On 21st June 2016, Giannutri was requested by the shipyard to perform extra cleaning in cargo oil tank (COT) no. 2 port in preparation for extensive hot works necessary to replace several steel structures.
The extra cleaning in COT no. 2 port was assigned to an OS and two painters. An AB joined later. None of the personnel who were assigned this work was involved in the ‘toolbox’ meeting.
After the afternoon coffee break, the OS and the AB assigned to work in the COT made their way.
During the entry into the COT, the OS fell at a height of about 14.0 m, from the top ladder down to the COT tank top, sustaining fatal injuries.
Figure 1: Transverse section and access to the COT
Cause of death
The autopsy confirmed that the cause of death were injuries compatible with a fall
from a height. It also confirmed that there were no traces of alcohol or narcotics in the
- The immediate cause of death was serious injuries compatible with a fall from a height;
- The COT entry procedure and the expected changes in the weather conditions during the day were not discussed;
- The entry inside a COT was not deemed as a critical item, even perhaps due to it being perceived as part of the routine on board a tanker inside a shipyard;
- Considering the numerous (successful) earlier entries inside the COT, the OS would have been confident that he had a good and clear understanding of the work environment and of the work instructions;
- The successful earlier entries inside the COT may have created an expectancy bias, which was not addressed, despite the change in weather conditions that contributed to a change in the way the final entry into COT no. 2 port was negotiated;
- The value they put on performing the task they were assigned to do, biased their appreciation of the changing dynamics in making the COT entry;
- The situation may have been seen as one which was of no threat, manageable and within control.
Figure 2: Sketch of the accident
- Toolbox meetings are to be attended by senior ranks and personnel / crew members assigned to carry out the actual work;
- Forecast changes in the conditions which affect risk, need to be addressed during toolbox meetings.
Interorient Marine Services (Germany) is recommended to:
- carry out regular observations on board as part of their proactive safety management in order to analyse, understand and address how crew members carry out tasks on board.
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Source: Transport Malta