Tombarra fall wire fatality: Updated reports

The first is Tombarra Part A Report No 19A/2012.

The following key issues are highlighted in this report:

• A rescue boat fell 29 metres killing one of the boat’s four crew.
• The boat’s fall wire parted following the failure of a proximity switch which enabled the davit’s winch to overload the wire.
• A holistic view of the design, approval and compatibility of davit and winch systems is essential to prevent individual components of the system being overstressed to the point of failure.
• It is essential that ships’ crews always test safety devices before use and do not rely on them for their safety.
• The rescue boat was found to be 50% overweight. During the investigation, other rescue boats were found to be up to 110% overweight.
• The additional weight was due to water ingress through the hull and subsequent entrapment in the boat’s internal stiffeners and foam-filled compartments buoyancy spaces, and could only be removed by drilling holes or removing the deck.
• The crew were unaware that the boat was significantly heavier than designed.
• The number of other rescue boats, made by differing manufacturers which have also been found to be overweight, indicates that the problem of water entrapment within buoyancy spaces is widespread and potentially extends to lifeboats and leisure craft.
• The investigation identified the need to weigh the boats on a regular basis.

The second is Report No 19B/2012 Part B -The weight of the rescue boat.

The UK MAIB’s earlier preliminary findings and updated findings were published in:

• 07/12 Fall fatality during platform abandonment
• 09/11: Failure of fall wire – update to Safety Flash 05/11