, with the after hook’s no.2 hookbearer moving only 18 mm from the fullytripped position due to the lost motion in theoperating cable.

Operation and maintenance ofthe on-load release systemAlianthos had a number of documents on boardrelating to the operation and maintenance of thelifeboat on-load release system. These included;Shigi Shipbuilding Company’s originaloperation and maintenance manual for thelifeboat and the 1997 circular relating specif-ically to the on-load release system. Thesedocuments contained instructions for trippingand resetting the on-load release system andvarious warnings relating to its operation andmaintenance. While some of the documents onboard the vessel, including the instructions foroperating the lifeboat davits, had been translatedinto Cyrillic text used by the Ukrainian crew,these had not. There was no ship-specificprocedure relating to the operation of the systemcontained within the International SafetyManagement Code procedure manuals on board.

Two etched steel instruction plaques withEnglish text, one for releasing the hooks and theother for resetting the hooks, were mountedinside the port lifeboat. The instructions on bothof these plaques were unintelligible, as thereference numbers for the parts of the systemwere missing, both in the diagrams and in thetext. Even if the numbers had been present onthe instruction plaques, as they were in the otherdocumentation on board, the resettinginstructions would still have been somewhatconfusing to the operator as a single diagramshows the system in both states, ie. tripped andreset (as in figure 2). The diagrams on bothplaques include parts of the mechanism that arehidden below deck level and so are not readilyvisible to the operator and this may also lead tosome confusion.

The lack of reference numbers, the English textand confusing diagrams rendered theinstructions for operating the on-load releasesystem inside Alianthos’ port lifeboat effectivelyuseless to its crew.

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The warning plaque pertaining to the position ofthe no.3 hook bearer cam plates and safety pins,which Shigi Shipbuilding stated had beensupplied to the vessel, was not fitted in thelifeboat. The written warning and diagrams onthis plaque would have provided the crew withenough information to ascertain that the afterhook, in particular, was not resetting fully andmay have prevented the incident.

Instructions on maintaining the on-load releasesystem were included in the documentation onboard. The maintenance described consists ofthe periodic inspection, actuation, resetting andgreasing of both forward and aft no.2 hookbearers. The updated maintenance instructionssupplied by Shigi Shipbuilding in 1997 includesthe following warnings relating to the teleflexcables and instruction plaques within the boats:

If there is any problem with the cables, contactShigi Shipbuilding immediately.

and:

Make sure the Instruction poster and CautionNotice for the hook release mechanism are clearand legible. If they are hard to read, contact ShigiShipbuilding immediately.

It appears that these warnings were either notknown to, or had been ignored by the crew asboth of these problems pre-existed the incidentfor a lengthy period of time.

Maintenance of the on-load release system inthe port lifeboat was manifestly poor. Thegeneral condition of the system was poor, withflaking paint and corrosion on the hooks andgrease on both hooks and the operatingmechanism which was old, hard and contam-inated. Both teleflex cables were stiff and poorlyadjusted. There were no maintenance records forthe system on board, the reasonable assumptionbeing that the system had not received anysignificant maintenance for a protracted period.The adequacy of the maintenance carried out onthe system in November 1999, only 14 monthsprior to the incident, must also be questionedbased on the general condition of the system.

The lack of maintenance over time was directlyimplicated in the incident as a thoroughinspection of the on-load release system wouldhave revealed the problem with the after hook’soperating cable.

Crew Training

The safety management system aboardAlianthos included a standard form forscheduling safety drills. According to the form,an ‘abandon ship’ drill is scheduled every threemonths to comply with the requirements ofSOLAS, in the months of March, June,September and December. In practice however,the master indicated that he conducted drillswhen the ship’s operations, schedule andweather permitted, generally when the ship wasat anchor or in port.

As the management of Alianthos had changed inNovember 1999, the maximum time any of thecrew had served on the vessel was a singlecontract of six months, in addition to aroundtwo months of the current contract. Thus nomember of the crew had participated in morethan three lifeboat drills on the vessel prior tothe incident. The crew had conducted a lifeboatdrill on the day before the incident. The masterstated that he had ordered another drill thefollowing day as he felt that the crew were notsufficiently conversant with the operation of thelifeboats.

The third mate, who had reset the on-loadrelease system immediately prior to the incident,had been on the vessel only three months. Hehad not operated the on-load release systemprior to this occasion and his only training onthe system was some verbal instruction given bythe mate immediately before the drill. He hadno previous experience of the type of on-loadrelease system fitted in Alianthos’ lifeboats.Given his lack of experience, minimal training,the lack of a ‘reset indicator’ and the unintel-ligible instruction plaques in the boat, it ishardly surprising that he did not recognise thatthe hooks were failing to fully reset.

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Conclusions These conclusions identify the different factorscontributing to the incident and should not beread as apportioning blame or liability to anyparticular individual or organisation.

Based on the evidence available, the followingfactors are considered to have contributed to theincident involving Alianthos’ port lifeboat on 24January 2001:

1. The hooks were not fully reset when thelifeboat returned to the ship immediatelyprior to the incident and the after hooktripped under load when the davit cradlesmade harder than normal contact with theirstops at deck level.

2. The forward davit cradle failed as a resultof the sudden increase of load, applieddynamically, when the whole weight of thelifeboat was suspended suddenly from theforward fall.

3. The on-load release hooks in Alianthos’port lifeboat could not be fully reset usingthe operating mechanism in the prescribedfashion.

4. There had been up to 60 mm of lost motionin the cable system operating the after hookmechanism for a lengthy period of time.

5. The design of the on-load release operatingcable system is inadequate with respect tomaintaining cable alignment over time,specifically when in compression.

6. The design of the on-load release systemdoes not incorporate any mechanicalsafeguards against incomplete resetting ofthe hooks.

7. There was no readily visible mark toindicate the status of each hook releasemechanism.

8. The maintenance of the on-load releasesystem was poor.

9. The operating instructions for the on-loadrelease system inside the boat wereeffectively useless to the crew.

10. The warning plaque relating to the positionof the no.3 hook bearer cam plates had notbeen fitted inside the lifeboat.

11. The crew training was deficient with regardto the operation of the on-load releasesystem.

It is also considered that:

12. The operation of the davit winch at the timeof the incident was not a factor as the afteron-load release hook would not haveopened when the davit cradles made contactwith their stops if it had been fully reset.

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20

FIGURE 11:Alianthos: Events and causal factors chart

Even

ts

Cond

ition

s

Inci

dent

It is recommended that:

1. Owners and operators of ships carryingShigi lifeboats fitted with SZK-5 on loadrelease systems should seriously considerretrospectively fitting hydrostatic interlocks.

2. Indicators be fitted on Shigi lifeboats toclearly show crew when the on-load releasehook mechanisms are fully reset.

3. Regular programmed planned maintenanceand inspection of lifeboat on-load releasesystems by specifically trained andqualified personnel should be instigated.

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Recommendations

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SubmissionsUnder sub-regulation 16(3) of the Navigation(Marine Casualty) Regulations, if a report, orpart of a report, relates to a person’s affairs to amaterial extent, the Inspector must, if it isreasonable to do so, give that person a copy ofthe report or the relevant part of the report. Sub-regulation 16(4) provides that such a personmay provide written comments or informationrelating to the report.

The draft investigation report was sent to thefollowing: Alianthos’ master, third mate andmanagers, Shigi Shipbuilding Company and theAustralian Maritime Safety Authority.

A submission was received from ShigiShipbuilding Company, the following is anextract from that submission:

First of all, we would like to express our respectand admiration for the thorough and scrupulousinvestigation carried out by your inspectors. Weare deeply impressed by the meticulousness andfairness of the report, and are in agreement withall its findings and recommendations.

We are of course greatly disturbed that a numberof incidents have occurred with type of lifeboat.Although we did everything in our power toensure complete safety for crew members whendesigning the boat and its release system, inretrospect we can see that there were some designflaws, which taken together with lack of regularmaintenance and proper training, have had tragicconsequences.

However, we would like to stress that we didwhat we could to prevent the present incident onthe ALIANTHOS taking place. The circular wesent on August 28, 1997 was found among thevessel’s documents, and it is indeed unfortunatethat the Warning Sign we attached therewith wasnot put up inside the lifeboats. As stated on page19 of the report, "the written warning anddiagrams on this plaque would have provided thecrew with enough information to ascertain thatthe after hook, in particular, was not resettingfully and may have prevented the accident." Wealso supplied replacement instruction stickersdetailing the Release and Resetting procedures atthe same time, "in case the original stickersbecame faded and difficult to read," and hadthese been put up also, the parts numbers

described on page 19 as missing would have beenclearly visible.

Also, we do believe that, had proper maintenancebeen carried out regularly in accordance with ourmanual’s instructions, this incident may wellhave been prevented. We are in full agreementwith the report’s comment on page 20 that "Thislack of maintenance over time was directlyimplicated in the incident as a thoroughinspection of the system would have revealed theproblem with the after hook’s release cable."

With regard to the aspects of the SZK-5 hookrelease system’s design which were found to befactors in causing this incident, we would like itto be known that all of these have beeneliminated in the SZK-30 and SZK-36 releasesystems we have been producing since 1992.(The SZK-5 ceased production the same year.)

Namely our present release system has:

1) an indicator (color marking) clearly showingwhether the hooks have been fully reset,

2) a hydrostatic interlock, and

3) the teleflex cable is screwed in directly at bothends. With the turnbuckle and clevises eliminatedfrom the release handle end, deflection of thecable (lost motion) as occurred in this incident isno longer a possibility.

And further:

Regarding the Recommendations given at the endof the report:

1) We are ready and willing to retrofit ahydrostatic interlock on the SZK-5 hook releasesystem, and indeed already have done so on anumber of lifeboats at the request of theirowners.

2) We are also prepared to provide indicators onlifeboats with the SZK-5 release system. Sendingout a circular to all ship owners with lifeboatshaving this release system is something we willseriously consider.

3) As for the final recommendation regarding aregular maintenance and inspection program bytrained and qualified personnel, we have servicesuppliers in the Netherlands and Singapore whohave completed a training program with us herein Osaka, and who are authorized by us to carryout maintenance and inspections of our hookrelease systems. We hope to expand our networkof trained and qualified service suppliers aroundthe world, and are of course ready to providesuch service ourselves.

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AlianthosName Alianthos

Former names Young Senator-1992, Rubin Elegant-1994, C.S. Elegant-1999

IMO No. 8805169

Flag Malta

Classification Society Nippon Kaiji Kyokai

Vessel type Bulk carrier

Owner Alianthos Shipping Company

Year of build 1988

Builder Namura Shipbuilding Company, Japan.

Gross tonnage 36 074

Summer deadweight 65 850 tonnes

Length overall 225.78 m

Breadth, moulded 32.20 m

Draught (summer) 12.822 m

Engine Mitsubishi Sulzer 6RTA62

Engine power 7 838 kW

Service speed 14.05 knots

Crew 19 (Ukrainian)

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72 Independent investigation into the lifeboat incident on board the Maltese flag bulk carrier Alianthos

at Geelong, Victoria on 24 January 2001

ISSN 1447-087XISBN 1 877071 19 6

Alianthos. 12 .2002