UK MAIB has published an investigation report into an incident where at 13:53 on 20 July 2021, the bosun of the roll-on/roll-off cargo vessel Clipper Pennant was fatally crushed when he became trapped between a moving vehicle and the vessel’s structure.
The incident
Clipper Pennant was alongside in Liverpool, England, loading a cargo of semi-trailers. A tractor unit driver pushed a semi-trailer into a corner space, marshalled by the vessel’s bosun in his assigned role as banksman. The driver then disconnected the tractor unit and drove away. Shortly afterwards, the bosun was found trapped between the rear of the semi-trailer and the vessel’s structure, having sustained fatal injuries.
The accident happened because the tractor unit driver did not stop pushing the semi-trailer when they lost sight of the bosun during the manoeuvre. This was due to a procedural workaround that had become routine practice at the port, whereby the banksman was expected to move to an unsighted position behind a nearby semi-trailer. However, the bosun in this instance did not act as expected. He instead stood on a painted walkway located inside the vehicle lane to marshal the semi-trailer into the space, and so remained in its path as it approached. The semi-trailer had inadvertently been parked at an angle, encroaching the walkway and striking the bosun.
The investigation found that the working practices on board Clipper Pennant did not reflect industry guidelines and company procedure; there was no documented procedure for stowing semi-trailers in the more hazardous corner stowage spaces, which led to the development of local workarounds that went unchallenged; and organisational oversight was insufficiently effective, both in the approach of the vessel’s operator, Seatruck Ferries Limited, to learning lessons from previous accidents and the management of the port and its tractor unit drivers by the vessel’s charterer, P&O Ferries Limited.
Since the accident, Seatruck Ferries Limited has taken several actions to improve safety on its vehicle decks, including developing a new safe system of work that recognises dynamic danger zones and establishing standard loading procedures that better reflect the work performed. The company has also engaged with the industry to share its findings following several trials and tests of new procedures on company vessels and in various ports.
A safety recommendation has been made to industry bodies to develop a jointly agreed and consolidated industry Code of Practice for vehicle deck safety on roll-on/roll-off vessels. The Maritime and Coastguard Agency and Health and Safety Executive are recommended to amend their relevant codes and guidelines to reflect industry best practice. Recommendations have also been made to: P&O Ferries Limited to review how it achieves assurance that its ports adhere to its operational procedures and that a jointly agreed safe system of work is in place on chartered vessels; and to CLdN RoRo Limited (formerly Seatruck Ferries Limited) to improve its organisational safety culture and ensure effective supervision of vehicle deck cargo loading operations.
Conclusions
Safety issues directly contributing to the accident that have been addressed or resulted in recommendations
- Clipper Pennant’s bosun was fatally crushed when a semi-trailer struck and trapped him against a stiffening beam that protruded from the vessel’s structure next to a corner stowage space on the upper vehicle deck.
- The bosun was acting as a banksman, standing near the stiffening beam on an unofficial painted walkway to allow him to marshal the semi-trailer into the space while also stopping it from encroaching into the walkway. However, this was an unsafe area to stand as it was in the path of the approaching semi-trailer with limited escape options.
- The tractor unit driver was not monitoring the bosun as they pushed the semi-trailer toward the space because their attention was focused on pivoting the semi-trailer into position within the vehicle lane. The tractor unit driver did not stop when they lost sight of the banksman because they expected that the banksman would relocate to a designated safe area behind the adjacent semi-trailer.
- Clipper Pennant’s crew had painted the unofficial walkway to help prevent vehicles from parking too close to the longitudinal bulkhead and to enable access to the crew break room door.
- The painted walkway was dangerous because it was inside the vehicle lane. The modification likely led to a false sense of security and placed the crew in the direct path of vehicles when the walkway was used for marshalling.
- The reduction in the lane’s marked width also eroded the safety margin for pivoting semi-trailers and increased the likelihood of a semi-trailer being parked at an angle within the lane and encroaching the walkway.
- Seatruck’s SMS was ineffective in controlling hazards arising from the unsafe use of walkways or modifications. Walkways had been painted across the fleet with insufficient controls, such as physical barriers.
- The tractor unit driver did not stop when they lost sight of the bosun because of an undocumented procedural workaround that assumed the banksman would move to a safe area behind the adjacent semi-trailer.
- The loading operation on the upper vehicle deck was unsupervised because the bosun had stopped acting in his supervisory capacity to focus on lashing and marshalling the semi-trailers; the deck officers were busy with other responsibilities; and the upper vehicle deck had no CCTV cameras fitted.
- The deck ratings did not monitor the bosun as the semi-trailer approached the corner space because they frequently worked independently and focused on their own tasks to ensure the efficient loading of cargo.
- The unsafe procedural workaround for loading partially enclosed spaces conflicted with the Seatruck and P&O SMSs and neither company had completed a risk assessment or SSW for the workaround.
- Seatruck and P&O did not stop the partially enclosed space procedural workaround because a formal assessment of the workaround would have probably led to either the affected spaces being removed from service or the need to develop space‑specific procedures.
- There were shortfalls in the standards of tractor unit driving at the Port of Liverpool, likely because local management’s perception of risk had degraded over time, resulting in a tacit acceptance of some unsafe acts and workarounds that had become ‘normal’ practice.
- There was routine and widespread divergence from safe working practices on vehicle decks in the industry because the procedures and guidelines did not reflect how people actually worked.
Safety issues not directly contributing to the accident that have been addressed or resulted in recommendations
- Although a single whistle blast was heard by the tractor unit driver immediately before the bosun was struck, it was not sounded in sufficient time for the driver to stop pushing the semi-trailer and prevent the accident. The reliance on whistle signals as a primary method of protecting people was hazardous. This was particularly true when crew members were out of sight of the tractor unit driver and unable to use visual signalling methods.
- The crew on board Clipper Pennant did not adopt vessel or task-based risk assessments, which was also identified as an issue following the fatal accident on Seatruck Pace in 2018. The opportunity to consider and implement more effective control measures was therefore missed.
- Although Seatruck expected that GRAs were to be revised and adapted with specific risk assessments, it had not taken sufficient action to ensure its crews recognised vessel-specific hazards and implemented appropriate mitigation measures.
- Although Seatruck issued a company safety flash following the similar near accident on board Clipper Pennant in October 2020, there was no management review of the procedures and the report was closed without evidence of appropriate follow-up actions being taken.
- The missed opportunity to learn the lessons from the previous similar incident indicated that Seatruck’s incident analysis process was ineffective and reflected an insufficiently robust approach to organisational learning and continuous improvement.
- The absence of a supportive reporting culture on board Clipper Pennant and across the wider Seatruck fleet reduced the opportunity to recognise and address accident precursors.
- P&O did not audit its ports to ensure company procedures were being implemented, which led to a mismatch in working practices and the use of obsolete documentation.
P&O did not have a consolidated SMS for its port operations that contained standards for tractor unit driver training and assessment, nor was there a national occupational driving standard for them to follow. - Contrary to PSS guidance, Seatruck and P&O had not formally aligned their procedures during the Clipper Pennant charter to identify gaps or conflicts and establish further control measures. This was because the procedures were broadly similar, and it was assumed both SMSs would work in tandem.
Other safety issues not directly contributing to the accident
The IMO updated its guidelines for vehicle deck securing arrangements in 2020, but these did not reflect the increased maximum width of road vehicles and the athwartships securing point spacing requirement remained the same.
Actions taken
MAIB actions
The MAIB has issued a safety bulletin advising operators to ensure that, where tractor units are being used to push semi-trailers, safety procedures must be in place to ensure deck crew are not standing in the vehicle’s path. Operators were also advised to review their cargo handling procedures to identify the hazards associated with stowage spaces where there may be limited areas for escape and, where necessary, carry out specific risk assessments for such spaces.
Actions taken by other organisations
The Maritime and Coastguard Agency has updated Chapter 27.6 of the Code of Safe Working Practices for Merchant Seafarers to include guidance on risk assessments for areas where staff could become trapped when vehicles are reversing during loading operations.
CLdN RoRo Limited has:
- Carried out an internal investigation to establish the root causes of the accident.
- Implemented a new safe system of work for vehicle deck operations across the CLdN fleet that establishes dynamic danger zones and stops crew from marshalling in the path of approaching semi-trailers. The procedures were developed through:
- Review of the company’s existing vehicle deck procedures by an internal working group.
- Shoreside secondment of a C/O to work on the drafting and consultation of revised procedures.
- Trials conducted on board company vessels, including Clipper Pennant.
- Training days undertaken at various ports, attended by stevedores.
- Consultation with vessel crews and stevedores on the development of revised cargo handling procedures.
- Shared its new safe system of work with the industry to promote best practice and work towards standardised operating procedures.
- Introduced the role of fleet training officer, held by a senior deck officer on a rotational basis, operating across company vessels to observe working practices, train crew, and provide feedback to the company, particularly on vehicle deck safety.
- Introduced the management role of fleet training superintendent to supervise the implementation of procedures and the fleet training officer role.
- Introduced a cargo operations familiarisation form for deck officers and ratings to assess their proficiency and knowledge of cargo handling procedures, the cargo loading plan, hazardous areas on the vehicle deck, and the associated risk assessments.
- Restructured the management team and created new senior roles, including a safety and operations director, fleet and crew director, and fleet safety manager.
- Employed additional staff to help support the marine and technical superintendents.
- Implemented regular ship/shore meetings to bring together stevedores, crew, and operational staff to discuss safety.
- Implemented regular ship/shore meetings with external charterers of company vessels to bring owners and charterers together with stevedores, crew, and operational staff to discuss safety.
- Attended and contributed to the regular vehicle deck safety meetings organised by the UK COS in conjunction with PSS.
- Enhanced internal audit processes with external support and audited the processes for assuring the effectiveness of ISM implementation.
- Fitted CCTV cameras to all Seatruck tractor units to assist drivers with blindside visibility and to support company investigation and training.
- Completed the installation of recording CCTV cameras on Clipper Pennant’s and other company vessels’ vehicle decks. Shoreside CCTV has also been introduced.
- Commenced audits of vehicle deck procedures using the vessels’ CCTV.
- Started investigating the use of technology to improve vehicle deck safety.
- Updated the SMS risk assessment form to include a direction to complete tailored task-specific risk assessments as part of permit to work requirements, including additional risks and control measures.
- Issued a fleet notice introducing the updated risk assessment form and further highlighting that the form should be used for developing task-specific risk assessments.
P&O Ferries Limited has:
- Issued a safety alert to its workers about the risks associated with the hazards identified in the accident.
- Carried out an internal investigation to establish the root causes of the accident.
- Revised its SMS procedures for cargo handling operations to ensure the safety of its crew when working near vehicle deck areas with restricted escape routes.
- Implemented additional guidance and training materials for its stevedores and tractor unit drivers regarding safe driving practices and areas to avoid.
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Source: GOV.UK
