05/2015 - Gov.mt

Marine Safety Investigation Unit
SIMPLIFIED SAFETY INVESTIGATION REPORT
201403/019
The Merchant Shipping
(Accident and Incident Safety
Investigation) Regulations,
2011 prescribe that the sole
objective of marine safety
investigations carried out in
accordance with the
regulations, including analysis,
conclusions, and
recommendations, which either
result from them or are part of
the process thereof, shall be
the prevention of future marine
accidents and incidents
through the ascertainment of
causes, contributing factors
and circumstances.
Moreover, it is not the purpose
of marine safety investigations
carried out in accordance with
these regulations to apportion
blame or determine civil and
criminal liabilities.
REPORT NO.: 05/2015
MV MEIN SCHIFF 2
Damage to lifeboat’s davits travelling wire ropes
in St. Georges, Grenada
13 March 2014
Course of events
During the month of May 2011,
all the wire ropes on Mein Schiff
2 lifeboats were replaced by a
firm specialising in the supply
and rigging of steel wire ropes.
On 04 December 2013, the first
of a series of wire rope failures
was detected (Figure 1).
NOTE
This report is not written with
litigation in mind and pursuant
to Regulation 13(7) of the
Merchant Shipping (Accident
and Incident Safety
Investigation) Regulations,
2011, shall be inadmissible in
any judicial proceedings whose
purpose or one of whose
purposes is to attribute or
apportion liability or blame,
unless, under prescribed
conditions, a Court determines
otherwise.
The report may therefore be
misleading if used for purposes
other than the promulgation of
safety lessons.
© Copyright TM, 2015.
This document/publication
(excluding the logos) may be
re-used free of charge in any
format or medium for education
purposes. It may be only reused accurately and not in a
misleading context. The
material must be
acknowledged as TM
copyright.
The document/publication shall
be cited and properly
referenced. Where the MSIU
would have identified any third
party copyright, permission
must be obtained from the
copyright holders concerned.
MV Mein Schiff 2
March 2015
part
of
the
lifeboats’
arrangement and are used to
extend and retract the telescopic
under deck stored power
(UDSP) davits housed in the
deck ceiling (Figure 2). No
weight is taken by the travelling
wire when the lifeboats are in
the stowed position.
Figure 1: Broken wire rope strands
(travelling wire rope no. 7)
On 13 March 2014, while the
vessel was at St. Georges,
Grenada, the crew members
were carrying out a routine
inspection of tender boat no. 12.
During the inspection, a wire
strand in the aft travelling wire
rope was found broken.
The travelling wire ropes are
1
Figure 2: UDSP davits extended out
Pending wire rope replacement,
the damaged strand was
temporarily secured by the crew
201403/019
to prevent it from spinning and opening up.
lifeboat no. 5. On further examination, three
strands from the forward travelling wire rope
were found severely damaged (Figure 5). It
was also noticed that the wire rope was rigid
and difficult to pull through the davits
sheave.
Tender boat no. 12 was inspected again on 26
March 2014, at Castries in St. Lucia. While
extending out the UDSP davit, a cracking
sound was heard. The crew detected three
damaged strands from the forward travelling
wire rope. The damaged section of the wire
rope was intractable and strained to pass
through the davit sheaves (Figures 3 and 4).
Figure 5: Damaged travelling wire rope on lifeboat
davits no. 5
Following the incident, the travelling wires
of all the lifeboats and tender boats were
examined by a certified shore contractor at
La Romana, Dominica on 04 April 2014.
The examination revealed four broken wire
rope strands on the aft travelling wire of
lifeboat no. 11. A recommendation was
made to replace all lifeboat davits’ travelling
wires.
Figure 3 & 4: Damaged travelling wire on lifeboat
no. 12
Planned maintenance and inspections
Pursuant to SOLAS regulation III/20 and
III/36, and MSC.1/Circ.1206/Rev.1 on
Measures to Prevent Accidents with
Lifeboats,
the
Company’s
safety
management system (SMS) provided
guidance to the crew members on the
operational readiness, maintenance and
inspections of lifeboats, davits, winches and
wire falls.
An LA4E Type Test Certificate, issued by a
firm authorised by DNV GL, confirmed that
the wire rope was a 22 mm 32 x 7 Soliflex,
rotation resistance, steel core (IWRC), right
hand ordinary lay (sZ) with a breaking load
of 380 kN and tensile strength grade of
1960 Nmm-2.
The travelling wires on lifeboat no. 12 were
eventually replaced on 22 and 28 March
2014.
The
Company
operated
an
Asset
Management Operating System (AMOS),
which provided information on the required
inspection and maintenance. All routine
inspections and maintenance undertaken by
the crew were logged in the AMOS.
On 30 March 2014, at Rousseau, Dominica,
the crew heard a cracking sound upon
extending out the UDSP davit arms of
MV Mein Schiff 2
2
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Inspections on Mein Schiff 2 were carried out
by the chief mate – safety, the staff chief
engineer and the chief electrical engineer.
Inspections were supervised by the staff
captain. Extensive visual inspections were
normally done on a monthly basis and the
davits wire falls were lubricated every three
months.
approximately 20 m to the sea. One crew
member was thrown from the lifeboat as it
entered the water and two crew members
managed to escape from the upturned
lifeboat by their own efforts. The remaining
five crew members were subsequently
declared deceased.
The MSIU safety investigation found that:
Since AMOS did not specifically make
reference to inspection and lubrication of
davit’s travelling wires, the master reported
that the travelling wires were inspected and
maintained at the same time as the lifeboat’s
wire falls.
the wire rope fall had parted near or
around the forward davit’s upper sheave;
the wire rope had parted at a site of preexisting corrosion wastage and that it
appeared dry and void of lubricant;
the cause of the corrosion was due to the
wire rope strands opening up under
tension, allowing seawater and other
contaminants to penetrate the inner core
and corrode the strands;
The master confirmed that the travelling wire
ropes were maintained by the application of
lubricant - Fluid Film WRO EP - after the old
grease would have been removed. However,
due to restriction of space in the under deck
area, the travelling wires were lubricated by
hand instead of a grease machine.
the wire rope fitted was not in
accordance with the manufacturer’s
recommended specifications; and
the
grease
with
the
incorrect
specifications had been used to lubricate
the wire rope during periodic
maintenance.
Annual inspection of lifeboats
All the lifeboats / tender boats were
satisfactorily inspected and serviced by an
approved shore company on 22 November
2013, in accordance with SOLAS regulations
III/20.3, II/20.11 and MSC Circ. 1206 /
Rev.1.
On 26 February 2013 at 0545(LT), Celebrity
Century2 was anchored in Kailua Kona,
Hawaii, ready to commence tender boat
operations. When tender boat no. 10 was
extended out, and before lowering it, the
forward wire rope fall parted, causing the
tender boat to swivel on the aft hook. The
tender boat remained hanging from the aft
hook, which then ripped off its base, causing
the boat to fall into the water, bow first, at an
approximate angle of 45° and a height of
15 m.
Similar accidents investigated by the
MSIU
On 10 February 2013, the Maltese registered
passenger vessel Thomson Majesty1 was
alongside in Santa Crux de La Palma when a
lifeboat carrying eight crew members
dropped to the sea and turned upside down.
The forward wire rope had parted, causing
the lifeboat to swivel on the aft hook.
The safety investigation had found that:
the wire rope had parted at a site of
severe pre-existing corrosion wastage,
As the lifeboat reached an angle of
approximately 45° to the horizontal, its end
and the hook failed and the lifeboat dropped
1
2
Vide MSIU Safety Investigation Report 05/2014 at
http://mti.gov.mt/en/Pages/MSIU/SafetyInvestigations-2013.aspx
MV Mein Schiff 2
3
Vide MSIU Safety Investigation Report 08/2014 at
http://mti.gov.mt/en/Pages/MSIU/SafetyInvestigations-2013.aspx
201403/019
Cause of the travelling wire rope failure4
A thorough examination and laboratory test
on the damaged forward and damaged aft
travelling wire rope of tender boat no. 12,
together with the undamaged aft wire rope
section were conducted in a specialised
engineering laboratory by the MSIU.
which reduced the wire rope’s crosssection and load carrying capacity;
it
required
Scanning
Electron
Microscope
(SEM)
and
Energy
Dispersive X-ray spectroscopy (EDS)
analysis to determine that the wire ropes
crowns exhibited severe corrosion attack
representing as much as 50% reduction
in its cross-section. Therefore, a change
in the internal cross-section of the wire
rope would not have been evident by
visual examination such as that
performed by either the ship’s crew or
the contracted external technicians;
Micro-hardness
The micro hardness tests and measurements
on the wire samples confirmed that the steel
used for the construction of the wire rope
was within the industry’s norm. The poor
performance of the wire rope under tensile
load was therefore related to its deterioration
during service rather than to a sub-standard
grade of metal.
the laboratory analysis of the grease
from the failed wire rope revealed that it
was
contaminated
with
high
concentrations
of
the
elemental
components of sea water as well as
metals, including iron and zinc, thus
precluding it from serving as an anticorrosive protection;
The tensile testing of wire rope sections with
no significant deterioration indicated that the
tensile properties had remained virtually
unchanged since the original tests on the wire
rope, which were carried out in 2011.
the Company’s processes for ordering,
supplying, maintaining and inspecting
the wire ropes were not integrated as an
overall safety system to manage the long
term integrity of the wire ropes.
Corrosion damage
Both damaged and undamaged sections of
the wire rope showed general signs of
corrosion. However, the degree of corrosion
damage varied between the wire rope
sections and within the same undamaged
section. The tests indicated that a section of
the undamaged aft wire had signs of
advanced corrosion and was void of surface
lubrication. Another section of the same was
found in good condition. The zinc plating on
the wires was intact and clearly visible
through the lubricant.
MSIU Safety Alert
As a result of the safety investigation into the
lifeboat accident on board Thomson Majesty,
MSIU Safety Alert 01/2013 was issued and
published in February 2013. The MSIU
Safety Alert made several recommendations
regarding the potential hazards, wire rope
lubrication, and inspection of wire ropes3.
The examination and tests concluded that the
wires in the wire rope strand parted at a site
of very severe corrosion wastage.
4
3
Vide MSIU Safety Alert 01/2013 at
http://mti.gov.mt/en/Pages/MSIU/SafetyAlerts.aspx
MV Mein Schiff 2
4
The purpose of a marine safety investigation is to
determine the circumstances and safety factors of
the accident as a basis for making
recommendations, and to prevent further marine
casualties and incidents from occurring in the
future.
201403/019
There was an evident failure to maintain a
suitably protective level of lubricant at
sheave locations where the wire rope rested
when the lifeboat was in stowed position.
There was also an apparent failure to detect
the wire rope’s deteriorating condition at
periodic inspections (Figures 6a and 6b).
Figure 7: Details of damaged aft rope, showing
extensive corrosion reaching the inner lays, broken
wires and strands.
Broken wires
All the three available wire rope samples had
broken wires in the outer lay with the ends
protruding from the wire rope.
Figure 6a: Detail of damaged forward wire rope section
showing onset of degradation of galvanised layer of outer
lay,
The damaged forward and undamaged aft
sections contained several broken wires. It
was observed that where the sections were
not heavily corroded, the wire breaks were
scattered and few in number. This was
attributed to mechanical and / or corrosion
fatigue. The degradation was linked to
corrosion dynamic loading and from repeated
bending and vibration.
The damaged aft section of the sample had
several wires and an entire strand broken and
separated from the wire rope due to very
severe corrosion attack (Figures 8 and 9).
Figure 6b: Detail of damaged aft wire rope strand
showing extensive corrosion.
Figure 8: Detail of a broken outer lay strands of
undamaged aft section (insert showing corrosion
induced necking)
MV Mein Schiff 2
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201403/019
grease contaminated with salt particles, fine
debris, dry corrosion products, and paint
residues rubbing of the rope against the metal
structure (Figure 11).
There was also
evidence of abrasion wear.
Figure 9: Detail of a single broken wire of the
damaged forward section (insert showing fracture
morphology)
Rope measurements and deformation
The rope diameter measurements were
checked at multiple locations along all
undamaged sections of the wire rope.
Figure 11: Paint flakes found amongst other debris
around the wire rope sections
The results confirmed a marginally thinner
rope of 21.65 mm compared to the original
specified 22 mm wire rope. The reduction
was well within the range acceptable for
multi-strand wire ropes.
However, the
corroded regions showed 19.2 mm; a
significant reduction in the wire rope size.
Tensile strength
Several strands from the outer and inner lay
of the different three sections were tested as
single wire could not be individually gripped
and loaded due to the very fragile condition.
The damaged forward section of the wire
rope showed localised signs of deformation
with the onset of ‘birdcage’ or basket
deformation (Figure 10). The outer lay wires
appeared longer, exposing the core lay to the
environment.
These results clearly showed that for wire
rope segments with no significant
deterioration, tensile properties remained
virtually unchanged since the test
certification, originally carried out in 2011.
Tests were performed on damaged strands,
taken from the aft and forward wire rope
section. A significant reduction in load
bearing capacity, largely due to corrosion,
was measured.
Tensile tests showed that the mean breaking
load of ten strands was only 6.2 ± 1.7 kN,
with a recorded minimum breaking load
amongst the strands tested as low as 3.4 kN.
Inner strands composed of ~1.3 mm wires
were also tested from different rope sections.
Tensile specimens obtained from the aft
sections showed the largest drop with a
breaking load of 15.1 ± 0.7 kN.
Figure 10: Onset of birdcage deformation
Lubrication
During the laboratory examination, all of the
wire rope sections appeared dry and grainy.
The damaged forward wire rope was covered
in a thin coat of grease but the aft sections
showed a very inhomogeneous cover of
MV Mein Schiff 2
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201403/019
For the inner strands, the measured reduction
in breaking force was around 26% compared
to almost 50% for outer layer strands due to
the protection provided by the outer wires.
Nevertheless, the entire wire rope section had
suffered sufficient damage such that the
resultant breaking force of the rope was
341.5 kN. The cumulative strength of the
wire rope was much lower than 2011, when
the rope was newly constructed.
RECOMMENDATIONS
In view of the recommendations made to
Transport Malta’s Merchant Shipping
Directorate in safety investigation report
05/2014, no further safety recommendations
have been issued to the flag State
Administration in this safety investigation
report.
Celebrity Cruises Inc. is recommended to:
CONCLUSIONS
1.
The damaged wire ropes were heavily
corroded with several outer lay wires
broken and protruding out from the
wire rope;
2.
The outer lay wires of one of the
damaged wire rope section had basket
deformation;
3.
The wire ropes’ deteriorating
condition was not detected during
inspections by the shore-based
competent company;
4.
Due to the location and design of the
davits, inspecting the wire rope for
any signs of damage was difficult;
5.
The level of knowledge and
experience of the crew members was
inadequate to recognise corrosion
damage;
6.
The crew suspected wire damage
when they heard the wires cracking
and visually noted the broken strands;
7.
The wire rope was unevenly
lubricated around the davits sheaves.
8.
The steel used for the wire rope
construction was within the industry’s
norm;
9.
The laboratory tests of undamaged
sections of the wire rope showed that
the tensile properties had remained
virtually unchanged since the original
tests in 2011.
MV Mein Schiff 2
05/2015_R1 amend its safety management
system manuals to specifically address
the inspection and maintenance of
lifeboat’s travelling wires;
05/2015_R2 provide training on inspection
and maintenance of wire ropes to crew
members, with particular emphasis on
early detection of defects including
corrosion damage;
05/2015_R3 raise awareness on the
importance of wire rope maintenance
and discuss with the relevant crew
members the findings of safety
investigation reports 05/2014, 08/2014
and this safety investigation report
during safety management meetings.
7
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SHIP PARTICULARS
Vessel Name:
Mein Schiff 2
Flag:
Malta
Classification Society:
Lloyd’s Register
IMO Number:
9106302
Type:
Passenger
Registered Owner:
Tui Cruises Ms Main Schiff Ltd.
Managers:
Celebrity Cruises Inc.
Construction:
Steel
Length Overall:
262.51 m
Registered Length:
227.25 m
Gross Tonnage:
77302
Minimum Safe Manning:
21
Authorised Cargo:
Not Applicable
VOYAGE PARTICULARS
Port of Departure:
St. Georges
Port of Arrival:
St. Maarten
Type of Voyage:
International
Cargo Information:
Not Applicable
Manning:
807
MARINE OCCURRENCE INFORMATION
Date and Time:
13 March 2014 at 1030
Classification of Occurrence:
Marine Incident
Location of Occurrence:
Coastal waters
Place on Board
Boat deck
Injuries / Fatalities:
None
Damage / Environmental Impact:
Not Applicable
Ship Operation:
On anchor
Voyage Segment:
Arrival
External & Internal Environment:
Calm seas with a Northeasterly fresh breeze. Air
temperature was recorded at 28°C.
Persons on board:
2719
MV Mein Schiff 2
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