BSafe Case Study 14 — Released Before the Second Gripe Was Even On

A PSC Inspection Triggers a Drill

Deficiencies found during a Port State Control inspection led the PSCO to order an abandon-ship drill using the port lifeboat. The chief officer, as lifeboat commander, took five crew out on the water, then returned alongside. Hoisting it back required several attempts to reconnect the davit suspension links, and difficulty resetting the hook release gear — two crewmen had to pull hard on the release handle just to get it into a position where the safety pin could even be inserted. Some of the lifeboat crew weren't convinced the hooks had actually reset correctly, even once hoisted.

An Instruction That Didn't Land

With all six crew disembarked at the embarkation deck, the bosun and two crewmen were tasked with securing the lifeboat into its davit — connecting gripe wires fore and aft before the Fall Preventer Devices (FPDs) could safely be released. The bosun told the men in the boat explicitly not to release the FPDs until he'd connected both gripes. He secured the aft gripe and was still working on the forward one when the chief officer arrived and instructed the men in the boat to release both FPDs anyway. The moment the forward shackle pin came out, the hook opened, and the unsupported forward end of the lifeboat fell onto the handrails below — striking the bosun.

What the Investigation Found

• The accident followed a breakdown in communication — crew were not empowered to challenge orders or participate in the decision at the moment it mattered.
• The SMS was ineffective and poorly implemented in practice: FPDs had reportedly been fitted to the starboard lifeboat while underway, rendering that boat inoperable in an emergency — a real misunderstanding of the device's purpose.
• Crew performance during the drill itself indicated a genuinely poor level of training.
• Following the incident, the ship's own safety committee recorded that there had been no incidents or near misses on board — despite this one having just happened.
• The manager's own review identified training shortcomings but produced no action plan to actually improve emergency-response standards.
• Maintenance records showed the release gear inspected monthly as required — but the investigation found the moving parts dirty and painted over, including the reset indicator, with no evidence of real inspection in the six months since the last annual service.

Recommended Actions

Direct from the investigation's findings:

1. An instruction given by a more senior officer that contradicts a safety-critical instruction already given by someone actively doing the job needs to be questioned in the moment, not simply followed — a functioning Stop Work Authority culture protects the person mid-task, not just the person giving the original order.
2. Equipment like FPDs needs training that covers correct use in every phase of operation, not just how to fit it — fitting it in a way that disables the lifeboat entirely defeats its purpose.
3. A safety committee's incident review is only useful if it accurately reflects what happened — recording ‘no incidents’ immediately after a real one undermines the entire process.
4. Painted-over moving parts and reset indicators on life-saving equipment should fail a real inspection, not pass one that's being conducted in name only.

Human Element Analysis

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Related Reading

• BSafe Case Study 2 – another lifeboat-related incident where an intervention attempt didn't hold