Executive summary
On the afternoon of 8 January 2011, the passenger vessel Volendam was alongside in Lyttelton. Some of the crew were carrying out routine maintenance on one of the starboard lifeboats when at about 1400 the forward lifeboat fall wire parted and 2 crew members fell into the water; the lifeboat remained suspended by the aft lifeboat fall wire.
The alarm was raised and a rescue boat and crew were launched shortly afterwards. One of the crew members who had fallen into the water was recovered by the rescue boat. However, the other crew member could not be found despite a search being carried out by the vessels rescue boat, the port authority, the coastguard and emergency services.
The body was eventually found and retrieved from the sea bed some 4 hours later by port authority divers. The lifeboat was irreparably damaged and the tender launch aft of the lifeboat was also damaged, requiring repairs to the hull before the Volendam could sail.
Both crew members who fell into the water were wearing safety harnesses that were attached to a line strung between the lifeboats lifting hooks. When the fall wire failed this line also failed. Neither of the crew members was wearing any form of buoyancy aid or lifejacket.
A subsequent investigation into the failure mechanism of the forward fall wire showed that the wire in the failure zone was heavily corroded which caused a loss of structural strength in the immediate vicinity of the failure. The final failure was due to a tensile fracture of the remaining cross section of the wire.
Because of the design of the lifeboat davits, the wire in the vicinity of the failure, was difficult to access to apply a protective coating of grease to the wire, and it was difficult to ensure that the coating was applied around the whole circumference of the wire in this area.
On inspection of the remaining davit systems on board the vessel, 10 fall wires were found to be sufficiently corroded in an area at or near the fixed point termination to require remedial action.
Three urgent safety recommendations were made to the manufacturer of the davit systems, to: alert all owners of vessels fitted with the SPTDL-150P model of davit fitted to the Volendam to the circumstances of this accident and issue instructions on what immediate inspections should be carried out make a technical assessment of other lifeboat davit models it had produced to identify similar safety issues existing with these models, and if so alert owners of these models review the design of the davit system SPTDL-150P with a view to remedying the tendency in this case for the fixed arm davit to flex inwards under load and contact moving parts of the structure.
Key lessons
A wire rope is only as good as its weakest part. Unless an inspection covers the entire length of the wire, a thorough inspection has not been made. Wire ropes in a marine environment require frequent and thorough lubrication to prevent corrosion; otherwise other measures will need to be taken to prevent premature failure of the wire ropes. When selecting a securing point for a safety harness, consideration should be given to its vulnerability in the event of other catastrophic failures. A personal buoyancy device should always be worn when working outside a ships rail. Robust job hazard analysis (JHA) can prevent injuries and save lives, but only if the procedures that result are then followed by the crew.
Interim factual report
The interim factual report for this inquiry published in February 2011 is superseded by the final report, but remains available using the link in the sidebar to the right in order to maintain a complete public record.