Gerardo Abadilla Tongobanua · Prevention of Future Deaths report

On 17th February 2011 I commenced an investigation into the death of Gerardo Abadilla TONGOBANUA, 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:
Ia Mediastinal haemorrhage
Ib Traumatic rupture of aorta

Conclusion: Mr. Tongobanua died as the result of an accident

The jury concluded that on the 7th February 2011 Mr. Tongobanua fell 29 metres during a fast rescue boat drill onboard the MV Tombarra while docked at Royal Portbury Dock, Bristol. The rescue boat and Mr. Tongobanua 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. Tongobanua he was subsequently pronounced dead at Bristol Royal Infirmary, Bristol.

1. 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 lifting 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.

2. 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 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