The Transport Malta has issued safety investigation report into the fatality of a crew member following a fall inside cargo hold on board the Maltese registered container vessel Cagliari on 30 November 2015.
The incident
On 30 November 2015, the Maltese registered container vessel Corelli, was underway from Fos, France to Cagliari, Italy for cargo operations as part of her scheduled trading pattern. One of the ship’s fitter who had entered the cargo hold no. 1 with a team of two other crew members to carry out scheduled maintenance works, fell from one of the stringers and was fatally injured after hitting hard onto the tank top inside the cargo hold.
Efforts by the crew members to resuscitate him right after the accident were unsuccessful. The deceased was landed ashore on the following day, upon the vessel’s arrival at the port of Cagliari, Italy.
The safety investigation concluded that the immediate cause of the accident was the (unintentional) close proximity of the crew member to the edge of the stringer, which had no protection.
Actions Taken
- Illumination – aimed to improve the lighting condition in situations when work in dark spaces is necessary;
- Quality – aimed to ensure that entry into enclosed spaces and work carried out inside is well addressed in the safety management system of the vessel;
- Technical – aimed to minimise the risks at the work site by the erection of physical barriers and adoption of symbolic barriers;
- Safety and First Aid – aimed to ensure adequate response to assist and provide medical care to injured crew members;
- Personal – aimed to ensure evaluation of personal records related to accidents which are suffered whilst serving on board; and
- Education – aimed to provide safety information to crew members, including during vacation leave periods (on line training). The action also includes vessel visits by Company auditors and information on risk prevention and operational health and safety.
Conclusions
Findings and safety factors are not listed in any order of priority.
1. Immediate Safety Factor
- The immediate cause of the accident was established to be the crew member walking unexpectedly into the gap on the second stringer level, which had no protection.
2. Latent Conditions and other Safety Factors
- The fitter was neither familiar with vessel’s cargo hold access, nor with the internal arrangements (configuration of stringer levels, web frames, ladders, etc.);
- Although the stringers were occasionally used by crew members as walkways, the structures were neither fitted with guardrails and safety barrier systems nor with other type of fencing in way of the unprotected edge, to prevent a fall to the lower tank top;
- The paint used was neither of the anti-skid type nor did its colour forewarn the crew members of the risk of falling because of the unprotected edge;
- A risk assessment prior to the entrance into the cargo hold had not been carried out;
- The lighting conditions on the side stringer level areas were poor to pitch darkness;
- The fitter did not carry a handheld flashlight during his access to the cargo hold;
- Although the fitter was neither properly equipped (flashlight) nor familiar with the cargo hold access, he was not supervised in an effective manner;
- There was neither any visual contact with the fitter nor supervision of his actions while he was standing about 0.5 m from the unprotected edge of the stringer level;
- The main factors, which influenced the decision to access the space during that particular time of the voyage were knowledge, attentional and strategic.
3. Other Findings
- Records of rest and work did not suggest that the deceased had worked in excess of the maximum permitted hours;
- The safety helmet belonging to the fitter was not properly secured (not strapped) on his head, possibly because the chin strap was not worn;
- The weather conditions and ship movements were not considered to be contributing factors to the accident.
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Source: MTIP
