Investigation Report: Officer Died After Fall
The U.K. Marine Accident Investigation Branch (MAIB) has released its investigation report into the death of an officer in Thailand, citing an inherently unsafe situation.
On May 11, 2016 the chief officer on board the U.K. registered general cargo ship Johanna C fell from a large steel cargo unit that was being repositioned in the vessel’s forward hold. The chief officer was moved ashore and taken to a local hospital by ambulance, but he died shortly after arrival.
The chief officer’s fall down the hole in the crankshaft web onto the deck was almost certainly caused by his loss of balance when the web and/or lifting slings jolted as the slings were tensioned. As no defects or deficiencies were found with the lifting slings or the crane’s operation, the sudden and unexpected movement must have been caused by other factors, such as the slings not being correctly positioned either side of the web’s center of gravity mark.
It was inherently unsafe and unnecessary for the chief officer to stand on top of the cargo while it was being lifted, said MAIB in the report. The risks of standing on a load under tension were not recognized.
“Standing on top of the crankshaft web, which was 1.35 meters (4.4 feet) above the deck and being lifted, was inherently unsafe and unnecessary. The web could either have been re-hoisted and re-landed without any change in work method, or it could have been secured where it landed, albeit slightly askew from its intended position.”
Several crewmembers had the opportunity to challenge the chief officer when he stood on the crankshaft web and instructed it to be lifted. However, they did not do so. Like on board many cargo ships, working on top of the cargo was seen as a routine practice. Consequently, although Johanna C’s operating manual required the vessel’s crew “to stop any lifting operations, if they have any safety concerns,” they probably had none.
Furthermore, although: the shifting of the crankshaft webs occurred during darkness; the risk assessment for the task was not recorded; the master did not seek the advice of the ship manager’s loading master; and, the slings had no certification of test.
However, none of these deviations from the onboard procedures is likely to have influenced or impacted on the chief officer’s actions. The hold was well lit, the chief officer participated in the informal risk assessment, the method of transfer worked and the slings did not fail.
Nonetheless, the general lack of adherence to cargo procedures, which was probably influenced by a ‘can-do’ attitude and the attraction of financial reward, is of concern, said MAIB.
The response of Johanna C’s crew to the chief officer’s fall was immediate and positive. The chief officer was semi-conscious and, although he was lying in a very awkward position, this did not delay his initial survey and treatment. “The crew’s response following the chief officer’s fall was immediate and positive.”
The report is available here.