Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2092
Initial Report
While lifting a 9m tender into the garage, the forward lifting point gave way. Luckily, at this point, the tender was over the chocks and dropped about 30cm into position, causing only minor damage. A crew member was inside the tender but was not injured.
Lifting points were tested annually and visually inspected regularly, but due to the design, the underside of the lifting point was inaccessible, and any corrosion was not visible.
The lifting point was rebuilt and strengthened, and an inspection hatch was made. The vessel’s SOPs were amended, so that crew members attach the crane hooks to the lifting points, exit the tender before it is lifted, and only enter the tender once in the water.
CHIRP Comment
The report is positive: many safety improvements were made, and the vessel is to be commended for its positive safety culture. The equipment’s design hampered the inspection of the underside of the lifting equipment. Often, we dissuade ourselves from raising safety reports on poorly designed or installed equipment in the belief that they are ‘too big to change’ or ‘it must be right – it was built that way’. But even naval architects sometimes get it wrong, and if it had been reported, it could have been rectified when next in refit. Do not be afraid to report and record concerns about design deficiencies. Organisational safety management systems operate on a cycle of
continuous improvements, and ship designers will be only too glad to receive feedback so that improvements can be made.
Useful references that detail the examination and inspection regimes for lifting equipment include the UK MCA’s MGN 332(M+F) Amendment 1 and the Cayman Island’s Shipping Notice 04/2021. Additionally, UK MGN 560(M) sets out the SOLAS III/36 requirements for launching appliances; these must be adhered to if the tender is also classified as a lifeboat or rescue boat. Accompanying an inspector during a thorough examination is a good learning opportunity: watch what they check for and ask questions.
Key Issues relating to this report
Safety Culture: The swift rectification of these defects indicates a positive safety culture on board. On this vessel, the crew can be confident that their safety concerns will be listened to.
Alerting: If you see something wrong – speak up. Just because it was built that way does not mean it is correct!
Design: Readers are encouraged to be constantly vigilant to poor design and to feed this back to designers and architects who often do not have to work with the equipment they develop.