Mobile Scaffold Towers can pose a threat to the crew if not properly taken care of. An investigation report by the Transport Malta Marine Safety Investigation Unit highlights this and today we are presenting the findings of that case study to make shippers aware of such onboard accidents.
Incident Summary
At about 1550, on 19 October 2017, a mobile scaffold tower, which was being used in cargo
hold no. 1 on board MV Delsa, toppled over. Consequently, one of the ABs, who at the time
of the accident was still on the scaffold tower, was seriously injured.
After being administered first aid, the master made contact with the USCG for medical
assistance and diverted the vessel towards Cold Bay in Alaska for medical assistance.At 2105, the injured AB was air lifted by a USCG helicopter and transferred to a local hospital.
- The safety investigation found that at the time of the fall, the AB was still on the scaffold
tower but with his safety harness detached, while two other crew members had released the securing lashings of the mobile scaffold tower in preparation for shifting. - Furthermore, the mobile scaffold tower was not assembled in accordance with the manufacturer’s instructions. The MSIU has issued one recommendation to the
Company designed to ensure safe use of the mobile scaffold on board.
FACTUAL INFORMATION
The vessel
MV Delsa is a Maltese-registered bulk carrier of 35,884 gt fitted with five cargo
holds. It was built in China in 2015 by Zhejiang Shipbuilding Co. Ltd. The vessel’s
registered owner is Delsa Ltd., managed by Franco Compania Naviera S.A. of Greece,
and classed by RINA of Italy. The vessel’s length overall is 199.99 m, has a breadth of
32.26 m and a deadweight of 63,166 tonnes.
Delsa is powered by a five-cylinder MANB&W 5S60ME-C8, 2-stroke diesel engine,
producing 8,300 kW at 91 rpm. This drives a single fixed-pitch propeller, with a service
speed of 14.25 knots.
Crew
Delsa’s Minimum Safe Manning Certificate required a crew of 14. There were 20 crew
members on board at the time of the accident. The crew members were from Ukraine,
Romania and Indonesia. The injured crew member was a 42 year old AB from Indonesia. He had joined the vessel in June 2017.
Together with two other ABs, he had used the mobile scaffold tower before. The working language on board was English
Weather conditions
At the time of the accident, the weather was reported to be clear with good visibility (12
nautical miles). The sea state was slight with a 1.0 m swell from the West Northwest. A
moderate breeze was also from the West Northwest. Air temperature was recorded to
be 8 °C.
Narrative
On 06 October 2017, Delsa departed from Tianjin, China, in ballast condition for the Port of Longview, Columbia River, Washington, U.S.A. During the voyage, several crew members
were engaged in cleaning and maintenance of the cargo holds. On 19 October 2017, the
crew were painting inside cargo hold no. 1.
In order to get access to the upper levels of the cargo hold, it was decided to erect the
vessel’s mobile scaffold tower. The chief officer, carried out a ‘Risk Assessment’ as required by the Company’s Safety Management System, and also completed the Company Risk Assessment Form and the ‘Working Aloft / Over-side Permit Checklist’.
The forms were also countersigned by the Master. According to the ‘Permit’, which was completed by the chief officer at 1245, the work was scheduled to start at 1300 and finish at 1700. The bosun was identified as the ‘Team Leader’. As part of this process, the ABs assigned with the task, were given a demonstration of how to assemble and disassemble the scaffold tower, and the safety precautions that had been taken during its use.
According to this checklist, all of the ABs involved in the task had the required PPE; a
safety lifeline was made fast at the top of the cargo hold and additional persons were on
stand-by. On both the Risk Assessment Form and the Permit Checklist, the only ‘Remark’ was that ‘[a]ll time use additional lashing for securing scaffolds’.
The mobile scaffold tower, which was delivered on board on 08 July 2017, was assembled by the crew (under the supervision of the bosun and the chief officer) to a height of 15.0 m. It was then secured by four lashings at the fifth tier, about 10.0 m from the tank top.
Accident Happening
The work started as scheduled and continued until it was time for the afternoon break.
After the break, the ABs swapped positions and AB no. 2 climbed the scaffold tower. At
around 1550, the crew, who were working in cargo hold no. 1, decided to shift the scaffold
tower forward in order to continue with their work. AB no. 2, who was on the top platform,
around 15.0 m high, unhooked his harness from the safety lifeline and started making
his way down the scaffold tower. At the same time, the two ABs, who were assisting
down on the tank top of cargo hold no. 1, released the lashings, one by one, in order to
make the mobile scaffold tower ready for shifting.
At this time, the brakes on the four wheels were on and the drop-down legs on the
bottom trestle were still in the lowered position. The last lashing was released when
AB no. 2 reached the third stage level, i.e. around 7.0 m from the bottom. At this stage,
the top part of the mobile scaffold tower toppled over, throwing AB no. 2 to the tank
top.
Post-accident Actions Taken
The bosun was informed of the accident at about 1550 and proceeded to the forecastle to
inform the bridge. The OOW immediately informed the master and the chief officer,
who was on the bridge at the time. The latter immediately made his way forward to assist
the injured AB and administer first aid. On his way forward, the chief officer stopped by the ship’s hospital and collected the oxygen bottle, the stretcher and the First Aid kit.
Upon arrival, the chief officer found the injured AB breathing with difficulty, suffering from pain and not feeling his left side. An inter-muscular injection was administered to relief the pain and hot-water bottles were put around the body.
The master immediately informed the Company, his agents in the USA and also the
USCG. The vessel was instructed to deviate to Cold Bay, Alaska, where the USCG has its Coastal Air Station, in order to make a rendezvous with the USCG helicopter and
evacuate the injured AB.
At 1750, the master deviated the vessel from her original route and headed for Cold Bay.
At 2020, when the vessel was about 130 nautical miles Southeast from Cold Bay, the
USCG helicopter landed one USCG medical officer on board Delsa. At 2105, the injured
AB was successfully evacuated from the vessel.
Sustained injuries
After the AB was evacuated by the USCG helicopter and taken to the USCG station at
Cold Bay, he was immediately transferred to the Providence Medical Center, at Anchorage, Alaska, USA, where multiple diagnostics had been completed, including
MRI / CT Scan / X-rays.
The AB was diagnosed to have suffered lung damages and a fracture / compression
fracture. He had to be operated on and also required follow-up physiotherapy.
- The mobile scaffold on board
The aluminium mobile scaffold tower, in-use at the time of the accident, was manufactured
by a company in Greece, the latter being certified to ISO 9001:2008 quality standard.
According to the Company, the scaffold tower, which was purchased in June 2017
and received on board in July 2017, was specifically ordered to meet the vessel’s
requirements.
This meant that the original dimensions had to be altered. The scaffold’s base was modified from the original dimensions of 0.75 m by 2.00 m to 1.44 m by 2.50m
These modifications necessitated the submission of drawings / documents to the Hellenic Register of Shipping (HRS) of Greece for ‘Type Approval’. The approval was still pending at the time of the accident.
ANALYSIS
Aim
The purpose of a marine safety investigation is to determine the circumstances and safety
factors of the accident as a basis for making recommendations, and to prevent further
marine casualties or incidents from occurring in the future.
- Weather conditions as a contributing factor
The vessel’s motion in the prevailing weather conditions was reported to be negligible and
the crew members were working comfortably inside the cargo hold. The weather conditions were not considered to be contributing factor to the accident.
- Health & Safety – working aloft
Working aloft was addressed in the Shipboard Safety Management Manual2. It covered working aloft in various places, including the funnel or the main mast, as well as the use of staging or the Bosun’s chair, and working overside.
The Manual also provided for a risk assessment to be performed prior to any work aloft is carried out and also for the ‘Working Aloft / Over-Side Permit’ to be completed.
The works that were ongoing in cargo hold no. 1 were progressing from bottom-up and
the safety investigation is of the view that in order to reach the upper sections of the cargo
hold, the crew had no other alternative but to use the mobile scaffold tower, which was
available on board.
The use of the scaffold was agreed on 19 October, following a discussion between the
master and the chief mate. Its use was considered as the safest option to reach the
upper levels of cargo hold no. 1. Moreover, the weather conditions were acceptable and
the vessel was not rolling.
The chief officer carried out the ‘Risk Assessment’, using the Company Form DM-003, and completed the ‘Working Aloft/Over-side Permit Check List’ between 1230 and 1245. Both forms were countersigned by the master. However, it is to be noted that in this part of the Manual, the ‘Risk Assessment’ and the ‘Permit’ documents did not address the use of mobile scaffold towers and the hazards associated with it. In fact, most of the points on the Permit’s Checklist have been marked ‘N/A’ (not applicable).
- Safe use of the mobile scaffold tower
The use of mobile scaffold towers on board vessels, especially in cargo holds, is
becoming a common practice. These towers are normally used for cleaning, maintenance,
repairs and even for close-up inspections by Class surveyors.
Mobile scaffold towers are designed to be used on stable and level surfaces. When using a mobile scaffold tower on board a vessel, extra precautions need to be taken to ensure that it does not topple over or fail under any working condition. These precautions should include, but not limited to, assembling the mobile tower as designed and effectively securing it to provide a safe working platform. 
Furthermore, when shifting a mobile tower, its height should be reduced so as to avoid it from toppling over. This means that at no time should a mobile scaffold tower be shifted with persons on it.
As explained elsewhere, at the time of the accident, the vessel was still waiting for a ‘Type Approval’ from HRS. The Company confirmed that in the meantime, the manufacturers provided an ‘Attestation of Type Examination’ (issued by HRS). However, the safety investigation concluded that this attestation referred to a completely different type of scaffolding from the one in use at the time of the accident. Furthermore, the Instructions Manual for this mobile scaffold tower makes references to scaffold towers with different dimensions from the one in use, except for one page / drawing which relates to the type in use, namely, the 1.40 m by 2.50 m tower.
This page also gives details of the maximum height, which is 10.0 m, on how to assemble
the base of the tower, complete with the outriggers / stabilisers and drop down legs,
and how to connect it to the tower frames.
According to the Company, this Instructions Manual, which is provided by the manufacturers only in the Greek language, was placed on board and only the pages
indicating how to assemble the frames were translated into the English language. The
Company felt that other instructions in the Instructions Manual, covering the use of
personal protective equipment did not need to be translated into English.
The Company explained that these were not translated because Appendix I of the Safety
Management Manual (Section 2.3.2 – Working aloft and Section 3.5 – Health &
Safety) addressed this matter sufficiently and thoroughly. Moreover, the Company explained that the Shipboard Safety Management Manual made detailed reference to hazards and safety precautions to be taken when working aloft and at heights and this therefore also addressed working on scaffold towers.
According to the Company, both the risk assessment process and the Permit Checklist
required that a meeting is held with the involved crew members, instructions are
given on how to assemble the mobile tower and the precautions to be taken. However,
the safety investigation revealed that the mobile scaffold tower was not assembled in
accordance with the drawing provided in the Instruction Manual, including:
- the mobile scaffold tower base was not assembled exactly as indicated in
(Figure 1) – the four stabilisers / outriggers, which connect the base to
the tower, were missing the connection struts to the tower frames - the mobile scaffold tower was rigged up to a height of 15.0 m (whereas
according to the drawing, the maximum height was 10.0 m).
- Task Supervision
The three ABs working in cargo hold no. 1 joined the vessel together in June 2017. It is
stated that they all had their mandatory ‘Onboard Familiarization Training’ when
they joined the vessel. Furthermore, according to the Company, the three ABs all
had previous working experience on the mobile scaffold tower.
It would appear that one of the crew members listed in the work permit as a team leader and hence meant to supervise the task was not in the cargo hold at the time of the
accident.
- Safety concerns with the use of the scaffold
Falls from mobile scaffold towers are a common cause of serious injuries and even
loss of lives. This accident is not the first one of its kind to be investigated by MSIU3
and statistics show that accidents involving mobile scaffold towers are common onboard
ships, in particular on bulk carriers.
Available accident data also indicated a number of common factors, including:
- hazards not identified;
- inadequate and/or missing information,
- instruction, training or supervision provided
- appropriate safety equipment not used.
Probable Causes
In this case, it was concluded that the immediate cause of the accident was the
releasing of the securing lashings at a time when the AB was still on the mobile scaffold
tower. The safety investigation identified three possible causes:
- the crew members assumed that the mobile tower would remain safe and stable after releasing the securing lashings, since the wheels remained locked and the legs down;
- the approach taken by the crew members would have saved time; and /or
- the procedure may have already been carried out on a number of previous occasions without an accident.
The mobile scaffold tower had not been erected in accordance with the manufacturer’s instructions and, hence, it was also very likely that the tower was unstable when the securing lashings were released.
It is recognised that the centre of gravity had shifted away from the centre, causing the
upper part of the scaffold to tip over. The crew member going down the scaffold could
have very well been the reason for the (horizontal) shift in the scaffold’s centre of gravity.
Making reference again to the checklist and permit, these two documents made no
reference to the use of internal, vertical ladders fixed to the scaffold and which would
have potentially prevented the horizontal shift in the centre of gravity.
Then, the fall protection had not been fitted with a multi-anchor point and therefore, the
descent of the crew member necessitated him to remove the protection altogether.
As indicated in the three points above, such cues had not been detected prior to the
accident and hence, risk levels were miscalculated, albeit not during an official
risk assessment exercise.
Concluding remarks of the investigation report
- The immediate cause of the accident was the releasing of the securing lashings at a time when the AB was still on the mobile scaffold tower;
- The crew members assumed that the mobile tower would remain safe and
stable after releasing the securing lashings, since the wheels remained locked and the legs down; - The approach taken to shift the scaffold structure would have saved time;
- The procedure may have already been carried out on a number of occasions
without any accidents; - 5. The ‘Risk Assessment’ and the ‘Permit’ documents did not address the
use of mobile scaffold towers and the hazards associated with it; - The mobile scaffold tower was not assembled in accordance with the
drawing provided in the Instruction Manual; - There was no task supervision inside the cargo hold just before the accident
happened - Internal, vertical ladders have not been used by the crew member to
descend the scaffolding; - The fall protection had not been fitted with a multi-anchor point and
therefore, the descent of the crew member necessitated him to remove
the protection altogether; - Hazard cues had not been detected prior to the accident and hence, risk
levels were miscalculated, albeit not in an official risk assessment exercise.
SAFETY ACTIONS TAKEN DURING THE COURSE OF THE SAFETY INVESTIGATION
Following the accident, the Company adopted a number of safety actions with the
aim of preventing similar future accidents:
- Deck officers and ratings serving on Delsa were provided ‘Extra Training’
on ‘Working Aloft Safety; - A thorough review of the technical specifications of the mobile scaffold
tower was carried out; - The vessel’s ‘Working Aloft Procedures’ have been reviewed;
- The Risk Assessment procedures have been reviewed and now include the
hazards of “…improper assembly of scaffolding as per manufacturer’s
instructions” and “the lack of proper supervision”; - The ‘Working Aloft/Over-side Permit Checklist has been reviewed and
further “checks” (inspection of scaffolding condition prior use by responsible personnel & supervisor) has been included; - The accident was discussed at the first Safety & Occupational Health Committee Meeting on board
- A Fleet Circular has been prepared on the accident and circulated onboard all
ships managed by the Company.
RECOMMENDATIONS
Franco Compania Naviera S. A. is recommended to:
19/2018_R1 Ensure that climbing of scaffold is always done from the inside
in order not to compromise the horizontal position of the tower’s centre of gravity.
SHIP PARTICULARS
- Vessel Name: Delsa
- Flag: Malta
- Classification Society: Registro Italiano Navale (RINA)
- IMO Number: 9729544
- Type: Bulk carrier
- Registered Owner: Delsa Ltd.
- Managers: Franco Compania Naviera S. A.
- Construction: Steel
- Length Overall: 199.99 m
- Registered Length: 194.53 m
- Gross Tonnage: 35,884
- Minimum Safe Manning: 14
- Authorised Cargo: Solid Bulk
VOYAGE PARTICULARS
- Port of Departure: Tianjin, China
- Port of Arrival: Washington, USA
- Type of Voyage: International
- Cargo Information: In ballast
- Manning: 20
MARINE OCCURRENCE INFORMATION
- Date and Time: 19 October 2017 at 15:50 (LT)
- Classification of Occurrence: Serious Marine Casualty
- Location of Occurrence: 54° 06.4’ N 160° 069.9’ W
- Place on Board: Cargo hold
- Injuries / Fatalities: One injury
- Damage / Environmental Impact: None reported
- Ship Operation: In passage
- Voyage Segment: Transit
- External & Internal Environment: Clear weather and good visibility (12 nautical miles). The sea state was slight with a 1.0 m swell from the West Northwest. A moderate breeze was also from the West Northwest. Air temperature was recorded to be 8 °C.
- Persons on board: 20
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Source: Transport Malta Marine Safety Investigation Unit
