Unit 6: Additional Micro Analysis of Accident Reports – Reviews 11 to 20

6.8 An Investigation into Root Causes of Accident – Falling Weight

Reference Number

C0013289

Description

A CCTV footage from the shore, which captured most of the accident, showed that the Hatch Cover was lifted by the ship’s Gantry Crane, operated by the Chief Officer, which then disconnected from the crane and fell onto the closed hatch cover beneath, where two crew members were laying out supports for it. One of the two crew members, managed to escape, the other one was crushed and declared dead. The Danish Maritime Authority detained the ship. Personnel should not be permitted to work if the Gantry Crane had any malfunction according to Procedures No.36 & No.37, in the case in which it was permitted to work, a “Specific Risk Assessment”, should have been carried out and the malfunction taken into consideration.

Key Root Causes

ISM non-conformity (Inadequate risk assessment - Gantry Crane was malfunctioning – Noting that the Procedures 36 and 37 were violated as the specific risk-assessment was carried out by not considering the particular circumstances of the work to be done, specifically the hydraulic deficiency of the Gantry Crane)

Management fault (Personnel were permitted to work, i.e., the two ABs went under the Hatch Cover, in order to place the supporting wooden stanchions, despite the fact that the Gantry Crane was malfunctioning. 

Crew related (Safety Management System Procedures violation was a contributing factor to the accident).

Casualties

1 fatality

Action-Recommendation

Had procedures in place for operating the Gantry Crane as well as Gantry Crane Manufacturer’s instructions, been implemented and a Specific Risk Assessment been carried out, the accident would have been avoided. under no circumstances personnel pass beneath a load that is being lifted where the operator of the lifting equipment does not have a clear view, and an effective system of radio or other contact to be implemented.

Would it happen again

No, if procedures respected and an effective risk-assessment had taken place.

 

Title: An Investigation into Root Causes of Accident – Falling Weight

Accident Investigation Review 18 - Falling Weight

1. Introduction 

In this accident investigation was carried out by a qualified accident investigator employed by a leading 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 a systematic 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

A CCTV footage from the shore, which captured most of the accident, showed that the Hatch Cover was lifted by the ship’s Gantry Crane, operated by the Chief Officer, which then disconnected from the crane and fell onto the closed hatch cover beneath, where two crew members were laying out supports for it. One of the two crew members, managed to escape, the other one was crushed and declared dead. The Danish Maritime Authority detained the ship. Personnel should not be permitted to work if the Gantry Crane had any malfunction according to Procedures No.36&No.37, in the case in which it was permitted to work, a “Specific Risk Assessment”, should have been carried out and the malfunction taken into consideration.

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

Conduct proper oversight to ensure adherence to procedures and the instructions provided by the Gantry Crane Manufacturer, particularly emphasizing the prohibition of personnel passing beneath a lifted load when the operator lacks a clear view. This should be accompanied by a detailed risk assessment aimed at preventing the recurrence of such accidents. Implement a robust communication system, such as radios, to facilitate effective communication.

5. Observations

 The investigation report reveals a clear violation of procedures (36 and 37) involving inadequate risk assessment, which neglected to consider specific work circumstances, notably the malfunctioning Gantry Crane's hydraulic deficiency. This allowed personnel to proceed with work under the Hatch Cover, placing wooden stanchions, despite the crane's malfunction. The lack of proper risk assessment and violation of Safety Management System Procedures both significantly contributed to the accident. 

6. Comments

The accident investigation report reveals a tragic incident involving a Gantry Crane malfunction during hatch cover operations. The findings emphasize the critical need for strict adherence to procedures, including prohibiting personnel from working beneath a lifted load without clear operator visibility. Robust oversight, detailed risk assessments, and effective communication systems are recommended to prevent similar accidents. The report underscores the significance of proper risk assessment to ensure the safety of crew members during crane operations.