Summary
On 2 July 2015, the container ship Madinah was preparing for arrival at the port of Lyttelton. Part of those preparations involved the bosun (deck crew foreman) and a deck trainee rigging the port-side accommodation ladder over the ship’s side in readiness for the ship’s docking.
Both the bosun and the deck trainee were wearing safety harnesses. The bosun sent the deck trainee to fetch buoyancy vests, which were required to be worn for any task outside the ship’s railing. When the trainee returned the bosun had already swung the accommodation ladder over the side, clipped his safety harness to a plastic-coated wire and walked along the accommodation ladder to try to lift the handrails into place.
In doing so the bosun lost his balance and fell into the sea. The wire to which he had clipped his safety harness had broken. A crew member on the deck threw a lifebuoy into the water near the bosun. The bosun was last seen swimming towards the lifebuoy.
The pilot launch that was heading towards the Madinah at the time arrived in the area and started the search. Despite an extensive search using several other small craft and a helicopter for the next two hours, the bosun was never found.
The Transport Accident Investigation Commission (Commission) found that if the bosun had been wearing a buoyancy vest his chances of surviving would have been significantly greater. It also found that the wire rope to which the bosun had connected his safety harness broke because it was severely corroded and also that it had not been constructed and installed in accordance with best industry practice.
Two safety issues identified were: there was no dedicated formal procedure for rigging the accommodation ladders and gangways on board; and although the procedures on board for responding to a man overboard met industry best practice, the shipboard response to the emergency did not follow those procedures.
A third safety issue identified was the use of plastic-coated wire for safety-critical applications. If the plastic coating becomes damaged, salt water can enter and become entrapped in the coating, which causes accelerated corrosion. The plastic coating makes it virtually impossible for the wire to be inspected or surveyed properly. The Commission has raised this issue in a previous inquiry and made recommendations to the Director of Maritime New Zealand to address the issue.
The vessel’s manager has taken safety action to address other safety issues discussed later in the report. Therefore, the Commission has not made any new recommendations arising from this inquiry.
Key lessons arising from this inquiry included
- where it is necessary for a crew member to work over the side of a ship when at sea, they must wear a safety harness attached to a designated strong point and must wear a buoyancy vest.
- plastic-coated wires must be treated with caution. Seafarers and surveyors alike must not make assumptions about the condition of any wire that they cannot see, especially when the wire has a safety-critical purpose and is required by rules, regulations or procedures to be examined thoroughly.
- a man-overboard situation requires timely and intuitive actions by the crew in order for the rescue to be successful. Crew should follow quick-reference checklists to ensure that: the alarm is raised in the appropriate way; the position of the casualty is recorded and tracked; and the ship is returned to the casualty in the most expeditious way.
Findings
- The bosun was not wearing a buoyancy vest when he fell into the water. A buoyancy vest would have significantly enhanced his chances of surviving after falling overboard.
- The bosun fell into the sea because the wire rope to which he had connected his safety
harness broke when he lost his balance and fell. The design of the wire rope and its method of attachment to the ship were not fit for the purpose of attaching a safety harness. - The wire rope parted because it was significantly weakened by corrosion. The corrosion had gone undetected because the wire was coated in plastic, a significant safety issue that prevented the wire rope being properly inspected and maintained.
- There was sufficient personal safety equipment provided on board the Madinah for safely
rigging the accommodation ladder while at sea in good weather conditions. However, there was no formal procedure on board to guide the crew in the proper safety precautions to take. - The shipboard emergency response to the bosun falling overboard did not follow best industry practice, which would have been unlikely to alter the outcome in this case. However, in different circumstances, such as if the bosun had been wearing a buoyancy vest, any delay in retrieving someone from the water can prove fatal.
Safety actions
- compiled a document on the procedure for safe rigging of gangways/accommodation
ladders, which has been distributed fleet-wide - carried out a close inspection of all wires associated with gangways and
accommodation ladder wires, fleet-wide - retrofitted gangways and accommodation ladders with new wires and ancillary
equipment where deemed necessary, fleet-wide - compiled and instituted detailed inspection routines for gangways and
accommodation ladders, which have been included in the planned maintenance
system fleet-wide - compiled internal audit checklists for superintendents and the Health, Safety,
Environment and Quality team for standing wires and associated equipment, for use
throughout the fleet.
Recommendations
- The Commission may issue, or give notice of, recommendations to any person or organisation that it considers the most appropriate to address the identified safety issues, depending on whether these safety issues are applicable to a single operator only or to the wider transport sector
- The safety actions taken by Seaspan Ship Management Ltd have negated the need for recommendations to be made.
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Source: Transport Accident Investigation Commission
