Lessons Learned: Ensure Crew Members Strictly Follow The Code

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Hong Kong Merchant Shipping has issued an information note to draw lessons learned from a fatal accident happened on board a Hong Kong registered general cargo ship during routine cargo hold inspection at Morong anchorage, Indonesia.

The incident

AHong Kong registered general cargo ship (the vessel) was awaiting berth for loading cargo at Morong anchorage, Indonesia. On the afternoon of the day of the accident, the chief engineer (the C/E) climbed down the fixed vertical ladder fitted under the aft access manhole on the tween deck (the access manhole) of the No.1 cargo hold (the hold) as usual to enter the lower cargo hold for inspecting the water ingress detection system and mechanical ventilation system, while the deck crew members and the second engineer (the 2/E) were carrying out painting work for the upper part of the hold.

Soon after, the 2/E suddenly heard a scream followed by the sound of an object hitting heavily against the tank top of the hold, and found the C/E lying unconsciously on the tank top near the fixed vertical ladder just under the access manhole. Afterwards, the master immediately informed the local agent to seek urgent medical assistance, and organised crew members to rescue the C/E who was found injured with serious head bleeding and showed no vital signs. The C/E was sent to the local hospital onshore, but unfortunately he was declared dead.

Findings

The investigation identified that the contributory factors leading to the accident were that the C/E failed to comply with the requirements set out in the “Code of Safe Working Practices for Merchant Seafarers” (the Code) to seek permission and adopt suitable control measures for the safe entry into the hold; the crew members failed to follow the requirements of the Code to properly secure the lid of the access manhole and use warning signs to indicate the potential hazard of falling from the vicinity of the access manhole; the crew members failed to comply with the requirements of the Code and the shipboard safety management system (SMS) to conduct toolbox meeting before work and adopt the required control measures during work; and the C/E failed to comply with the requirements of the Code and the shipboard SMS to conduct risk assessment for his inspection work in the hold.

The investigation also found that the shipboard safety training was ineffective, in particular on the aspects of conducting risk assessment and toolbox meeting, supervising the implementation of preventive measures and wearing appropriate personal protection equipment; and the C/E lacked safety awareness regarding the risks of his inspection work in the hold.

Lessons Learned 

  • Strictly follow the requirements of the Code in respect of the safe entry into cargo holds, including seeking permission from the responsible officer before entry and taking suitable control measures during work;
  • Strictly follow the requirements of the Code to properly secure the lid of manhole and use warning signs to indicate the potential hazard of falling from the vicinity of any manholes and openings;
  • Strictly follow the requirements of the Code and the shipboard SMS to conduct toolbox meeting and risk assessment before work;
  • Enhance shipboard training to familiarise crew members with the safety procedures for working in the cargo holds, remind them to wear appropriate personal protection equipment and improve their safety awareness regarding the potential hazard of falling; and
  • Ensure crew members strictly follow the Code and the shipboard SMS to conduct risk assessment and toolbox meeting on board, and ensure shipboard training to cover the safety requirements of working in cargo holds.

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Source: Safety4sea