Lack of Procedure Led to Fatal Gangway Accident
New Zealand's Transport Accident Investigation Commission (TAIC) has issued its final report into the fatal accident aboard the container ship Madinah off Lyttelton last year.
During preparations for arrival at Lyttelton, the bosun and a deckhand on the Madinah were rigging up the vessel's accommodation ladder in preparation for docking.
The bosun sent the deckhand for life vests, then independently clipped his safety harness to a wire rigged near the deck edge. He then walked out onto the ladder to put the handrails into place. In the crew’s common practice this was a two-man evolution, as the rail was known to catch if it was not lifted at both ends at once.
When the bosun attempted to lift the ladder's outboard handrail, it sprung back and he lost his balance, putting his full weight onto the safety wire. It parted, and he fell off the accommodation ladder into the sea.
A crewmember threw him a life buoy; he was last seen swimming to close a distance of forty feet towards it. He was not wearing a life vest.
The deckhand radioed the bridge to report the emergency. The master immediately ordered rudder hard to port to kick the stern away, but decided not to order additional life buoys thrown as there was already one in the water near the bosun.
The captain alerted an approaching pilot boat of the accident at about 1316. The pilot advised the ship not to turn about to return to the position of the man overboard and to allow the pilot boat to conduct the search.
The pilot boat found his hardhat and gloves at 1333.
Authorities searched for hours by helicopter and by surface craft, but the bosun was never found.
After the search, the Madinah continued to her next port of call, Napier, where investigators met her and interviewed her crew.
The TAIC found several key deficiencies leading up to the accident:
- an absence of procedure for rigging the gangway
- a failure to follow best practice in response to a man overboard situation
- the use of plastic-coated wire – which may corrode inside, undetected – for a safety-critical application.
The agency also cited the UK P&I Club's recommendations for the use of both safety harness and lifejacket during the rigging of gangways:
"The process of rigging the stanchions and the side ropes is inherently dangerous as there can be little for crew members to hold on to until this is completed. Crew should always wear a safety harness and lifejacket during this operation," the Club wrote in a 2014 safety bulletin.