Able Seaman Chin-Fu Huang on the Ever Elite died after falling from an accommodation ladder in uncontrolled descent in San Francisco Bay. His death was not merely the result of a failure of a key component in the accommodation ladder’s lifting mechanism but of systemic failures in the vessel’s safety system. We’ll cover the lessons of this tragedy in reverse chronological order, based on the report by the UK’s Marine Accident Investigation Branch.
This was the third occupational health and safety related fatality on board EMU’s eleven UK registered vessels within an 8 month period.
AB Huang was spotted about half a metre below the surface by the crew of a tug, Z5, between 10 and 15 minutes after entering the water. He was recovered on board the pilot boat Golden Gate but there were no signs of life.
He was not wearing a lifejacket. Although he had suffered blunt force trauma during his fall and may have been unconscious due to a blow or cold-shock, an appropriate lifejacket would have held his face above water preventing him from drowning.
Lifejackets and hardhats had been mandated for the task following a risk assessment. Although two lifejackets had been been available, but unworn, they were of the wrong type and would have been of minimal value.
Lifejackets – the right type of lifejacket – must always be worn when working outboard.
The time taken to find Huang was 10 to 15 minutes. That time might have been shortened if MOB drills and training had been effective but they were not. For example, no-one thought to throw lifebelts with self-activating lights into the water, although they were available. Doing so may have provided a conscious or semi-conscious MOB with a much-need flotation device or provided searchers with a visible reference that might have reduced the time taken to find Huang.
At the same time the GPS MOB marker was not activated, the VDR recording was not saved and other actions normally carried out in an MOB situation were not carried out.
Do you and every member of your crew know exactly what to do in an MOB incident?
Standing on the accommodation ladder presented a work-at-height. Huang fell from it because he was not wearing a fall arrest system and none were available on the ship although fall restraints were.
A fall restraint prevents a seafarer from moving far enough to fall over an edge. A fall arrest is a harness and lanyard fixed to a secure point which will minimise damage to the seafarer if he or she falls.
Work at height always presents a risk of falling. An adequate risk assessment of Huang’s task would have identified the need for a fall arrest and appropriate anchor-points, rails or wires for it to be fixed to.
Commonsense would describe this sort of accommodation ladder as lifting equipment and, as such, subject to safety measures, maintenance and testing requirements of Merchant Shipping and Fishing Vessels (Lifting Operations and Lifting Equipment)(LOLER) Regulations 2006, LOLER.
Since the beginning of this year accommodation ladders are required to meet ISO 7364:1983, but the standard is outdated and does not take account of current technology or shipboard practice and there is no requirement to identify or eliminate potential single points of failure. Yet another example of compliance not meeting safety needs.
Following a spate of accommodation ladder incidents in the Australian port of Newcastle authorities there recommended the use of a subwire/preventer to support a suspended accommodation ladder. As a result, Nakano, manufacturer of the Ever Elite accommodation ladder developed an adjustable preventer, or sub-wire, arrangement for its single flight accommodation ladder systems for use on vessels operating in Australian waters.
If it lifts and lowers, it’s lifting equipment and appropriate safety measures should be taken. In this case the accommodation ladder effectively became a manrider and fitting a preventer or subwire arrangement may have prevented the winch failure becoming a tragedy.
Many of the foregoing issues should have been identified in safety audits carried out on behalf of the MCA before and after the accident but were not, something MAIB found “particularly disturbing”.
Auditors must not only be competent and experienced but also knowledgeable about the requirements of the flag-states whose vessels they audit. They must also be aware of the potential negative outcomes if SMS shortfalls are not identified.
The hoist winch failed because of the incorrect assembly of a critical part. Says the MAIB report: “It is apparent that Nakano recognised that intrusive maintenance of its gearboxes was a relatively complex task. It made a recommendation to Evergreen in 2004 either to employ Nakano service engineers to carry out gearbox repairs or to replace defective gearboxes with factory assembled spares. However, the subsequent supply of more detailed installation instructions and assembly diagrams also indicates that, by 2007 the manufacturer considered the work required to fit the more resilient bearing housings was within the capabilities of ships’ crews.
”Deciding whether or not a person is competent to maintain a piece of equipment is the responsibility of vessels’ owners and masters, but all maintenance requires clear and accurate instructions and guidance. In this case, the Nakano manual did not provide anywhere near sufficient information to enable the gearboxes to be overhauled safely, and the more detailed guidance provided in 2007 was not available on board Ever Elite.
”Given the complex nature of the gearbox, the lack of detailed manufacturer’s guidance significantly increased the risk of error during re-assembly. However, this does not appear to have been considered by the ship’s staff before maintenance of the gearbox was commenced. Despite the remedial measures already taken by Nakano, the possibility of similar errors occurring on the remaining 27 vessels fitted with the same winch cannot be significantly reduced until all of the vessels concerned have been provided with appropriate technical information.”
It is important to ensure that technical manuals are clear, comprehensive and unambiguous.