OPTIMISM Training Platform

Table 22: Micro Presentation of a Review of an Accident – Review 9

Title: An Investigation into Root Causes of Accident – Fall from Height

Accident Investigation Review 9 – Case Study 9 Fall from Height

1. Introduction 

In this accident investigation was carried out by a qualified accident investigator employed by an Accident Investigation Agency. 

The investigation aimed to demonstrate the difficulties to establish the root causes of accidents. 

2. Background

The International Safety Management (ISM) Code, adopted by the International Maritime Organization (IMO), establishes a framework for safe operation and management of ships and the prevention of pollution. Shipping companies are required to implement and maintain effective safety management systems that comply with the ISM Code. The accident investigators were responsible for proposing remedies to ensure the accident does not happen again and in the process identify any other contributing root causes.

3. Methodology

The investigation by the accident Investigators involved a comprehensive review of accident using any documents forwarded to them to carry out the investigation according to the Agency rules and practice. The Investigators employed an approach to evaluate the accident and its root causes against the requirements set forth by the Agency.  C4FF reviewed the information available primarily from accident investigation report with a view to find out if ISM can be more effectively implemented or its effectiveness improved.

4. Investigation

In the accident, AB1 might have no sufficient time or have the skill to control the tag line and keep the tag line clear from himself. It was likely that AB1 might fail to release the tag line in time or suddenly be tangled by the tag line when the latter was abruptly tensioned by the fast-slewing crane without any warning which is clear sign of Recklessness.

Findings

4.1 Investigation Practice

The Investigation took place in accordance with the Accident Investigation Agency procedures and practice. The Investigators examined various aspect of the accident and SMS Manual containing policies, procedures, and records/documents as well as non-Quality Assurance and Control deficiencies to ensure their findings would stop this accident from happening again. 

4.2 Accident investigator’s Report

The risk assessment and planning of the lifting operations must be addressed in order to be perfectly aligned with the Code of Safe Working Practices. 

5. Observations 

The investigators' report reveals a critical error in the lifting operation, primarily stemming from the lack of effective communication among the lifting team members. Additionally, on-site supervision was inadequate, and the training on lifting operation and safety awareness for the lifting team was insufficient. 

6. Comments

The accident investigation report points out the importance of effective communication, proper risk assessment, and adequate training in lifting operations to prevent similar incidents. Addressing these issues and aligning with the Code of Safe Working Practices is crucial to ensure safety and prevent accidents during lifting operations.