Summary
On 05 November 2016, an able seaman (AB) on board the Maltese registered roll-on roll-off (ro-ro) ship Catherine was severely injured during cargo operations. He was discharged from the ship and was transferred to a local hospital for further treatment.
Catherine, a 21,287 GT vessel, was berthed at the port of Leixoes, Portugal. She was scheduled to depart at 2100. The weather was fine and the loading deck was reportedly dry.
Figure 1: Loading of trailers on weathe deck
Sunset was at 1825 and the deck lights were switched on. By around 1800, only a few ro-ro units were left for loading (Figure 1). The ro-ro units were marshalled in by a port stevedore, driving a tug master. No other stevedores were engaged to undertake the loading operation.
Two crew members were appointed as signallers. One AB was assigned to guide the tug master driver to stow the trailer units in their respective position. The second AB was responsible to signal the tug master to lower the trailer on the trestle. Both ABs had been also tasked with the lashing of the ro-ro units.
At about 1821, one of the trailers (Figure 2) was hauled up the weather deck at the rear of MAFI roll-trailer.
Figure 2: Photo of trailer involved in the accident
The first AB, who was positioned at the back adjacent to the roll-trailer, signalled the driver to stop. A trestle was placed underneath the trailer by the second AB who then signalled the driver to lower the trailer on the trestle and disengage the tug master. Meanwhile, the first AB walked behind the trailer to lash roll-trailer. Evidence available indicates that the driver reversed the tug master, entrapping the AB between the trailer and the MAFI (Figure 3).
At the time of the accident, the second mate was lashing cargo in the forward part of the ship and no other officer was present to watch over the loading of the trailer unit.
Figure 3: The MAFI roll-trailer and approximate position of accident
Cause of the injury
The direct cause of the injuries was the AB becoming entrapped between two cargo units during the cargo loading operation.
Perception of risk
There was no evidence to suggest that either an on board risk assessment or toolbox talk had been conducted at Leixoes. Neither was a safe system of work discussed with the crew members and the stevedore. The loading of the trailer on the weather deck was unsupervised and the crew did not use chocks to prevent sudden or unexpected trailer movements. With no safety briefing, the work practice adopted by the ABs and the port stevedore was contrary to the requirements of the SMS and the recommended safety measures were not enforced.
It was deemed possible that the frequent calls at the port of Leixoes, and the repetitive nature of cargo operations led the crew members to accept a higher degree of risk. This would seem to be the reason for the lack of on board review of risk assessment and safety briefings. It was also evident that the two ABs were also tasked to carry our other jobs which exposed them to hazardous situations. It was apparent to the safety investigation that the previous accident-free cargo operations may have induced a false sense of security amongst the crew.
Moreover, it was considered likely that these practices had eventually become the norm. Evidence submitted to the MSIU showed that the crew members had made adaptations to the Company’s SMS which possibly went undetected and hence never analysed. Indeed, the injured AB recounted in hospital that he was aware of the risks but felt that after five months on board, he had a good understanding of the risks associated with ro-ro ships.
Recommendations
In view of the master’s review of on board risk assessments following the accident, meeting between the crew and the stevedore on personnel safety, and subsequent satisfactory safety audit of cargo operations by the Company, no recommendations are made in this safety investigation report.
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Source: Transport Malta
