Gerardo Tonogbanua

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

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,

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: