Lack of training, poor compliance with procedures led to injury during lifeboat drill on cruise ship, TSB report finds

The Transportation Safety Board of Canada (TSB) recently released its investigation report into an incident in which one individual suffered a serious injury on a cruise ship as a direct result of the lack of training and compliance with procedures.

On September 9, 2018, a scheduled lifeboat drill was taking place on board Amadea, a cruise ship owned by Bahamas-registered Amadea Shipping, while it was docked in the port of Québec, Quebec.

Following the drill, a crewmember was seriously injured while stowing one of the lifeboats and was later transported to a local hospital by ambulance.

The accident occurred as several crew members were using the davit’s manual winch to complete the stowage of the lifeboat. To make this task easier, the bosun overrode the built-in safety feature which maintains a slight drag in the winch brake system by releasing the electromagnetic brake with a lever, further than what would normally be accomplished by hand alone.

The investigation also determined that the two davit arms were misaligned, requiring extensive manual winching of the lifeboat.

Two crewmembers continued manual winching and the excessive tension on the winch system caused them to let go of the crank handle. Because the electromagnetic brake was released, the crank handle suddenly kicked back and spun backwards, hitting a seaman on the head.

The seaman was not wearing any protective headgear.

The investigation revealed that the injured crewmember was neither trained nor familiarised with the task and was unaware of the risks and hazards associated with it.

The investigation also found that the onboard safety management system did not include training or any formal operating procedures on lifeboat recovery and stowage, or on operating the davit winches. If crewmembers are not trained in the safe operation of critical shipboard equipment such as life saving appliances, there is a risk that they will not operate such equipment in a safe manner.

In regards to the equipment design, it was determined that if the design allows operators to override or disable its built-in safety features, these features will not function as intended, increasing the risk that the crew will be injured while operating this equipment.

Additionally, when operating lifeboat winches and davits, and when using lashings, crewmembers need to wear proper personal protective equipment.

Following the occurrence, Amadea‘s manager, Bernhard Schulte Cruise Services, had the lifeboat’s davit and winch inspected. It also updated the vessel’s training manual so that it now includes a procedure for lifeboat recovery.

The procedure specifies that crewmembers must wear protective headgear (helmet), gloves, and safety shoes while performing any activity involving lifeboat winches, davits, and lashings.