Feb 062010

Fixing handrails in place while containers were being swung led to a fatality

Germany’s BundesBundesstelle für Seeunfalluntersuchung, Federal Bureau of Maritime Casualty Investigation, BSU, has described the deaths of two workers in two separate incidents “Senseless” and forcefully says employers should define the necessary qualification requirements for occupational safety and establish and enforce directives that ensure all persons are properly qualified to discharge their duties and responsibilities in the area of safety and health.

On 15 December 2008 at about 10101, a fatal accident occurred on board the German flagged container vessel Santa Alina in the port of Lomé, Togo. Two seamen were occupied with installing a handrail on an open hatch during the unloading operations. In the process, a 40-year-old seaman was hit by a swinging 40 foot container being lifted with the shipboard crane from the cell guide and pressed against the superstructure. The seaman suffered severe internal injuries and broken bones, to which he succumbed in hospital.


Crane operations should have been stopped

Says the BSU report: “It remains unclear why the experienced seamen tried to install a handrail designed to protect against falling into a hatch during an unloading operation and in the process exposed themselves to danger. The seamen should have requested the Officer on Watch to arrange for crane operations at the open hatch to be discontinued so that the work at the 1.40 m wide working passage and 10 cm high coaming could be carried out without interruption. Basically, the unloading operations should not have commenced before the handrail was installed. This situation was possibly due to the lack of communication between the shipboard and shore-based operations in Lomé.

In the second incident  On 30 March 2009 at about 2220, a fatal accident occurred on board the 1730 TEU2 container vessel CMV MOL Utility in the port of Tanga, United Republic of Tanzania. The vessel anchored inside the port for the cargo-handling operations to be carried out with the shipboard cranes as adequately sized berths were not available at the pier. The port hatch cover of cargo hold No. 3, which spanned half the vessel’s beam, was placed on the star board hatch cover of cargo hold No. 3. There was a parallel misalignment of some 0.6 m in width and some 0.9 m in height towards the middle of the vessel between the two stacked hatch covers.


It probably looked an easy jump. It was deadly.

At the time of the accident the Officer on Watch, the Third Nautical Officer, walked diagonally on the port hatch cover from aft starboard towards the open hatch on the forward edge of the aforementioned misalignment. While descending from the cover placed on the starboard hatch cover, the officer tripped, lost his footing and fell approx. 9 m onto a container stowed at the second position in the hatch.

First aid was given immediately on the vessel. At 2245, a motorboat, which had been requested for moving the seriously injured officer to hospital, reached the vessel and took the casualty.

At 2350, the Master learned in a telephone conversation with the local agent of the vessel that the Third Officer had succumbed to his injuries in the minutes before the call.

Says the BSU conclusion: “The question as to why the Third NO approached the area of the fall remains open. It is presumed that he wanted to look into the hatch from the edge of the hatch cover to check the progress of the unloading operations. However, because of the diagonal direction of his path towards the forward edge of the hatch cover in particular, it also seems possible that the officer had the intention of climbing across to the aft edge of the closed preceding hatch from the end of the forward edge of the starboard hatch cover amidships to get to the port side of the vessel from there.

“It is also only possible to speculate on the cause of the fall. However, it is arguable that the officer underestimated the height of the misalignment, approx. 0.9 m, and also the width of the available walking surface on the starboard hatch cover, approx. 0.6 m. When jumping down or climbing from the upper cover, he could then stumble and the area for catching the fall with his hands would be too small.”

“…Finally, it should be noted that irrespective of the absence of a specific occupational safety regulation that addresses the accident in question, the fundamental principles of occupational safety include not overcoming differences in height by jumping and, if possible, avoiding areas in which there is a danger of falling or ensuring adequate personal protection if entering such areas is crucial.”

BSU has a point. No amount of rules or regulations will protect someone behaving thoughtlessly, carelessly, recklessly. In both case the hazards were SBO – Screamingly Bleedin’ Obvious – and two men died because they did not have safety culture, or were not part of it.

Yet it isn’t enough to blame the seafarer’s themselves. Like any other culture, safety culture must be continually reinforced if it is to take root and be sustainable and ensuring that happens is the job of management.

“A culture of safety should be established on vessels to prevent occupational accidents by means of the so-called safety management system,” says BSU, “… Procedures for regular monitoring, measuring and recording health and safety performance should be developed, implemented and reviewed at regular intervals. The powers, responsibilities and authorisations for monitoring different levels of management should be assigned.

“…The BSU urges owners, vessel operators and seamen to work continuously on the culture of safety within the company so that accidents are reduced and the typical accident scenarios described in the following reports are prevented.

“The senseless deaths of a 26-year-old officer and a 40-year-old fitter, which were due to just a few split seconds of carelessness and recklessness, tragically demonstrate the significance of internalised and actively embodied occupational safety on board. They represent both a warning and call to every crew member to be aware of the fact that danger to life and limb can be interconnected with many activities on a sea-going vessel every day. This also, and especially, concerns those working procedures which are commonly perceived to be routine and are carried out as such.”


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