Investigation Report
Safety warning after malfunction of proximity switch results in failure of fall wire with loss of 1 life
Safety warning after malfunction of proximity switch results in failure of fall wire with loss of 1 life
- MAIB
- Investigation Report
- Lifting OperationsMachinery and Equipment
- Falls from heightFunctional safetyMechanical failure
- Inspection and maintenanceLifting operations
- Rescue-craft davitWinchWire rope
- Functional testingPre-use checksPreventive maintenance
- Marine industry
- Port and quaysideVessel
Summary
This bulletin examines a fatal rescue-boat hoisting accident aboard Tombarra at Royal Portbury Docks. A defective proximity switch allowed powered hoisting to continue, causing the fall wire to part. It addresses winch overload potential, switch suitability and installation, and recommends pre-hoisting tests, manufacturer-led maintenance and verification of electrical equipment seals.
Classifications: Falls from height; fall from height.
Classifications: Functional safety; safety instrumented systems; SIS.
Classifications: Mechanical failure; equipment failure.
Classifications: Inspection and maintenance; asset inspection; equipment maintenance.
Classifications: Lifting operations; load lifting; hoisting.
Classifications: Rescue-craft davit; FRC davit; rescue boat davit.
Classifications: Winch; winches.
Classifications: Wire rope; steel wire rope.
Classifications: Functional testing; function test.
Classifications: Pre-use checks; pre-use inspection.
Classifications: Preventive maintenance; preventative maintenance; planned maintenance.
Classifications: Marine industry; shipping industry; maritime sector.
Classifications: Port and quayside; quayside; harbour; harbor.
Classifications: Vessel; aboard ship; onboard vessel.
Summary
Urgent recommendation to owners and operators of vessel equipped with boat davits following accident results in loss of 1 life on car carrier Tombarra.
Themes: lifting operations, machinery and equipment.