UK Inquiry Tracker

Gerardo Tonogbanua

PFD Report Historic (No Identified Response) Ref: 2014-0245

Date of Report 27 May 2014

Coroner Maria Voisin

Coroner Area Avon

Response Deadline est. 22 July 2014

Other related deaths

Judiciary.uk Report PDF

No published response · Over 2 years old

Sent To

Response Status

Responses 0 of 3

56-Day Deadline 22 Jul 2014

Over 2 years old — no identified published response

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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroner's Concerns

_ The fall wire of MV Tombarra's rescue boat failed because the winch electric motor was capable of easily overstressing the fall wire to the point of failure_ There is currently no requirement within the Life-Saving Appliances (LSA) Code to consider design of the rescue boat davit; winch and fall wire, as a 'system' when assessing the suitability of the forces and loads applied: The Code infers that 'overstressing' of the falls or davits could occur: An electronic switch, fitted to the rescue boat davit onboard Tombarra, failed to operate and stop the winch motor: The LSA Code refers to 'safety devices' fitted to the davits which will automatically cut off the winch power to prevent overstressing of components This is reflected in the international standard ISO The lifting

15516 "ships and marine technology-launching appliances for davit-launched lifeboats" However; neither the Code nor the standard specify the number, definition or performance of the 'safety devices' fitted. Consequently, manufacturers have little guidance in these areas compared to manufacturers of industrial machinery

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe that one or more of your organisations have the power to take such action: The Marine Accident Investigation Branch (MAIB) report (19a/2012) into the failure of the fall wire made a recommendation (2012/128) to the MCA to submit proposed changes to the Life Saving Appliances (LSA) Code to reflect a 'system approach' to davit and winch installations. This recommendation should be progress accordingly. The British Standard Institution (BSI) should Iiaise with the MCA through the appropriate BSI committee to propose amendments to ISO standard 15516 along the following lines: Subclause 5_ 4 should be amended to include: "Where overstressing cannot be prevented by the design of the davit system, the safety devices and their associated control circuit shall be: Intended by their manufacturer for that purpose and environment; 2, The circuit shall be tolerant of at least one fault; The circuit shall be equipped with means of detecting and indicating faults; The instructions provided shall describe the actions to be taken when a fault is detected:

Report Sections

Investigation and Inquest

On 17/h February 2011 commenced an investigation into the death of Gerardo Abadilla TONOGBANUA, aged 23_ The investigation concluded at the end of the inquest commenced on 28th April 2014. The conclusion of the inquest was Cause of death: la Mediastinal haemorrhage Ib Traumatic rupture of aorta Conclusion; Mr. Tonogbanua died as the result of an accident

Circumstances of the Death

The Jury concluded that on the 7lh February 2011 Mr: Tonogbanua fell 29 metres during fast rescue boat drill onboard the MV Tombarra while docked at Royal Portbury Dock, Bristol. rescue boat and Mr. Tonogbanua fell when the fall wire hoisting the rescue boat back onto the Tombarra snapped: The wire snapped because the power of the winch motor was incompatible with the strength of the fall wire On this occasion the motor continued running past the stowed position because the proximity switch which would normally stop the motor failed: Despite efforts to resuscitate Mr: Tonogbanua he was subsequently pronounced dead at Bristol Royal Infirmary; Bristol,