202328 - Lax safety culture and bad design result in MOB fatality
A small cargo vessel was loaded and underway in coastal waters in daylight. Wind and wave conditions were calm and the three deck crew were engaged in routine preparations for unloading cargo on arrival. T
These preparations entailed loosening the cleats that secured the hatches as well as the sea fastenings securing the deck mounted excavator. One deck crew had loosened the port strap attached to the excavator bucket and he then began to climb down to deck level. He first climbed down onto the rail track, placing his right arm on the hatch deck for support. He then brought his left foot down, closer to the railings, but his foot slipped and he fell across the railings and overboard. None of the crew witnessed the fall at the time nor were they immediately aware of the accident; the actions of the victim were viewed later on the vessel’s CCTV recording. One seaman was behind the excavator, and the other was on the starboard side of the main deck loosening hatch cleats.
About 15 minutes after the victim had fallen overboard, the two other deck crew realised the third man was possibly missing. A search of the vessel ensued and the Master was informed. Some 22 minutes after the victim had fallen overboard the vessel was swung around, a sea search commenced and shore authorities were notified. Search and Rescue (SAR) activities were begun, including a helicopter and other nearby vessels. Search and rescue operations continued until darkness but only one shoe and a pair of overalls belonging to the victim were found.
The investigation determined that it was not uncommon for the crew to access or descend from the hatch deck using the rail track and railings instead of the dedicated ladders – as the victim did in this case. This avoided having to walk all the way to the end of the hatch deck, then down the ladder and back again, thus saving time. Some of the crew stated that they considered this somewhat risky, but that they resolved the situation by being extra cautious while moving up or down. At the time of the accident, there were no SMS procedures that addressed fastening work or movement on the hatch deck. This work was considered a routine operation, so no risk assessment was undertaken.
The investigation also found, among other things, that the vessel’s design still represents an inherent residual risk even though, following the accident, the company introduced a procedure to reduce the risk of falling overboard (i.e., only dedicated access routes shall be used to and from the hatch deck). The passageway along the main deck is narrow and the height of the railings is not sufficient to prevent the possibility of a fall from the hatch deck.
- The shipping company plans to increase the height of some railings in the areas the deck crew habitually use to access and leave the hatch deck, other than the approved access areas. The measure is intended as additional security in the event that crew do not comply with the procedure of using the approved access area (see comment below)
- The risks associated with ‘routine tasks’ can become normalised in individuals over time, resulting in the risk gradually being ignored or incorrectly perceived. Even routine tasks deserve a proper risk assessment and procedural guidance.
- It is important that risk assessments be undertaken not only by management and senior officers, but also by the crew who perform the work. This will help gain ‘buy-in’ from crew, enhance their understanding of risk, and ensure effective implementation.
Editor’s Note: Readers may have noticed the inherent contradiction introduced by the company after the accident. On the one hand the new procedure specifies that only dedicated access routes and ladders shall be used to and from the hatch deck. Yet, on the other hand, it was decided to increase the height of the railings in some areas along the ship’s side that are habitually used by crew to move up or down to prevent a fall in the event that procedures are breached. A strong safety culture means procedures are followed and any deviations are reported or called-out on the spot by any and all, not just senior leaders on the ship. Simply put, talk the walk, then walk the talk. Introducing an admittedly well-meaning physical defence against falling overboard but simultaneously stipulating that only dedicated access routes are to be used sends a signal that procedures may be breached and such breaches are ‘normal’. ‘Talking out of both sides of your mouth’ seriously undermines trust, another safety culture. This situation may introduce conformity challenges to any and all procedures going forward. While much has been written about safety culture over the years, interested readers may wish to peruse this Seaways article on the topic from some years back: https://safeship.ca/uploads/3/4/4/9/34499158/safety_culture_ pauldrouin.pdf fundamental element in a strong.