Fatal Fall into Hopper Tank While Cleaning Cargo Residue

Summary

Perth I loaded a cargo of 33,000 mt of Kaolin Clay and 11,000 mt of Feldspar in Bahrain bound for Mina Saqr Port in Ras Al Khaimah, UAE. Discharge of the bulk cargo commenced on 27 May 2016 and was completed on 30 May 2016.

Upon completion of cargo operations, Perth I proceeded to off port limits (OPL) where she remained adrift, while the crew cleaned and prepared the cargo holds for the next cargo of stone aggregate, which was to be loaded in the same port. At 0600, on 30 May 2016, the cleaning operations of all the cargo holds were commenced.

At approximately noon, on 31 May 2016, the chief mate inspected a cargo hold and observed cargo residue behind the water ballast line. He requested the area to be cleaned, and asked the bosun to ask one of the ABs to remove the cargo residue from behind the ballast line after dinner.

It was during the cleaning of the cargo residue in cargo hold that the AB slipped and fell from the port side hopper tank. After a number of hours in the ship’s hospital, assisted by the other crew members, the master managed to arrange for the injured AB to be eventually transferred to a hospital ashore. Soon after, however, the master was informed that the injured AB had succumbed to his injuries.

Immediate cause of the accident

The immediate cause of the fatal injuries was the fall from a height inside the cargo hold during cleaning operations,

Actions taken

• In accordance with Section 9 of the ISM Code, an internal investigation was carried out and the findings of the investigation were shared with the MSIU and the crew members serving on board Company ships;
• All masters and chief mates are required to attend courses in medical care and first aid, risk assessment, and incident and accident investigation and analysis;
• The relevant sections of the safety management manual have been amended to include information on the cleaning of cargo holds and related safety precautions;
• Additional contact details have been added to the Company’s official list to be used in cases of emergency on board.

Conclusions

Immediate Safety Factor

1. The distance between the two ladders had been calculated to be 1,500 mm. Consequently, AB 1 would have had to hold one of the lower rungs of the fixed vertical steps and then fully extend his body, for his feet to reach the first step of the aluminium ladder when descending to the cargo hold tank top;
2. The AB must have unclipped his safety harness and lost his footing while transitioning between the two ladders.

Latent Conditions and other Safety Factors

1. AB 2 had been distracted with cleaning up the area below and that his main focus as the stand-by man had been compromised;
2. No specific forms, checklists or specific text were available in the Company’s SMS for cargo hold cleaning operations;
3. The medical assistance which the crew members received was very limited.

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Source: Transport Malta

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