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 occurring 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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