Incident description:
Whilst the subject cargo vessel was anchored waiting to load cargo, a scheduled abandon ship drill was arranged, which was to include lowering of the starboard lifeboat to the water and testing of the on-load release mechanism. The operation was to be carried out under the supervision of the 2/O with the bosun, oiler, A/B and electrician also participating. When it came to raising the lifeboat from water level, it was found that the electrical hoist winch was inoperable. At this point, the bosun engaged the winch handle with the intention of operating the winch manually.  However, the electrician then took steps to restore the electrical power to the winch, at which point, the winch motor began to rotate under power causing the handle to rotate at high speed, striking the bosun on the head. The bosun sustained severe head trauma and appears to have died almost instantly.

Analysis:
At the time the bosun engaged the winch handle, the electrical controller was still in the hoist position. Therefore when the power was restored, the winch immediately started to rotate. Investigation also revealed that the winch electrical cut out device for preventing powered operation of the winch with the manual handle engaged was not functional. The cause of the casualty can be attributed to a number of operational and maintenance failures, including a lack of supervision by the responsible officer, poor communication between crew involved in the operation and a malfunctioning safety device. With regard to the latter, it was found that the cut-out was not included in the routine maintenance checklist and that instructions for inspection and maintenance were not clear.

Lessons learned:

The operation should have been subject to a risk assessment and pre-work meeting to identify potential hazards and necessary safety precautions.

• The responsible officer did not adequately supervise the operation by positively directing the actions of the crew members involved
• Poor communication between crew
• Power controls should ideally be designed to return to the neutral off position when not being operated
• Inadequate maintenance of safety devices and insufficient provision for correct routine inspection
• Inadequate crew familiarisation with safe operational procedures and maintenance requirements

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