This report summarizes a marine occupational fatality investigated by the Republic of the Marshall Islands Maritime Administrator. The incident occurred on board a bulk provider throughout cargo dealing with and upkeep operations at Rio Tuba Anchorage, Philippines. The aim of the investigation was to determine the causes and contributing components and to advocate preventive measures to boost security at sea.
What Occurred
Throughout nickel ore loading operations, cargo barges alongside the vessel quickly ceased arrival. To make the most of the idle interval, crew and shore staff started upkeep on two deck cranes and their grabs, particularly to switch hydraulic strains.
Whereas one seize was positioned on deck in {a partially} open place for draining hydraulic oil, crew members observed {that a} seize wire thimble had dislodged. It was determined to instantly renew the wire. A threat evaluation (RA) and Toolbox Discuss have been performed earlier than the duty started. The seize’s hydraulic system had been drained, leaving the seize in a non-standard situation with out hydraulic strain. To take away the previous seize wire, the crew connected a series block between the wire and a deck D-ring to extract the wire from its wedge socket.
Through the operation, an In a position Seafarer Deck (ASD) entered underneath the seize to function the chain block. When the chain block got here underneath rigidity, the seize unexpectedly opened totally, forcing the through-beam downward and trapping the seafarer between the seize and deck. Instant efforts have been made to elevate the seize and supply first help. Regardless of fast medical response and evacuation to a neighborhood hospital, the seafarer was later declared deceased on account of inner hemorrhage and hypovolemic shock.
Why It Occurred
The seize opened all of the sudden on account of a mixture of technical, procedural, and human components. Technically, the seize was left partially open and unsupported after hydraulic oil drainage. When the chain block was tensioned, the added downward power overcame frictional resistance and brought on the through-beam to drop abruptly. Procedurally, there have been no particular directions from both the producer or the corporate for changing seize wires or draining hydraulic oil, and the crew incorrectly believed that the seize couldn’t transfer after oil drainage.
The chance evaluation performed earlier than the job did not determine hazards related to the seize’s non-standard situation, and the work was carried out concurrently with different upkeep operations and not using a coordinated security assessment. As well as, insufficient familiarization with the seize’s mechanical rules, restricted understanding of potential hazards, and failure to train stop-work authority contributed to the prevalence.
Actions Taken
Following the incident, the working firm and the seize producer applied corrective and preventive actions. The corporate integrated crane and seize upkeep hazards into officer coaching and appraisal processes, re-trained all crew underneath the Security Habits Program, and started growing a devoted coaching module on crane and seize upkeep. The incident and its classes have been circulated throughout the fleet with emphasis on efficient threat evaluation, toolbox talks, and secure upkeep practices.
The corporate’s documentation committees reviewed the necessity to revise the Cargo Operations Handbook and Job Hazard Evaluation library to incorporate procedures and mitigation measures for seize wire substitute. A security alert was issued fleet-wide, and technical superintendents have been instructed to make sure that producer upkeep procedures can be found within the working language of every vessel. All grabs are to be inspected by the producer on the subsequent alternative, and a cargo audit has been scheduled to confirm secure operational compliance. The seize producer, in the meantime, developed formal written directions for altering seize wires on the RC024-5-12 mannequin.
Classes Realized
Non-routine and unplanned jobs should comply with formal approval and complete threat evaluation procedures.
Hazards arising from tools in non-standard circumstances, equivalent to drained hydraulic techniques, should be recognized and managed earlier than work begins.
Coordination between departments and shore staff is essential when simultaneous operations happen in the identical space.
All personnel ought to obtain thorough familiarization with crane and seize techniques earlier than conducting upkeep.
Cease-work authority should be actively exercised every time unsafe circumstances or uncertainty about tools habits is noticed.
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Supply: REPUBLIC OF THE MARSHALL ISLANDS
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