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Marine Accident Reporting Scheme (Mars) Report No. 294
Darkened workspace and an unprotected hazard lead to fatality: MARS 201724
As edited from Accident Investigation Board of Norway report 2016/08
A gas tanker was moored at a shipyard and crew and shipyard personnel were busy preparing for maintenance. The shipyard had issued permits to enter tanks which, in theory, meant the tanks were adequately ventilated and illuminated. During a preliminary inspection it was found that a maintenance hatch cover had become dislodged from the deck in
the lower tank dome and had fallen 17 metres to the bottom of a cargo tank, leaving the maintenance hatch open and unsecured.
Work inside the tank started the next day. One of the tasks was to recover the maintenance hatch cover. Instructions were issued to the crew to be extra vigilant on account of the unsecured open hatch in the lower dome; none of them had entered this tank before but the bosun and AB had previously entered similar tanks.
The bosun, the AB and an OS began by lowering equipment to recover the hatch cover into the lower tank dome. The AB then went into the lower tank dome. He was not sure where the maintenance hatch was located so he used his torch to get an overview. When he had located the hatch, he started to rig the recovery equipment about 3 metres from the
opening.
The bosun followed close behind. He looked around to locate the opening in the deck then joined the AB. No lighting had yet been rigged up in the tanks but both men carried portable lights and felt comfortable that these would provide sufficient light for the time being.
Both men were working on preparing the equipment, with their backs to the entrance ladder. The OS followed a few minutes later carrying a hand-held torch. The bosun heard the OS as he started to climb down the ladder but after one or two minutes he realised the OS was not with them. He shone his light around the space to locate the OS but he was nowhere to
be seen.
The bosun then went over to the open hatch and looked into the tank. He then saw the OS lying immobile at the bottom of the tank 17 metres below. Within 10 minutes the victim had been brought out on deck and first aid was administered. The victim was brought to a nearby hospital but he was subsequently declared dead.
Lessons learned
• Even if the paperwork is done, as in this case, the permits to enter tanks were completed, always ensure the required safety
measures are actually in place before starting the work. Proper lighting and a barrier around the open maintenance hatch would have prevented the fatality.
• Often, we tend to get on with the work without first analysing the workspace for possible hazards. Before starting a task ask
yourself, ‘What needs to be done here to make the workspace safe?’
• The ordinary seaman was apparently aware of the open and unsecured maintenance hatch when he entered the tank, but he did not know exactly where in the tank the hatch was located; he had never been inside a cargo tank before. Familiarisation with the space and the hazard would have helped him avoid the accident.
• Hand held lights are no substitute for cluster lighting arrangements. When possible, always work in a properly illuminated
space.
Elevator maintenance injuries: MARS 201726
An engineer and an oiler were undertaking maintenance on the ship’s elevator. They had opened the inspection cover to the reduction gear of the elevator winch and were inspecting the gears while turning them manually
using the turning handle.
At one point, other crew enquired via UHF radio whether the elevator work had been completed as they wanted to use the elevator. Since the inspection had just been finished, the engineer responded in the affirmative and requested the assisting oiler to switch on the breaker of the elevator. The oiler saw that the turning handle was still inserted in the gearbox,
and asked the engineer to confirm whether it was OK to switch on the breaker.
The engineer said yes and accordingly the oiler switched on the breaker of the elevator. At about the same time, the elevator was activated by the other crew, causing the turning handle to quickly turn; it hit the engineer in his
face and arm causing injuries.
Lessons learned
• The engineer made an error; he had a lapse, forgetting to remove the turning handle before having the elevator motor energised via the breaker. Everyone makes errors but teamwork and procedures should eliminate single point failure and reduce the consequences of an error. For example, had the oiler specifically pointed out to the engineer that the turning handle was still in the gear-box rather than just asking for confirmation that it was okay to turn on the breaker, the
engineer would surely have removed it.
• Always follow procedures when undertaking specific jobs. In this case, allowing activation of the elevator while still in the elevator machinery room was most certainly against procedures.
Improvised work method causes injuries: MARS 201727
As edited from Marine Safety Forum Safety Alert 16-20
During deck maintenance a roller on a winch fairlead was found to be seized. The crew decided to attempt to loosen the roller by using a pallet lifting strop, wrapped several times around the roller, and then fastened to the rail crane fitted on the vessel. When the crane driver applied tension the pallet strap hook broke. The resulting snap-back of the strop hit one of
the crew in the back causing severe injuries.
The pallet strop hook was incorrectly secured to the crane hook, making it much weaker than the Safe Working Load (SWL) of the lifting strop itself.
Lessons learned
• A critical examination of the hook-up before tension was applied would have revealed the hazard; the strop hook is not meant to have tension applied in that fashion. Always do a mental risk assessment when trying new work methods. Ask yourself ‘What can happen here?’
• When tension is applied to a system, always stand well clear of the potential snap-back zone.
Voyage plan ignored – vessel scrapes bottom: MARS 201729
Edited from BEA-mer (France) official report published May 2015
A ro-ro ferry had just left berth and was on a heading of approximately 330° in order to drop the pilot on the port side so that he would be sheltered from the prevailing north-easterly wind. Before the pilot disembarked he apparently warned the Master to pay attention to the nearby shoal but the Master did not recollect this advice. The vessel’s voyage plan took
it some distance away from the shoal. Port access rules also specify that such vessels as the ro-ro must pass at least at 1.5nm to the north-east of the lighthouse near the shoal. In fact, the ro-ro was not following the voyage plan, and passed only 0.33nm from the lighthouse.
Once the pilot had disembarked, speed was increased but the heading was kept at 330°, bringing the vessel over the shoal, indicated as having a depth of 6.5m. The vessel was drawing 6.49m and was now making over 16 knots. Some vibrations were felt and, as the vessel continued its voyage. The crew investigated but found no immediate evidence of
water ingress.
The vessel made several more local voyages over multiple days with passengers and vehicles before an underwater inspection revealed bottom damage that was eventually linked to the earlier vibrations.
Lessons learned
• As mentioned in past MARS reports 201610
The accidental activation of the elvator led to injuryand 201716, if you hear shuddering noises accompanied by vibrations throughout the ship, you should suspect you have touched bottom even if all else appears normal.
• Voyage plans are made to keep the vessel in safe water – follow your plan.
• Squat increases with vessel speed and can easily increase a vessel’s draft by a metre or more. Check your vessel’s squat characteristics.
Improvised work method proves dangerous: MARS 201731
As edited from Marine Safety Alert 16-22
The deck crew were bringing mooring lines up on deck in preparation for port arrival. Theoperation included transferring a mooring line from the starboard locker storage spool to theaft deck winch. In order to expedite the work,
a crew member held a crow bar in place to act as an improvised fairlead. This was intended to deviate the line around a pillar while the line was tugged directly from the storagespool to the deck winch under power.
During this operation the crow bar slipped; the deck crew member holding the crow bar caught his fingers between the bar and roller. Severe injuries to three of his fingers resulted.
Lessons learned
• Improvised work methods are rarely safe.
• There should never be undue haste when undertaking a task. This leads to unsafe
practices which can cause negative consequences.
• Normal operating procedure in this instance was to first remove the mooring line from thestorage spool and then bring it onto the winch without having to angle around the pillar. This procedure was not written down nor was it communicated to the new crew member undertaking the job.
