Uncontrolled decent of lifeboat during release gear test on Royal Fleet Auxiliary vessel Fort Victoria with 2 people injured

Location: Berthed at ship repair yard in Falmouth, England.

Accident Investigation Report 9/2005

Read our marine accident investigation report, which includes what happened and actions taken:

Fort Victoria.pdf (647.62 kb)


On 10 September 2004, a Maritime and Coastguard Agency (MCA) surveyor, and a lifeboat crew member, sustained back injuries during a planned lifeboat exercise drill which took place on board RFA Fort Victoria.

Safety Issues

  • it was not clear who was in control of the exercise
  • although some crew members were slightly concerned about the height of the boat before it was dropped, no one intervened or questioned the decision
  • the surveyor’s actions were affected by a heavy workload
  • no risk assessment had been carried out for a routine on-load release gear test


Both RFA and MCA have made changes to operational procedures to ensure that a similar accident does not occur again. Recommendations have been directed at the International Lifesaving Appliance Manufacturers’ Association (ILAMA) to improve aspects of the ergonomic design of lifeboats and safety warning signs.

This report was published on 18 May 2005.

Published 23 January 2015