Summary
On 05 May 2015, at about 2010 (LT), Amber was port side alongside ready to cast-off and depart from Skikda, Algeria. As single up of mooring lines was commencing in preparation for casting-off, a pedestal fairlead failed at its deck attachment, hitting an AB and fatally injuring him. At that instant, he was on the port quarter, away from the ropes’ snap back zones.
The safety investigation concluded that unmooring operations were planned 
and executed according to industry practices. It also found that various corrosion mechanisms, over a relatively long period of time, contributed to the ultimate detachment of the pedestal fairlead from the main deck.
However, the hazards, and more so the risk associated with failure of mooring equipment, were not reasonably foreseeable by the crew members.
The MSIU has issued two recommendations to the Company designed to ensure examination of mooring equipment attachments to the main deck and to address health and safety awareness during mooring practices.
Situation on the poop deck of Amber at the time of the accident
Cause of death
The autopsy determined the cause of death to be severe head injury. The AB had also suffered multiple injuries to his neck and ribs possibly due to the direct impact of the pedestal fairlead.
Potential snap back zone, trajectory sector, and potential trajectory path
Safety management and risk awareness
Throughout the course of the safety investigation, it became apparent that there was limited knowledge of the hazards associated with this type of failure. This is understandable, considering the focus of the industry (due to historical records) on mooring rope related accidents rather than actual failures of mooring equipment.
The hazards associated with the pedestal fairlead failure only became known to the crew members after the accident – even because there were no inspection records / measurements of the welds, which could have indicated any hazards and / or latent defects. However, the detachment per se was indicative of the presence of structural problems. The Company’s safety management system (SMS) did not address the particularities of similar failures. This was also considered to be the result of lack of knowledge and awareness on the related hazards. Due to the combination of the factors just explained, the actual level of risk, which the master had on board, as a result of the structural condition of the pedestal fairlead attachment to the deck, was unclear. This is so because as a result of the lack of information, neither the Company nor the master was able to conduct a proper risk assessment. The MSIU believes that risk evaluation had been compromised.
One of the main aims of risk assessments is to identify whether a system is acceptable in its current state or changes in its parameters are required so that an acceptable status is achieved. However, risk assessment is only one process, which follows risk perception. As already indicated in this section, the difficulty experienced by the crew members on board Amber was immediately evident at the perception stage. Empirical research in other safety-critical domains on the subject matter demonstrates that hazard perception comes from an array of factors, which range from detection to cognitive inferences. These factors are listed below in order of strength: perception of human senses; comparison with standards; perceptible events that could have been related to hazardous conditions; and memory recall. Amber crew members had none of these factors available until after the accident happened and hence their ability to assess risk was also limited, if not compromised.
Amber’s second mate, indicating where he and the AB were actually standing at the time of the accident
A wrong mental model would have been activated, compromising risk identification and management. To make the situation even more complex, the crew members were not receiving any disconfirming cues and until the failure of the pedestal fairlead, there were no visible conditions on board, which would have alerted the crew members of any developing danger.
Conclusions
- The AB died of a severe head injury, after finding himself in the trajectory of a pedestal fairlead that was detached from the deck under the load of a tensioned spring line;
- The progressive failure at the pedestal-to-deck attachment had been ongoing undetected for probably at least five years;
- It is likely that detachment of the pedestal fairlead from the deck would, in the continued absence of detection of progressive failure and remedial action, have occurred irrespective of mooring practices and conditions;
- There is limited awareness in general on the hazards related to the detachment of mooring equipment from the deck;
- The second mate took adequate action against foreseeable danger. The risk of the pedestal fairlead becoming detached and the consequences were not foreseeable;
- The crew members were not receiving any disconfirming cues and until the failure of the pedestal fairlead, there were no visible conditions on board.
Deck beneath base of pedestal fairlead (red arrow on main photo shows direction of trajectory taken)
Recommendations
- thoroughly examine the deck attachments of the mooring equipment fitted on board, in particular where such equipment is on doublers.
- assess the risks related to potential trajectory paths of detached mooring equipment on the forward and aft mooring stations and review the safety management system accordingly.
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Source: Transport Malta
