New Zealand Defence Force - Te Ope Kaatua O Aotearoa
Tuesday May 10, 2005
Navy lifeboat accident findings
A RNZN Court of Inquiry has completed an investigation into the circumstances surrounding an accident that occurred
during a lifeboat drill on the Royal New Zealand Navy tanker HMNZS ENDEAVOUR on 16 August 2004 in Sydney.
Twenty-two Sailors were in the lifeboat when it released prematurely from the ship and landed upside down in the water.
Thirteen were injured in the incident.
RNZN Maritime Component Commander Commodore Jack Steer who assembled the Court of Inquiry has accepted the Court's
findings and all sixteen of its recommendations will be implemented. No disciplinary action will be taken against any
individual.
Three main factors were identified which together contributed to the accident:
1. a faulty release mechanism
2. the absence of a correctly fitted safety indication guard
3. incorrect drills by the lifeboat crew
The Court noted that it was the combination of all three of the factors occurring together that caused the accident.
The Royal New Zealand Navy is taking the following specific actions to give effect to the Court's principal
recommendations:
1. repositioning safety and operating signs and developing or purchasing new training equipment
2. improving procedures for use of the ship's lifeboats, including training procedures, lifeboat maintenance, and
operation
3. reviewing policy and training for the operation and maintenance of all RNZN ship life saving equipment including the
future PROJECT PROTECTOR fleet
The Court noted that many of the ship's company performed exceptionally well on the day in rescuing the injured sailors
and that two in particular exemplified the RNZN's core values of commitment, courage and comradeship by entering the
water to rescue several of their shipmates. It also noted the valuable support provided by the Royal Australian Navy.
BACKGROUNDER
navy lifeboat accident findings
On August 16, 2004 the Royal New Zealand Navy tanker HMNZS ENDEAVOUR was conducting a lifeboat drill while alongside
Fleet Base East in Sydney. During the drill the port lifeboat fell from the ship landing upside down in the water with
22 crewmembers inside: 13 crewmembers were injured.
A Court of Inquiry was assembled on August 18, to determine the cause of the accident. The Court has now completed a
comprehensive investigation into the circumstances surrounding the accident and has made these findings.
Summary
It is the conclusion of the Court that the accident occurred due to a number of issues and is not attributable to a
single cause.
A mechanical fault on the port lifeboat release mechanism combined with personnel not following the correct procedure
for launching the lifeboat, and the decision to proceed with launching without a correctly fitted safety indication
guard are considered the primary factors leading to the accident. Insufficient training leading up to the accident was
also a contributing factor but the Court found that no individuals were negligent in their duty.
Findings
The RNZN Court of Inquiry has completed a comprehensive investigation into the lifeboat accident. The time taken to
complete the Inquiry is indicative of the thoroughness and detail of the investigation, and of the challenges faced by
the Court.
The challenges included the need to acquire a thorough understanding of the technical nature of the releasing
mechanisms, and to take into account the traumatic nature of the accident and the effects that it had on witnesses. The
RNZN is satisfied that the Inquiry has been concluded in a timely manner, taking into account all the surrounding
circumstances.
The Inquiry's greatest concern was with the lifeboat release mechanism. A defect in the lifeboat release mechanism
(which disconnects the ship's davit hooks from the lifeboat) identified prior to the accident had been corrected but the
maintenance process was not reviewed. Thus a further, more significant design fault in the lifeboat release mechanism
was not identified.
Post-accident investigations revealed the release mechanisms failed to secure correctly in the "locked" position once
the lifeboats are lifted from the water by their davits. The fault is believed to be the result of either a design or a
manufacturing error, and would have been in existence on both lifeboats since they entered service with the RNZN.
A second contributing factor was the failure to stop the launching when it became apparent that a safety guard on the
release mechanism was not in place. The guard is designed to prevent the accidental operation of the release mechanism
lever and to act as an indicator to show whether the lever is in the 'locked' or 'open' position. The guard was held in
place by hand to determine the position of the lever but was misread as 'locked' due to a parallax error.
During inspection of the release mechanism of the (undamaged) starboard lifeboat it appeared that the release mechanism
lever, even with the safety guard fastened in its correct position, was close enough to the boundary between 'locked'
and 'open' that both ENDEAVOUR's Executive Officer and a Lloyd's inspector initially thought the lever was in the
'locked' position.
The Court also found that the manufacturer's signs inside the lifeboat detailing the release process were inadequate and
did not clearly explain the correct release process.
The lack of formal training provided to the lifeboat crew is significant and represented a safety concern.
Actions
As a result of the findings and recommendations the RNZN has completed the following.
(1) Safety and operating signs in ENDEAVOUR's lifeboats made clearer and more logical.
(2) Improved procedures for use of ENDEAVOUR's lifeboats promulgated, including training procedures for all personnel
involved in lifeboat maintenance, launch and operation.
(3) Policy and training in relation to the operation and maintenance of all RNZN ship life saving equipment (to include
the future PROJECT PROTECTOR fleet) reviewed.
(4) Lifeboat safety, maintenance and training procedures reviewed.
(5) Procedures and processes for the repatriation of injured ship based personnel from overseas reviewed.
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ENDS