This report summarizes a marine occupational fatality investigated by the Republic of the Marshall Islands Maritime Administrator. The incident occurred on board a bulk carrier during cargo handling and maintenance operations at Rio Tuba Anchorage, Philippines. The purpose of the investigation was to identify the causes and contributing factors and to recommend preventive measures to enhance safety at sea.
What Happened
During nickel ore loading operations, cargo barges alongside the vessel temporarily ceased arrival. To utilize the idle period, crew and shore workers began maintenance on two deck cranes and their grabs, specifically to replace hydraulic lines.
While one grab was placed on deck in a partially open position for draining hydraulic oil, crew members noticed that a grab wire thimble had dislodged. It was decided to immediately renew the wire. A risk assessment (RA) and Toolbox Talk were conducted before the task began. The grab’s hydraulic system had been drained, leaving the grab in a non-standard condition without hydraulic pressure. To remove the old grab wire, the crew attached a chain block between the wire and a deck D-ring to extract the wire from its wedge socket.
During the operation, an Able Seafarer Deck (ASD) entered under the grab to operate the chain block. When the chain block came under tension, the grab unexpectedly opened fully, forcing the through-beam downward and trapping the seafarer between the grab and deck. Immediate efforts were made to lift the grab and provide first aid. Despite rapid medical response and evacuation to a local hospital, the seafarer was later declared deceased due to internal hemorrhage and hypovolemic shock.
Why It Happened
The grab opened suddenly due to a combination of technical, procedural, and human factors. Technically, the grab was left partially open and unsupported after hydraulic oil drainage. When the chain block was tensioned, the added downward force overcame frictional resistance and caused the through-beam to drop abruptly. Procedurally, there were no specific instructions from either the manufacturer or the company for replacing grab wires or draining hydraulic oil, and the crew incorrectly believed that the grab could not move after oil drainage.
The risk assessment conducted before the job failed to identify hazards associated with the grab’s non-standard condition, and the work was performed simultaneously with other maintenance operations without a coordinated safety review. In addition, inadequate familiarization with the grab’s mechanical principles, limited understanding of potential hazards, and failure to exercise stop-work authority contributed to the occurrence.
Actions Taken
Following the incident, the operating company and the grab manufacturer implemented corrective and preventive actions. The company incorporated crane and grab maintenance hazards into officer training and appraisal processes, re-trained all crew under the Safety Behavior Program, and began developing a dedicated training module on crane and grab maintenance. The incident and its lessons were circulated across the fleet with emphasis on effective risk assessment, toolbox talks, and safe maintenance practices.
The company’s documentation committees reviewed the need to revise the Cargo Operations Manual and Job Hazard Analysis library to include procedures and mitigation measures for grab wire replacement. A safety alert was issued fleet-wide, and technical superintendents were instructed to ensure that manufacturer maintenance procedures are available in the working language of each vessel. All grabs are to be inspected by the manufacturer at the next opportunity, and a cargo audit has been scheduled to verify safe operational compliance. The grab manufacturer, meanwhile, developed formal written instructions for changing grab wires on the RC024-5-12 model.
Lessons Learned
- Non-routine and unplanned jobs must follow formal approval and comprehensive risk assessment procedures.
- Hazards arising from equipment in non-standard conditions, such as drained hydraulic systems, must be identified and controlled before work begins.
- Coordination between departments and shore workers is critical when simultaneous operations occur in the same area.
- All personnel should receive thorough familiarization with crane and grab systems before conducting maintenance.
- Stop-work authority must be actively exercised whenever unsafe conditions or uncertainty about equipment behavior is observed.
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Source: REPUBLIC OF THE MARSHALL ISLANDS