A life-raft was inadvertently dropped onto the jetty during replacement of the ratchet straps on the hydrostatic pressure release unit. Three crewmembers were replacing the securing straps on the life-raft, which were arranged on a common sliding cradle, three rafts on each side of the vessel. The strap holding each raft was connected to a hydrostatic release unit at one end, and to a strong point at the other. A ratchet was used to tighten the strap.
The life-rafts were individually secured by a crane while the straps were being replaced. When the crane was holding the topmost life-raft, one crewmember accidently released the ratchet strap of the middle raft. The raft slid off the cradle and dropped approximately 10 meters to the pier. The life-raft container was damaged; no-one was injured.
What went wrong?
- Human error lead to accidental release of unsecured raft;
- There were no watchmen, nor barriers cordoning off the potential drop zone.
What were the causes?
- The risk assessment was not suitable or sufficient: the risk assessment used for this job was primarily intended for the tasks of lifting the life-rafts out of storage;
- It did not identify the risk of confusing the straps; this particular risk was not discussed during toolbox talks beforehand;
- The straps were not identified nor temporarily marked before the task – the crewman took the wrong strap;
- The responsibility of releasing the strap was not clearly assigned to any one particular person, and who was going to do it, was not agreed beforehand.
- Develop better situational awareness: the person who released the wrong life-raft believed his action was correct;
- Mistakes will be made: the risks of human error occuring should always be taken into account;
- Assign clear responsibility: ensure that team members know which task is done by which person – before starting work;
- Check the drop zones: investigation revealed that the area on the quay underneath the life-rafts was not easily accessible because access to the gangway was restricted to comply with ISPS requirements.
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