202547 Ro-ro loading fatality

As edited from MAIB (UK) report 16-2024

A ro-ro vessel was in port and the vessel’s crew, assisted by shoreside tractor unit drivers, was loading semi-trailers onto the upper vehicle deck. The bosun, acting as a banksman [directing traffic], was marshalling a tractor unit as it pushed a semi-trailer into a tight corner stowage space. He positioned himself on a painted walkway at the rear of lane 21 to guide the trailer. The walkway was located inside the vehicle lane.

The tractor unit driver lost sight of the banksman as he was backing up, but, following a routine but unsafe workaround practice common at the port, continued the manoeuvre even after doing so. The driver assumed the bosun had moved to a safe position behind an adjacent trailer. However, the semi-trailer was at a slight angle, causing its rear to encroach upon the painted walkway where the bosun was standing. The bosun was trapped and crushed against a steel stiffening beam protruding from the vessel’s superstructure.

Another crew member found the bosun unresponsive. The alarm was sounded and crew members rushed to the scene. The semi-trailer that had crushed the bosun had to be moved by another tractor unit to allow access to him. First aid and CPR was administered until paramedics arrived, but the bosun’s injuries were too severe. The victim was declared deceased at the scene.

Lessons Learned

The investigation into the accident revealed several critical safety failings:

• Dangers of unofficial workarounds: An undocumented and unsafe procedural workaround for loading semi-trailers in difficult spaces had become routine practice, overriding official safety protocols.
• False sense of security: Painted walkways that are not physically segregated from vehicle lanes can create a false sense of security and do not provide adequate protection. This lesson was also highlighted in a previous fatal accident.
• Breakdown of visual contact: The fundamental safety principle of maintaining visual contact between the banksman and the vehicle driver was violated. The driver continued manoeuvring after losing sight of the bosun.
• Inadequate supervision: The upper vehicle deck operations were effectively unsupervised. The bosun was occupied with marshalling and lashing, and other officers were engaged in separate duties, preventing oversight of unsafe practices.
• Organisational and procedural failures: There was a significant gap between written procedures and actual work practices. The investigation found that the vessel operator and the port operator had not effectively aligned their safety procedures, and lessons from previous similar accidents had not been fully implemented.  

As edited from MAIB (UK) report 16-2024