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MARINEACCIDENTINVESTIGATIONBRANCHACCIDENTREPORTLESSSERIOUSMARINECASUALTYREPORTNO9/2015MAY2015ReportontheinvestigationoftheaccidentalreleaseofalifeboatonNagatoReeferSouthampton,UKon9April2014ExtractfromTheUnitedKingdomMerchantShipping(AccidentReportingandInvestigation)Regulations2012–Regulation5:“ThesoleobjectiveoftheinvestigationofanaccidentundertheMerchantShipping(AccidentReportingandInvestigation)Regulations2012shallbethepreventionoffutureaccidentsthroughtheascertainmentofitscausesandcircumstances.Itshallnotbethepurposeofaninvestigationtodetermineliabilitynor,exceptsofarasisnecessarytoachieveitsobjective,toapportionblame.”NOTEThisreportisnotwrittenwithlitigationinmindand,pursuanttoRegulation14(14)oftheMerchantShipping(AccidentReportingandInvestigation)Regulations2012,shallbeinadmissibleinanyjudicialproceedingswhosepurpose,oroneofwhosepurposesistoattributeorapportionliabilityorblame.©Crowncopyright,2015Youmayre-usethisdocument/publication(notincludingdepartmentaloragencylogos)freeofchargeinanyformatormedium.Youmustre-useitaccuratelyandnotinamisleadingcontext.ThematerialmustbeacknowledgedasCrowncopyrightandyoumustgivethetitleofthesourcepublication.Wherewehaveidentifiedanythirdpartycopyrightmaterialyouwillneedtoobtainpermissionfromthecopyrightholdersconcerned.AllMAIBpublicationscanbefoundonourwebsite:www.gov.uk/maibForallenquiries:MarineAccidentInvestigationBranchSpringPlace105CommercialRoadSouthamptonEmail:maib@dft.gsi.gov.ukUnitedKingdomTelephone:+44(0)2380395500SO151GHFax:+44(0)2380232459Pressenquiriesduringofficehours:02079444166/3176Pressenquiriesoutofhours:02079444292CONTENTSGLOSSARYOFABBREVIATIONSANDACRONYMSSYNOPSIS1SECTION1-FACTUALINFORMATION21.1ParticularsofNagatoReeferandaccident21.2Background41.3Narrative41.4Crew91.4.1Master91.4.2Chiefofficer91.4.3Bosun91.4.4Crew’stimeonboard91.5PortStateControlinspections91.5.1Background91.5.2PSCinspection,2January2014101.5.3PSCinspection,9April2014101.5.4ISMCodedeficiencies101.5.5Firedrill111.6Rectifyingthedeficiencies111.6.1Damagedlifeboat111.6.2Abandonshipdrill,12April2014121.6.3Fire-fightingtraining121.6.4InternationalSafetyManagementCodeaudit131.7Manager’sreviewofISMdeficiencies131.8Lifeboatreleaseandretrievalsystems141.8.1Background141.8.2MSC.1/Circ.1327141.8.3AmendmentstoSOLASChapterIII151.8.4ClassNKtechnicalinformationpaper151.9NagatoReefer’slifeboatreleaseandretrievalsystem151.9.1Design151.9.2ResettingtheLRRS161.9.3Warningsigns191.9.4ModificationstocomplywithSOLASRegulationIII/1.5201.10NagatoReefer’sfallpreventerdevice201.10.1MAIBvisittovessel,20April2014201.11Lifeboats201.11.1Annualinspection,October2013211.11.2Inspectionatabandonshipdrill,15March2014211.11.3Weeklyinspection,22March2014211.11.4Post-accidentinspection,9April2014211.11.5Post-accidentlifeboatrepairandinspectionreport,29April2014231.12Emergencydrills241.12.1Regulatoryrequirements241.12.2Manager’srequirements241.12.3NagatoReeferabandonshipdrills251.13Safetycommitteemeetings251.14Previousaccidents261.14.1MAIBsafetystudy1/2001261.14.2LifeboataccidentsreportedtotheMAIBinthedecade2002-2012261.14.3SeaUrchin,22May200626SECTION2-ANALYSIS282.1Aim282.2Theaccident282.3Lifeboatreleaseandretrievalsystem282.3.1ResettingShigiSRS-37typeLRRS282.3.2Useoffallpreventerdevices292.3.3Useoffallpreventerdevicesonpassage292.4SafetyManagementSystem292.4.1Crewcommunications302.4.2Crewtraininganddrills302.4.3Safetycommitteemeetings302.4.4Maintenanceinspections312.4.5ManagementCompany’sreviewofaccident312.5Post-accidentinterferencewithaccidentsite32SECTION3-CONCLUSIONS333.1Safetyissuesdirectlycontributingtotheaccidentthathavebeenaddressedorresultedinrecommendations333.2Safetyissuesnotdirectlycontributingtotheaccidentthathavebeenaddressedorresultedinrecommendations333.3Othersafetyissuesnotdirectlycontributingtotheaccident34SECTION4-ACTIONTAKEN354.1KyokuyoCompanyLimited35SECTION5-RECOMMENDATIONS36FIGURESFigure1-NagatoReeferFigure2-Lifeboatinterior–steeringpositionandhookreleasehandleFigure3-FallpreventerdevicefittedtostarboardlifeboatFigure4-PortlifeboatdavitFigure5-Gripewires(onstarboardlifeboat)Figure6-LifeboathulldamageFigure7-Forwardhook,asphotographedpost-accidentat1608Figure8-LifeboathookreleasegeararrangementFigure9-HookassemblyarrangementFigures10a-10d-HookresettingsequenceFigure11-HookresetsignsdisplayedinlifeboatFigure12-Portlifeboat–forwardhookassemblyFigure13-Starboardlifeboat–afthookassembly(asfound)Figure14-Starboardlifeboat–releaselever(asfound)ANNEXESAnnexA-Manager’ssafetynoticetoitsvessels,May2014AnnexB-ClassNKcircularsTEC-0694,0966AnnexC-SRS-37resettingprocedureAnnexD-Lifeboatanddavitpre-inspectionreport,October2014AnnexE-Portlifeboatrepairreport,April2014GLOSSARYOFABBREVIATIONSANDACRONYMSCAPCorrectiveActionPlan(ISM)CoCCertificateofCompetencyDPADesignatedPersonAshoreFPDFallPreventerDeviceIMOInternationalMaritimeOrganizationISMCodeInternationalSafetyManagementCodeLRRSLifeboatreleaseandretrievalsystemMCAMaritimeandCoastguardAgencyMOUMemorandumofUnderstandingMSAMarineSafetyAdvisoryPPEPersonalProtectiveEqui