MA2021-2
3.7
FREEFALL LIFEBOAT ACCIDENT
INVESTIGATION REPORT
(mv ORANGE PHOENIX)
February 18, 2021
The objective of the investigation conducted by the Japan Transport Safety Board in
accordance with the Act for Establishment of the Japan Transport Safety Board is to determine the
causes of an accident and damage incidental to such an accident, thereby preventing future accidents
and reducing damage. It is not the purpose of the investigation to apportion blame or liability.
TAKEDA Nobuo
Chairperson
Japan Transport Safety Board
Note:
This report is a translation of the Japanese original investigation report. The text in Japanese
shall prevail in the interpretation of the report.
MARINE ACCIDENT INVESTIGATION REPORT
January 20, 2021
Adopted by the Japan Transport Safety Board
Chairperson TAKEDA Nobuo
Member SATO Yuji
Member TAMURA Kenkichi
Member KAKISHIMA Yoshiko
Member OKAMOTO Makiko
Accident type Fatality of a crew member
Date and time Around 11:20 on November 16, 2019 (local time, UTC+9 hours)
Location Wakayama Shimotsu Port, Wakayama Prefecture
Around 252 true bearing, 1.6 nautical miles (M) from Wakayama
Hokko West Breakwater Lighthouse
(approximately 34°13.6’N, 135°05.3’E)
Summary of the Accident While the cargo ship ORANGE PHOENIX with the master and 20
crew members aboard was anchoring at Wakayama Shimotsu Port,
Wakayama Prefecture, a crew member died of a fall from a lifeboat
to the deck when engaging in the lifting and recovery of the lifeboat
in an abandon ship drill.
Process and Progress of the (1) Set up of the Investigation
Investigation The Japan Transport Safety Board appointed an investigator-
incharge and one other investigator to investigate this accident
on November 18, 2019.
(2) Collection of Evidence
November 19, 2019: On-site investigations and interviews
November 28, December 16, 2019, March 2, 5, 6 and 26, August
5, 12 and 18, 2020: Collection of questionnaires
(3) Comments from Parties Relevant to the Cause
Comments on the draft report were invited from parties relevant
to the cause of accident.
(4) Comments from the Flag State and the substantially interested
State
Comments on the draft report were invited from the Flag State
and the substantially interested State of ORANGE PHOENIX.
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Factual Information
Vessel type and name Cargo ship ORANGE PHOENIX (Republic of Panama registry)
Gross tonnage 107,229 tons
Vessel number 9700835 (IMO number)
Owner, etc. EL SOL MARITIME S.A.
Management Company TOYO SANGYO CO., LTD. (hereinafter referred to as “Company
A”)
Class Nippon Kaiji Kyokai
L×B×D, Hull material 299.94 m x 50.00 m x 24.70 m, Steel
Engine, Output Diesel engine, 16,420 kW
Date of launch, etc. August 2, 2014
(See Figure 1)
Figure 1 ORANGE PHOENIX
Crew Information Master (Nationality: Republic of the Philippines), male, 60 years old
Endorsement attesting the recognition of certificate under STCW
regulation I/10
Certificate of Master (issued by the Republic of Panama)
Date of issue: December 5, 2016 (valid until August 25, 2021)
Navigation Officer A (Nationality: Republic of the Philippines),
male, 47 years old
Endorsement attesting the recognition of certificate under STCW
regulation I/10
Certificate of Chief Officer (issued by the Republic of Panama)
Date of issue: March 20, 2017 (valid until January 7, 2021)
Navigation Officer B (Nationality: Republic of the Philippines),
male, 33 years old
Endorsement attesting the recognition of certificate under STCW
regulation I/10
Certificate of Navigation Officer (issued by the Republic of
Panama)
Date of issue: September 6, 2019 (valid until March 26, 2023)
Injuries to Persons Death of one person (Navigation Officer B)
Damage to Vessel (or None
Other Facilities)
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Weather and Sea Weather: Weather - clear, Wind - southeast, Wind force - 2
Conditions Sea conditions: Sea surface - calm
Events Leading to the The cargo ship ORANGE PHOENIX (hereinafter referred to as the
Accident "Vessel") with the master, Navigation Officer A, Navigation Officer
B, and 18 crew members (all of them were the nationals of the
Republic of the Philippines) aboard started anchoring around 10:00
on November 16, 2019 in Wakayama Shimotsu Port, Wakayama
Prefecture, for the purpose of waiting for entry into the port.
On the Vessel, the master instructed the crew members to conduct
launching of a lifeboat in an abandon ship drill that has been
implemented every month, and Navigation Officer A, Navigation
Officer B, and eight crew members started the launching work.
The crew members dropped a free-fall lifeboat that was installed on
the stern deck of the Vessel in an empty state to the sea surface
while hanging it with a hoisting wire. After that, they hoisted the
lifeboat up to the original lifting and recovery position and hooked
the hook of the release system installed at the stern of the lifeboat
on the ring of the boat davit. (See Figures 2 and 3.)
Guide rail
Figure 2 Lifeboat stored in the boat davit
Lifeboat's
Hook stern
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Ring
Figure 3 Hook of the release system and ring of the boat davit
After that, Navigation Officer A entered the lifeboat from the
doorway on the stern side of the lifeboat for the purpose of
conducting operation to restore the release system that fixes the
hook hooked on the ring. Navigation Officer B was taking
photographs near the doorway in the bent-over posture to keep the
photographs as a record of the drill. (See Figures 4 and 5.)
Safety pin lock
Safety pin
Hook
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Figure 4 Status of Navigation Offi
cer A's work (re-enactment)
n Officer B before the fall
ent)
Figure 5 Conditions of Navigatio
(re-enactm
Around 11:20, when Navigation Officer A operated the release system and
slightly inserted the safety pin, the hook was suddenly released and the
lifeboat moved approx. 1.5 to 2.5 m downward on the guide rail. Thereby,
Navigation Officer B lost his physical balance and fell head-first to the deck
that was approx. 6 m below. (See Figure 6.)
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Figure 6 Status of Navigation Officer B's fall (image)
Upon receipt of a report by radio from Navigation Officer A that
Navigation B fell to the deck, the master notified the agent of the
fall and called for rescue. The agent notified Japan Coast Guard of
the fall.
Navigation Officer B was transferred to Japan Coast Guard's
helicopter that came to assist upon receipt of the notification, and
was then taken by ambulance to a hospital in Osaka Prefecture.
However, he was pronounced dead by a doctor, and the cause of
death was confirmed as brain contusion.
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Other Matters (1) Operation to restore the release system
The release system comprises a release system part, a hand
pump part, and an oil-pressure cylinder part. (See Figure 7.)
Figure 7 Structure of the release system
Procedures for the operation to restore the release system were
as follows.
- Hook the hook of the release system on the ring of the boat
davit and hold the hook as it is. (See Figure 8 (a).)
- The lock piece is hooked on the hook (rear underside) when
the release valve of the hand pump is relaxed in the state of
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-8-
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- Navigation Officer A could see only the green paint of the
lock piece before he tried to insert the safety pin.
- Navigation Officer A tried to insert the safety pin but could
not insert it as the safety pin was blocked by the hook.
Regarding the operation to restore the release system, the
opinion of the lifeboat manufacturing company was as
follows.
- The fact that Navigation Officer A could see only the green
paint of the lock piece and the fact that the safety pin was
blocked by the hook are incompatible for the structural
reason as stated below.
①If only the green paint of the lock piece can be seen, the hook
is in the reset position (the state where the lock piece is
normally hooked on the end of the hook) and the safety pin
can be inserted.
②The fact that the safety pin was blocked by the hook
indicates that the lock piece was not hooked on the hook and
that the hook was not in the reset position.
(2) Approval and inspection of the lifeboat
The lifeboat of the Vessel had obtained Nippon Kaiji Kyokai's
type approval under the International Life-Saving Appliance
Code and MSC.81(70).
On September 28, 2019, the lifeboat manufacturing company
conducted the fifth-year inspection of the lifeboat, including the
overhaul maintenance of the release system and operation test,
and confirmed that the release system operated normally.
In addition, after the accident, the lifeboat manufacturing
company conducted an inspection of the lifeboat with the port
state control officer of the port state control and conducted a
series of operation confirmations for the release system, but no
abnormalities were revealed.
(3) Safety management
The safety management manual of the Vessel stated as follows
with regard to work done in a high place.
2.1.1 When having work done in a high place of 2 or more
meters from the floor and in a place where there is a
risk of falling, the following measures shall be taken.
a) Have the worker use a protective helmet and safety
belt / harness.
According to the statement of Navigation Officer A and the reply
to the questionnaire by Company A, Navigation Officer B was
wearing a workwear, safety shoes, and helmet at the time of the
accident, and at the beginning of the launching of a lifeboat, he
was also wearing a safety belt and hooking the hook of the belt.
However, when he got onto the doorway at the stern of the
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lifeboat, he removed the safety belt itself as the rope of the belt
was not long enough to reach the position on which the hook of
the belt was hooked.
According to the reply to the questionnaire by Company A,
before getting onto the lifeboat, Navigation Officer B confirmed
that the lifeboat was connected to the hoisting wire. However,
he did not notify anyone that he would get onto the lifeboat.
According to the reply to the questionnaire by Company A,
Navigation Officer A had known that Navigation Officer B
removed the safety belt itself, but said nothing special to
Navigation Officer B.
According to the statement of the master, the Vessel was not
being shaken by waves, etc. at the time of the accident.
(4) Taking the photographs of the abandon ship drill
The purpose of taking the photographs of the abandon ship drill
was to keep a record of implementation of the drill on paper and
present a port state control officer with the fact that the drill
was implemented without fail at the time of receiving a port
state control.
For the Vessel, no person in charge of taking photographs had
been decided in advance, and Navigation Officer B was taking
photographs at the time of the accident.
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Analysis
Involvement of crew Applicable
members
Involvement of vessel, Not Applicable
engine, etc.
Involvement of weather Not Applicable
and sea conditions
Analysis of the findings The cause of death of Navigation Officer B was brain contusion.
It is considered probable that Navigation Officer B lost his physical
balance and fell to the deck because after getting to the doorway at
the stern of the lifeboat with the safety belt itself removed, when
taking photographs in the bent-over posture for the purpose of
keeping a record of implementation of the abandon ship drill, the
hook of the release system was released from the ring of the boat
davit and the lifeboat moved downward along the guide rail.
It is considered probable that the hook of the release system was
released from the ring of the boat davit during the operation to
restore the release system because the safety pin could not be
inserted as it is likely that the lock piece was not hooked in the
appropriate place.
It is considered somewhat likely that before getting onto the lifeboat,
Navigation Officer B removed the safety belt itself because he
thought that the lifeboat would not move as the hook of the lifeboat
release system was hooked on the ring of the boat davit and the
lifeboat was connected to the hoisting wire although the rope of the
safety belt did not reach the lifeboat from the place on which the
hook of the safety belt was hooked.
It is considered probable that Navigation Officer B get onto the
lifeboat without notifying Navigation Officer A and other crew
members of it.
It is considered probable that although Navigation Officer A had
known that Navigation Officer B was not wearing the safety belt
when working outside the lifeboat, he said nothing to Navigation
Officer B about the removal of the safety belt itself because the rope
of the safety belt did not reach the lifeboat from the place on which
the hook of the belt was hooked.
It is considered probable that when engaging in the lifting and
recovery of the lifeboat in the abandon ship drill, Navigation Officer
B needed to wear the safety belt and hook the hook of the belt during
the work in a high place on the assumption of the risk of a fall, as
stated in the safety management manual.
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Probable Causes It is considered probable that the accident occurred in a manner
that, when the Vessel was doing the lifting and recovery work of the
lifeboat in the abandon ship drill while anchoring at Wakayama
Shimotsu Port, Navigation Officer B lost his balance and fell to the
deck because he was taking photographs in a bent-over posture at
the doorway at the stern of the lifeboat without wearing the safety
belt, and the hook of the release system was released from the ring
of the boat davit and the lifeboat moved downward along the guide
rail.
It is considered probable that the hook of the release system was
released from the ring of the boat davit because it is likely that the
lock piece was not hooked in the appropriate place.
Safety Actions Company A issued a document concerning the accident to gain the
attention of all the vessels it manages and also implemented the
following measures following the accident.
- The master and the chief officer provide the crew members with
on-site education concerning the release system restoration
procedures using an actual lifeboat on a regular basis.
- The master provides the crew members with on-site education
concerning appropriate equipment, such as a safety belt, for
work in a high place.
- The master holds a meeting before an abandon ship drill and
provides explanation to the crew members concerning the
prediction of danger, thereby having each crew member become
aware of safe work.
- Before conducting a lifeboat lifting and recovery work, the chief
officer confirms and thoroughly ensures the following key points
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of the work: the hook of the release system is hooked on the ring
of the boat davit; the hoisting wire is not released until the hook
is completely fixed; the reset position of the hook is confirmed
by the green paint of the lock piece; the hook is surely fixed with
the safety pin lock by inserting the safety pin.
- Each vessel holds an onboard safety meeting and gives
explanation about the details of the accident, and reports the
record of implementation of on-site education to Company A.
- Company A's supervisor visits the vessels Company A manages
and confirms that the release system is actually operated in an
appropriate manner.
It is probable that the following actions will be useful in preventing
the reoccurrence of a similar accident and reducing damage.
- When lifting and recovering a lifeboat, crew members make sure
to do the next work after confirming that the lifeboat was fixed
by surely conducting the lifeboat release system restoration
operation.
- When doing work at a place involving the risk of a fall, crew
members appropriately use a safety belt.
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Attached Figure 1 Outline Map of the Accident Location
Osaka Bay
Awajishima
Island
Wakayama Prefecture
Wakayama City
Kii Channel
Wakayama
Shimotsu Port
Kita Ku
Wakayama Hokko West
Breakwater Lighthouse
0.5 Accident location
(Around 11:20 on
November 16, 2019)
0.5
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