MARINE ACCIDENT REPORT DIVISION FOR INVESTIGATION OF MARITIME ACCIDENTS

Transcription

1 MARINE ACCIDENT REPORT DIVISION FOR INVESTIGATION OF MARITIME ACCIDENTS SC BALTIC Occupational Accident on 29 April 2008

2 Division for Investigation of Maritime Accidents. Danish Maritime Authority, Vermundsgade 38 C, DK 2100 Copenhagen Phone: , Fax: CVR-nr.: f The casualty report has been issued on 7 October Case: The casualty report is available on our homepage: The Division for Investigation of Maritime Accidents The Division for Investigation of Maritime Accidents is responsible for investigating accidents and serious occupational accidents on Danish merchant and fishing vessels. The Division also investigates accidents at sea on foreign ships in Danish waters. Purpose The purpose of the investigation is to clarify the actual sequence of events leading to the accident. With this information in hand, others can take measures to prevent similar accidents in the future. The aim of the investigations is not to establish legal or economic liability. The Division s work is separated from other functions and activities of the Danish Maritime Authority. Reporting obligation When a Danish merchant or fishing vessel has been involved in a serious accident at sea, the Division for Investigation of Maritime Accidents must be informed immediately. Phone: Fax: oke@dma.dk Cell-phone: (24 hours a day). Page 2

3 Contents 1 Summary Conclusions Recommendations and initiatives Initiatives Recommendations The investigation Factual Information Accident data Ship data The Crew The side-doors and the cargo elevators Narratives Treatment after the fall Procedure of work and instructions Safety Management System (SMS) Risk Assessment Safety Board Work/rest time fatigue Analyses The Accident Organization of the work and instructions The pusher-pin mechanism Safety Management System (SMS) Risk Assessment Safety Board...12 Page 3

4 1 Summary SC BALTIC was alongside in Ørsta, Norway. At around noon on 19 April the crew finished the discharging and loading and was making ready for departure. This included the closing of the side-doors. During this operation the ordinary seaman (OS) fell down from the elevator and was injured. The OS was closing the no. 2 side-door, the aft one. He was alone on this part of the tween-deck. During the closing operation the OS was standing on the cargo elevator, which was in a hoisted position. He tried to lower the elevator by using the remote control box, but nothing happened. Then suddenly the elevator fell down, because it slipped from a position where it, some way or another, had been in a tight corner and because the wires were slack due to the OS s attempt to lower the elevator. When the wires tightened up the elevator stopped abruptly about 2m above the tweendeck, and the OS was thrown off the elevator and down on the deck. The bosun, who saw the OS falling down, at once called other crew members and the captain. An ambulance was called for, and it arrived very soon after the accident and took the OS to the local hospital. The OS had broken his right arm, had damaged his left heel and had several minor wounds at his head. 2 Conclusions The elevator fell down because it was hoisted during the closing of the side-door it got stuck by the inside flap the wires were slack because the OS pressed the descend button on the remote control box.(6.1) The OS was not qualified to operate the side-door by himself. (6.2) The officer on watch did not keep sufficient control on the work. (6.2) The pusher-pin mechanism did not function properly and nothing was done to rectify it. (6.3) 3 Recommendations and initiatives 3.1 Initiatives The pusher-pin mechanism on side-door no. 2 has been repaired and the pusher-pin is now locked automatically. Page 4

5 3.2 Recommendations The owner is recommended to scrutinize the working instructions together with ships management in order to decide, whether there is a need for more specific work function descriptions, e.g. for opening and closing of side-doors and for operation of elevators. The owner is further more recommended to enjoin on its vessels the obligation to conduct a formal Safety Meeting in case of an accident 4 The investigation The Investigation Division has received written statement from the captain and has also interviewed the captain and other crew members during visit on board in Bergen on 7-8 May. The Division has also interviewed the injured OS at the Volda Hospital on 6 May. Finally the Division has received a report by the local police. 5 Factual Information 5.1 Accident data Type of accident Occupational accident Character of the accident Fell down on tween-deck from cargo elevator. Time and date of the accident 29 April 2008 at 1235 LT (UTC +2) Position of the accident Ørsta Harbour, Norway Injured persons One ordinary seaman (OS) Evacuation of injured persons Taken to hospital by ambulance 5.2 Ship data Name SC BALTIC Home port Nørresundby Call sign OVJV2 IMO No Register DIS Flag State Denmark Construction year 1975 Type of ship Pallets Carrier (side loader) Tonnage 3382 GT Classification Society Det Norske Veritas Length 94,6 m Engine power 2204 kw Area served Unlimited Regulation Meddelelser fra Søfartsstyrelsen B Owner Janus Andersen & Co. A/S Page 5

6 5.3 The Crew Number of crewmembers 10 Number of crewmembers certified to act as 3 bridge watch Watch on the bridge 2 shift Minimum Safe Manning 7 Occupation on board the ship at the time of the accident (crewmembers relevant to the accident) Captain Chief Officer (CO) Age, Certificate of Competency, other certificates, training, sailing time. 49 years of age, Master 1.degree, GOC, sailed as master in his own ships since Joined the company on 6 January 2008 as master of SC BALTIC. This is his second period, started on 5 April. Danish citizen. 34 years of age. RC Deck Officer/Recog. Cert.. About one year with the company. Signed on SC BALTIC on 28 April, the day before the accident. Polish citizen. 1 st Officer 40 years of age. Mate 3.rd degree. Radio Cert. Her second contract with the company, signed on 5 April. Danish citizen. Bosun 44 years of age. At sea sin His third contract with the company. On board SC BALTIC for 7 month, the last 3 month as bosun. Philippine citizen. The injured OS 37 years of age. At sea approximately 3 years, 6 month on board SC BALTIC. Philippine citizen. 5.4 The side-doors and the cargo elevators SC BALTIC is constructed with 2 side-doors and for each door there are two cargo elevators, which can run from the bottom of the lower hold up to the main deck. The side-doors function as ramps, when they are opened. Page 6

7 Inside flap Picture by the Investigation Division When there is a gap between the quay and the ship, an inside flap is placed between the ramp and the ship in order that the fork-lifts from ashore can reach the pallets on the deck. When the flap is not necessary, it is lifted from the door and placed on the quay. Before closing the door it is replaced on the door. The side-doors are opened and closed from the operators desk. The elevators are also operated from this desk and can also be operated from a remote control box. When the side-door is nearly closed, a pusher-pin clicks into a lock on top of the door. The pusher-pin then pulls the door to the final closed position. Pusher-pin Picture by the Investigation Division Page 7

8 On the no. 2 side-door the pusher-pin mechanism had been changed recently. The new pusher-pin did not function properly, because it did not lock itself. To lock the pusher-pin it was necessary either to push on the pusher-pin from below (standing on the elevator) or to use a sling round the pusher-pin and pull from the deck above. While doing so a second person must operate the pusher-pin from the operators desk to close the door. The pusher-pin mechanism on the no. 1 side-door, the old one, was functioning properly. The CO has explained, that he was aware of the fact that the pusher-pin mechanism on no. 2 door did not function properly. The 1 st officer was not aware of this, because it was not reported by the bosun. The bosun was well aware that the new pusher-pin had not functioned properly. 5.5 Narratives SC BALTIC sailed from London on 24 April with a full load of sugar on pallets. Part of the cargo was discharged in Tananger and in Bergen on April and in Kaupanger on 28 April. The ship sailed from Kaupanger on 28 April at 1920 LT. SC BALTIC arrived at Ørsta on 29 April at 1010 LT. In Ørsta the ship was to discharge 100 pallets of sugar from the hold and after that load 161 empty pallets on deck. The discharging started immediately after arrival and the whole deck crew, the bosun, the two ABs and the OS, were at work. According to the normal watch schedule the 1 st officer was on duty. Only the aft side-door and ramp was used. The pallets with sugar were discharged from the lower hold as well as from the tween-deck. The OS was operating the elevators from the control desk, the bosun was driving the forklift on the tween-deck and the two ABs were in the lower hold. In the hold and on the tween-deck was stored some garbage. The forward side-door was opened a little and the garbage was hoisted up to a vehicle ashore using the ships own crane. A little before 12 o clock the discharging of the sugar for Ørsta was completed and the crew continued with the loading of the empty pallets, 161 pallets in three slings. They used the ship s own crane, which was operated by one of the AB s. The other AB was receiving and lashing the pallets on the deck and the bosun and the OS was on the quay. They finished loading the three slings at about 1230 hours. The following is based on the bosun s statement to the Investigation Division: When the loading was completed, the bosun and the OS went down on the tween-deck to close the side-doors, while the two AB s continued lashing the pallets on deck. The bosun went to the forward side-door and the OS to the aft one. Between the two doors on the tween-deck were still pallets with sugar left for other destinations. They were loaded in a height of approximately 3 m. There is not enough electrical power available to operate both side-doors simultaneous. The bosun first closed the forward one and then called to the OS, that he Page 8

9 could close the aft one. The bosun then started to climb over the sugar to go to the aft door. He found that quicker than to go up on the deck, across the deck and down again on the tween-deck. When the bosun was atop the sugar he saw the OS standing on the elevator pushing at the pusher-pin to force it into the locked position. Immediately after he saw the OS operate the remote control box for the elevator. The bosun realized that the elevator wires were already slack, and he shouted to the OS, that the wire was slack. The OS seemed confused, and suddenly the elevator fell down and stopped abruptly approximately 2 m above the deck. The OS lost his balance and fell from the elevator to the deck. The bosun called help from other crew members and called the captain. The following is based on the captain s report and his statements: The captain was on the bridge together with the 1 st officer. The bosun had reported ready for departure, the two ABs were on the forecastle and the engine was ready. At this moment he heard a crash from astern. On his way down on deck he was told by crew members, that the OS had fallen down from the cargo elevator at the no. 2 sidedoor, which was closed. On his way down to the tween-deck he told people ashore to call for an ambulance. When he arrived at the tween-deck, he found the OS lying on the deck in great pain and the elevator lowered to the deck. Apparently the OS had been alone on the tween-deck, when he fell from the elevator. The captain therefore asked the OS, what had happened. Apparently the elevator had been in the hoisted position, when the side-door was being closed. Before closing the side-door, the ramp, an inside flap is hanged on to the door. The inside flap is used, when necessary, to close a gab between the ramp and the tween-deck. When it is not used, the flap is placed on the quay and then attached to the door before closing it. It seems that the flap has prevented the elevator from being lowered and that the OS has climbed up on the elevator to see, what was wrong. When he was on the elevator, the elevator has slipped from the Inside flap and fallen down. The OS has more and less confirmed the captain s statement during the interview by the Investigation Division. The OS was wearing safety shoes but no helmet, when the accident happened. 5.6 Treatment after the fall When the other crew members came to the OS the 1 st officer more or less took over. The OS was full of blood in the face and the 1 st officer was afraid of a possible fracture in the neck. She was therefore very careful to support his head. The chief engineer tried to calm the OS by telling him, that he was not seriously injured. It was apparent that the OS had broken his right upper arm. Page 9

10 The ambulance arrived shortly after the accident, and the salvage-corps men took over. The OS was taken to the local hospital. The 1 st officer followed in the ambulance. The OS was later transferred to the Volda Hospital. 5.7 Procedure of work and instructions The CO is the responsible officer for planning and organizing the loading and discharging operations. The CO and the 1 st officer run a 6 on 6 off watch schedule, a continuous schedule whether at sea or in port. The CO covers the and the12-18 watches and the 1 st officer the and the18-24 watches. The officer on the watch is the responsible officer for the ongoing work on the watch. According to the CO he talks to the deck crew on how to organize the work before a port operation. Normally the crew members will shift between the different jobs. The CO was not involved in the actual loading/discharging operation, as it was his hours off. According to the bosun he receives the loading and discharging plans before the arrival, and he organizes the work and gives his shipmates orders on what to do and instruct them on how to do it. That was also the case for the actual operation, for which he received the plans the evening before the arrival at Ørsta. It was the bosun, who told the OS to close the no. 2 side-door, and according to the bosun he had no hesitation by asking him to do it, because the OS had done it many times before. The OS has explained that he worked together with the bosun, who told him what to do. According to the captain, the CO and the 1 st officer, and also to the chief engineer, who happened to be a relative to the OS, and knew him very well, they would not expect the OS to close the side-door by himself. Although he had watched it being done many times, it was still a job for the bosun or the AB s, and the bosun should as a minimum always be overseeing the operation. 5.8 Safety Management System (SMS) Risk Assessment Safety Board SC BALTIC s SMS includes instructions and check lists for the different operations on board, and according to the text the ship has implemented an evaluation of risks of a number of tasks. These tasks are found in the ship s manual of the working environment. The Manual is available for the crew and according to the crew members, they had read the Manual. The Manual contains e.g. a working instruction for the work function opening and closing of hatch cover. According to the company DP this working instruction also Page 10

11 covers instruction for opening and closing the side-doors. Under personnel protection equipment to be used is entered: Gloves, safety helmet and safety shoes. According to the captain the crew has been told many times, that they must not stand on the elevators. According to the captain the crew had discussed the accident several times on board, but a formal discussion in the Safety Board had not taken place. 5.9 Work/rest time fatigue The individual crew members kept their own record of hours of rest. The deck crew members are not part of the bridge watch at sea. According to the records the deck crew members were well rested prior to the arrival at Ørsta. 6 Analyses 6.1 The Accident The OS was standing on the elevator. He was operating the remote control box to lower the elevator. The elevator did not descend, most probable because it was caught by the inside flap. The wires became slack because the OS pressed the descend button. The elevator slipped from the inside flap, fell down and stopped abruptly. The OS fell from the elevator down to the deck. It is not clear, why the elevator was in the hoisted position, when the side-door was being closed. The reason could be that the OS would press the pusher-pin into the locked position. The elevator fell down because it was hoisted during the closing of the side-door it got stuck by the inside flap the wires were slack because the OS pressed the descend button on the remote control box. 6.2 Organization of the work and instructions The OS was told by the bosun to close the side-door. The OS was used to have his work-instructions from the bosun. Page 11

12 According to the officers on board closing the side-doors would not be a job for the OS to handle by himself. The bosun, however, had no hesitation by ordering the OS to close the door after he himself had closed the no. 1 side-door and before he had moved to the no. 2 door by climbing over the sugar pallets. The bosun might have been pressed for time, because he had already reported ready for departure to the captain. The OS was not qualified to operate the side-door by himself, especially when something went wrong, as in this case. The CO and the 1 st officer were relying too much on the bosun to organize the work and to instruct the deck crew members in their different jobs. Consequently the officer on watch, during the actual time the 1 st officer, did not keep sufficient control on the work. 6.3 The pusher-pin mechanism The pusher-pin mechanism on the no. 2 side-door did not function properly. It did not lock to the door automatically, as it was supposed to do, which means that the pusherpin should be locked manual, either by pushing from beneath or by pulling from the deck above. The CO and the bosun have explained that they were aware of the malfunction, which had been the case since recently, when the mechanism on side-door no. 2 was changed. The 1 st officer has explained that she knew nothing about the malfunction, because the bosun had not reported it. Nothing was done to rectify the pusher-pin mechanism. The manual operation was apparently accepted. The CO joined the ship the day before the accident and could therefore not have arranged the installation of a properly functioning mechanism. If operated from the tween-deck, it was necessary to stand on the elevator to push the pusher-pin. This is contradicting the captain s instruction on not to stand on the elevator. In both cases it would need two persons to close the door, one pushing or pulling the pusher-pin and one at the operators desk. 6.4 Safety Management System (SMS) Risk Assessment Safety Board The ship s manual of the working environment is available to the crew, and according to their statements they have read the manual. The work function description for opening and closing of hatch cover includes the sidedoors. The actual description, however, very much relates to ordinary hatch covers, and there is no description of the special working functions related to the opening and closing of the side-doors. Page 12

13 The SMS contains no instructions / procedures for a formal reporting of malfunctions, e.g. the bosun reporting of the malfunction of the pusher-pin mechanism. In this case there seems to be a lack of information exchange between the bosun and the ships management. The accident was discussed informal between the crew members. It has not been discussed formally in the Safety Board. The work with the elevators and the side-doors are daily work for SC BALTIC s crew. The accident has shown that there are certain risks involved in this work. It is therefore important for the safe performance of the work that the risks and countermeasures are well understood. A meeting of the Safety Board to discuss the accident in a formal way could have improved the attention to these risks. Page 13