MAIB: Lack of Clear Safety Rules Led to Bosun's Crushing

 

The UK Marine Accident Investigation Branch (MAIB) has issued its final report on the fatal crushing of a Polish seafarer on a roll-on roll-off (RoRo) ferry in 2021.

On July 20, 2021, Kazimierz Ptak, who was working as the bosun of the RoRo cargo ferry Clipper Pennant, suffered fatal crushing during cargo loading operations at the Port of Liverpool. Ptak was working on the upper vehicle deck marshalling tractor unit drivers who were loading semi-trailers. Two other crew members were on the upper vehicle deck to help him with lashing. 

The 142-meter cargo ferry was in Liverpool for a scheduled charter by P&O Ferries. The charter consisted of four round trips between Dublin and Liverpool per week, with a weekend layover in Liverpool.

Seatruck Pennant, the owner of the vessel, considered the trade route one of the least intensive ferry routes on the Irish Sea, with cargo utilization averaging about 60 percent of the vessel’s total capacity. The vessel was operated by Seatruck Ferries. Seatruck was in September 2022 acquired by CLdN, a provider of short sea RoRo connections across continental Europe, which in March this year changed its name to CLdN RoRo Limited.

At 1130 on July 20, 2021, Clipper Pennant berthed alongside the ro/ro ferry terminal at Gladstone Dock. The vessel’s stern ramps were lowered and cargo discharge started a few minutes later.

Shortly after 1300, all cargo had been discharged and loading for the return voyage began. Semi-trailers were simultaneously loaded onto the main vehicle deck and the upper vehicle deck. The bosun was in charge of the upper vehicle deck, assisted by two ordinary seamen.

At about 1400, the bosun directed a tractor unit driver to push a semi-trailer into a stowage spot between a semi-trailer that had already been lashed and a bulkhead. The bosun had positioned himself between the moving semi-trailer and the bulkhead, and was crushed between them.

Investigators established that the accident happened because the tractor unit driver did not stop pushing the semi-trailer when they lost sight of the bosun during the maneuver. While this was due to a procedural workaround that had become routine practice at the port, whereby the banksman was expected to move to an unsighted position behind a nearby semi-trailer, this time round the bosun did not act as expected. This is because he instead stood on a painted walkway located inside the vehicle lane to marshal the semi-trailer into the space, and so remained in its path as it approached. The semi-trailer had inadvertently been parked at an angle, encroaching the walkway and striking the bosun.

MAIB Inspector of Marine Accidents, Andrew Moll OBE, described the accident as a tragic reminder of the inherent dangers of people and vehicles operating within the same area. “Ferry vehicle decks continue to be a hazardous environment and while the risks are well known this has not prevented the deaths of several crew and port workers across Europe,” he said.  

The investigation established that the working practices on board Clipper Pennant did not reflect industry guidelines and that there were no documented company procedures for stowing semi-trailers in the more hazardous corner stowage spaces, which led to the development of workarounds. MAIB asserted that Seatruck, P&O Ferries andd the port management also failed to learn from previous accidents and lacked organizational oversight. 

Seatruck has since taken several actions to improve safety on its vehicle decks, MAIB said, including developing a new system of work that recognizes danger zones and new standard loading procedures.