Fatal Fall from Height While Working Aloft


On January 29, 2017, crew members on board Shanghai Spirit faced some serious injuries as they had fallen from a height. The case report by the Australian Transport Safety Bureau deals with the technicalities of that incident. Here’s the detailed analysis of the incident.

What happened?

  • During the afternoon of 29 January 2017, the deck crewmembers of Shanghai Spirit were conducting painting and routine touch-up work in the cargo holds.
  • They used a mobile scaffold tower to access areas of bulkhead about 6 to 9 m above the hold bottom.
  • Two crewmembers conducted the work from the upper tiers of the scaffold tower and remained unsecured on it when it was moved.
  • To access the full length of the hold bulkhead, the work required repositioning the scaffold tower on multiple occasions.
  • After the work on the aft bulkhead was completed, it was decided to paint the hopper tank edge.
  • As the scaffold tower was moved with the unsecured crewmembers, it became unbalanced and toppled forward onto the deck.
  • The two crewmembers on the scaffold tower were seriously injured in the fall and were evacuated to a hospital ashore for treatment.

What the ATSB found?

  1. The ATSB found that, contrary to established procedures, two crewmembers remained on the unsecured scaffold tower in preparation for repositioning, rendering it top-heavy and unstable.
  2. Consequently, when moved it toppled and fell. Additionally, neither crewmember on the scaffold tower utilized the required safety harness and associated safety lines which would have prevented them from falling when climbing or working on the tower.
  3. Finally, the afternoon work in hold number four was not supervised by an officer as required by company procedure and in contrast to the morning activity.
  4. The absence of formal supervision, in combination with a desire to expedite the task in difficult working conditions, probably led to the crewmembers remaining unsecured on the scaffolding as it was repositioned.

What’s been done as a result?

  1. The scaffolding equipment operating instructions and maintenance manuals/guidelines have been included in the company’s safety management system.
  2. Further, there is now a requirement for monthly and quarterly inspection of the equipment.
  3. The use of scaffolding is now specifically classed as ‘working at heights’ and is therefore subject to all planning and precautionary measures such as risk assessment, working aloft permits and precautions.
  4. Personnel Protective Equipment training and awareness has been reviewed and enhanced.
  5. Additionally, new crewmembers will be subject to pre-joining training that now includes the use of scaffolding.

Safety message

This accident highlights the importance of adhering to procedures that assure safety as well as the value of effective supervision. Owners, operators, and crewmembers are reminded to plan and undertake risk assessments for assigned tasks in order to identify any shortcomings in procedures and required risk-mitigation measures.

General details
Date: 29 January 2017 Investigation status: Completed
Time: 1410 AEST (AEST = UTC +10) Investigation level: Complex – click for an explanation of investigation levels
Location   (show map): 28km NE of Port Alma Investigation phase: Final report: Dissemination
State: Queensland
Release date: 21 February 2019
Report status: Final Occurrence category: Serious Incident
Highest injury level: Serious

Vessel details

Vessel details
Operator Asia Maritime Pacific
Vessel Shanghai Spirit
Flag Hong Kong
IMO 9326328
Sector Bulk carrier
Type of operation Cargo
Damage to vessel Nil
Departure point Subic Bay, Phillippines
Destination Port Alma, Queensland, Australia


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Source: Australian Transport Safety Bureau


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