On 2 February 2011, while attempting to overcome a problem that had been known for some time but not fixed, the bosun of Hanjin Sydney climbed onto a hatch-coaming, something he had told others not to do, and subsequently fell into a cargo hold. A post-mortem examination concluded that the bosun died as a result of non-survivable injuries to his face, chest, abdomen, limbs and possibly the brain.
On a number of occasions, the bosun had warned the cadet that he should not sit or stand on the top of a cargo hold hatch coaming because it was possible that he may fall into the hold. While this demonstrates that the bosun was aware of the risks associated with climbing onto the top of the hatch coaming, his actions on 2 February show that he was willing to accept those risks himself.
He probably thought that he was suitably experienced; he would only need to be on the hatch coaming for a moment and that it was unlikely that he would fall. So, in an attempt to ‘get the job done’, he accepted the risks associated with climbing onto the coaming of the open cargo hold.
The bosun knew that he should not climb onto the hatch coaming and, in choosing to do so, he violated what was a good rule – the need to complete a working at height permit and adhere to its requirements when working at height.
The crew were lifting iron ore residue from the hold in a 200 litre drum. The cargo runner jammed because the bulldog grips attaching the shackle to the wire had jammed at the head of the davit in between the sheave and the davit head cheeks. It was while trying to unjam the cargo runner. The davit suddenly moved, he lost his balance and fell to to tank top 25 metres below.
When the bosun was faced with a jammed cargo runner, he disregarded the SMS requirements relating to working at height and climbed onto the hatch coaming of the open cargo hold. In doing so, he accepted a well understood risk, working at height, without implementing equally well understood risk controls.
Jamming of the cargo runner had occurred before and was a problem known to the crew. Prior to 2 February 2011, Hanjin Sydney’s crew had been provided with an opportunity to improve future safety by engineering a solution to a known problem – the davit cargo runner jamming if hoisted too high. However, they did not take the opportunity and, as a result, the system remained unchanged.
According to a response from Hanjin Ship Management because the problem of jamming was not reported to the chief mate, neither he nor Hanjin Ship Management were aware of it. As a result of the accident, it is now a requirement for the ship’s safety officer to be more proactive during tool box meetings and safety ‘walk arounds’ in questioning the crew about problems they are encountering during routine operations.
MAC notes that it is sadly common for officers and bosuns to be strict about other people’s safety while assuming that they need not listen to their own advice. This case, and many others, show that they do need to follow their own advice.
Fixing the problem with the cable runner was not a matter of obscure technology. It could have been done easily and quickly. It is not uncommon to simply accept a problem as a nuisance, move on, and do nothing, thus, as in this case, planting the seed of tragedy.
Fix it. Now.