On 25 August 2021, a fatal accident occurred on board tug En Avant 7 while assisting a bulk carrier. The Dutch Safety Board investigated the accident and gives a number of recommendations to prevent such incidents in the future.
The incident occurred in the Eastern Dockyard at Moerdijk, the Netherlands. The tug turned further than usual during a manoeuvre, causing the tow rope to become tensioned against the ship’s superstructure.
In the process, two crew members became trapped between the towline and the tug. One crew member sustained fatal injuries in the process. The other crew member sustained injuries and was briefly hospitalised.
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Unambiguous agreements and mutual communication were lacking
The immediate cause of the fatal accident was the entrapment of two crew members between the towline and the tug’s superstructure. During a manoeuvre, the towline turned further than usual. The towing wire suddenly came under tension due to the overspinning. The two crew members guiding the towline became trapped between the superstructure and the towline.
An investigation by the Dutch Safety Board revealed that prior to and during the manoeuvre, no unambiguous agreements had been made on mutual communication between crew members. As a result, the captain was not aware whether the workplace was safe while making the turn. The manoeuvre had not been discussed with the entire crew in its new composition, and crew members had different expectations of the other’s role.
In addition, there was no established education and training pathway to become a tugboat captain. The content and quality of the course depended on the job offer and the mentor’s interpretation and skills. In addition to his own training, the captain was responsible for supervising the trainee on board. Due to the nature of the work on board and because the captain himself was still in training, the captain lacked the experience and routine to supervise a trainee.
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Recommendations
Based on the investigation into the incident on the En Avant 7, the Dutch Safety Board arrives at the following recommendations.
Recommendations to the Muller shipping company:
- Ensure that the design of control measures for high-risk work is primarily organised by the shipping company, in cooperation with the crew, so that they are less dependent on the situation on board alone. Apply this regardless of whether there is a legal basis for the International Safety Management (ISM) code due to the size of the ship.
- To this end, establish agreements on customary work and specific manoeuvres within the company. Ensure that the necessary associated communication is known and clear to all crew members.
- Together with an auditor with practical experience, develop a measurable system to determine for crew members in a new function, role or situation whether the learning objectives from the training programme have been achieved, understood and observed.
In 2002, specific tug captain training was scrapped and the responsibility to train crew in specialisations was placed on shipping companies. By putting the completion of a training programme down to the shipowner, there are differences in degrees of quality. Therefore, the Safety Board makes the following recommendation to the Dutch Minister of Infrastructure and Water Management:
- Provide clear standards frameworks and requirements for ship-specific education and training objectives for a tugboat captain operating on Dutch inland waterways.
Picture by the Dutch Safety Board.
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