Inadequate Safety Equipment Leads to Fatality Onboard

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Transport Malta’s Marine Safety Investigation Unit (MSIU) issued an investigation report on the fatality of a crew member, after falling from a vertical ladder, onboard a bulk carrier in October 2016, while underway in the Caribbean Sea.

The incident:

On 20 October 2016, MV Samsun was navigating the Caribbean Sea, en route to Coronel, Chile. The maintenance works on the crane grab, stowed on a platform above the main deck, had been completed late in the afternoon. The crew members descended down the fixed vertical ladder. The bosun, who at the time was standing on top of the grab, was the last one to descend, when he fell from a height of about six metres.

It was established that as he unclipped his fall arrester to step down from the grab, he lost his footing and fell down on the platform and on the main deck. He suffered severe head injuries. The crew members administered first aid on site and later in the ship’s hospital. However, an hour later, he succumbed to his injuries.

Cause of death:

On 24 October 2016, a medical practitioner certified ‘multiple blunt traumatic injuries’ as the direct cause of the bosun’s death.

Crew members renewing the wire rope

Conclusions:

  1. The cause of death was due to multiple blunt traumatic injuries following a fall from a height;
  2. The crew member lost his footing while disengaging the fall arrester from its anchor point;
  3. The safeguards needed to reduce risks to an acceptable level had been implemented;
  4. The safety investigation had doubts on whether the risk of going up or down the grab had been addressed or discussed with the crew;
  5. After the completion of the work, disengaging this particular type of fall arrester was essential for the individual crew member to climb down from the grab;
  6. The type of fall arrester available on board and used by the bosun was not of the ideal design for vertical movements;
  7. A double legged energy absorbing lanyard was not available on board;
  8. The crew member’s behaviour during the day did not indicate possible effects of fatigue;
  9. The Fleet Instruction Manual addressed safe working practices and the use of protective clothing and equipment were well addressed but the Manual made no reference to hazards relating to access or egress from a worksite located at a height;
  10. The awkward shape, size, and position of the grab provided poor hand and foothold, exposing the crew to a precarious situation;
  11. Choosing the best alternative to climb down the grab meant that the crew member possibly rejected other options which may have been seen as worse options, making the acceptance of risk as more plausible;
  12. It is very probable that the crew member perceived that the risk involved was acceptable because it was under his control;
  13. No sudden or unusual ship movements were reported at the time of the accident.

The fall arrester in use at the time of the accident

Recommendations:

MSIU advises that the company should review and consider amending the Fleet Instruction Manual on safe access and egress to workplace assignments aloft and safety training on risks to crew members;

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Source: Transport Malta

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