Two crew members on a general cargo ship were injured when a suspended load fell and struck them. The suspended load were wire rope legs and shackles used to move the ship’s hatch covers (“the lifting gear”), which fell because the hoist parted (Figure 1) after one of the shackles became wedged at the storage location. Both crew members were standing inside the hazardous area around the suspended load, ready to manually guide the load clear of snagging hazards during the lift. The lifting gear had been stowed in the cargo hold ventilation duct space, where it was known to have snagged before. The lifting operation had not been formally risk assessed, and a lifting plan for the work had not been produced.
A 11,000 GT general cargo ship built in 2018, was to load a cargo of wind turbine tower sections (Figure 2). The deck crew, supervised by the chief officer (C/O), began to prepare the ship for cargo loading. This work was halted in the afternoon due to adverse wind conditions, but was scheduled to recommence later in the evening when the weather was expected to improve. At 2100 the weather had improved. The C/O conducted a safety briefing and took up the position as supervisor, accompanied by the bosun (BSN). The ship’s working lights were turned on, illuminating the area where the crew were to work.
Following the safety briefing, one of the able-bodied seamen (A/B) used the ship’s forward crane to remove the cargo hold ventilation duct space cover (Figure 3), so that the lifting gear could be retrieved. Two other A/Bs then entered the ventilation duct space and attached the first of two hatch cover lifting gear sets to the crane’s hook using a fibre sling (Figure 1). Both A/Bs then climbed out of the space and stood close to the hatch edge ready to guide the load and free any snags as it was lifted.
There was no designated storage space for the lifting gear on board. The lifting gear had been stowed on wooden pallets positioned on top of the ventilation duct coamings in the ventilation duct space ever since delivery by the shipbuilder. The lifting gear was made up of two slinging sets; each set weighed 0.6t and consisted of two 17m long, 52-millimetre (mm) diameter, wire rope legs joined together with a master link (Figure 4). Each wire leg had a shackle attached to an eye at the lower end.
Using a radio, the C/O instructed the A/B controlling the crane to commence lifting. After the load had been lifted about 2-3 metres, the gear snagged. The C/O ordered the crane driver to stop hauling and the two A/Bs on deck freed the snag by hand. With the two A/Bs remaining close to the edge of the hatch the C/O ordered the crane driver to start heaving again.
Shortly after the lifting operation recommenced, a shackle at the lower end of the load became snagged on a ventilation trunk coaming (Figure 3 inset). The C/O immediately instructed the crane driver to stop, but at the same time the fibre sling parted and the lifting gear fell to the deck, striking both A/Bs.
One of the A/Bs suffered a severe head injury while the other suffered a minor hand injury. Other crew members administered first aid and raised the alarm. Ambulance paramedics were soon on the scene and treated both A/Bs before transferring them to a local hospital. The A/B who had suffered the serious head injury was later transferred to a dedicated neurological injury unit, before eventually being repatriated.
After the accident the parted sling (Figure 1) and five other similar slings from the ship were examined at an expert testing centre. The report of these tests stated that all six slings would have failed a visual inspection as they were soiled and had illegible identification markings.
Further details about the incident and the lessons learned are provided in the summary of the case study.
In addition, a presentation and reflective learning form have been prepared based on the incident as suggested training materials. These can be used by Members or their crew in any way they see fit to encourage reflection and gain the maximum learning from this incident: to consider why the incident happened; “what it means to me”, and to then relate the identified learning points to one’s own personal situation.
Finally, a Britannia commentary on the incident has been prepared which discusses the key points in more detail in order to help develop the reflective learning from the case study.
CASE STUDY MATERIAL
The following lessons learned have been identified. These are based on the information available in the investigation report and are not intended to apportion blame on the individuals or company involved:
- The deck preparations had been delayed by weather and there was pressure to prepare the ship for the cargo loading.
- The operation was not stopped by any of the involved crew when the A/Bs positioned themselves close to the suspended load.
- The ship’s SMS did not contain a risk assessment or a procedure for the stowage and handling of the hatch cover lifting gear, nor any guidance for the conduct of a lifting plan and the identification of fall zones.
- With no procedure to follow, the crew had adopted their own method of carrying out the lifting operation. The crew had experienced similar snagging events on previous occasions. When these had occurred, the deck crew had manually freed the gear after the crane had stopped hauling. No Near Miss report or corrective actions followed.
- The ship had not been built with a dedicated storage area for the hatch cover lifting gear. In result, the crew had devised a local storage arrangement which might have appeared appropriate, however had a significant number of potential snagging hazards. This storage arrangement had not been subject to a formal risk assessment.
- The load fell because the synthetic fibre sling used to lift it parted under tension. Although the sling’s nominal SWL was more than twice the weight of the load being lifted, the sling was in a poor condition and should have been discarded.
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THIS CASE STUDY IS DRAWN FROM THE INVESTIGATION REPORT 11/2020 PUBLISHED BY THE MARINE ACCIDENT INVESTIGATION BRANCH (MAIB).
THE PURPOSE OF THIS CASE STUDY IS TO SUPPORT AND ENCOURAGE REFLECTIVE LEARNING. THE DETAILS OF THE CASE STUDY MAY BE BASED ON, BUT NOT NECESSARILY IDENTICAL TO, FACTS RELATING TO AN ACTUAL INCIDENT. ANY LESSONS LEARNED OR COMMENTS ARE NOT INTENDED TO APPORTION BLAME ON THE INDIVIDUALS OR COMPANY INVOLVED. ANY SUGGESTED PRACTICES MAY NOT NECESSARILY BE THE ONLY WAY OF ADDRESSING THE LESSONS LEARNED, AND SHOULD ALWAYS BE SUBJECT TO THE REQUIREMENTS OF ANY APPLICABLE INTERNATIONAL OR NATIONAL REGULATIONS, AS WELL AS A COMPANY’S OWN PROCEDURES AND POLICIES.