BMA Investigation: Lift fatality onboard Silver Nova

What happened

On the morning of 22 February 2024, the Bahamas-flagged passenger vessel Silver Nova was on passage off the coast of Brazil. Work was carrying on as normal below decks in the waste handling area, where incinerator operators were preparing for the transfer of ash to a holding area onboard, ready for disposal ashore at their next port. During the transfer, a wiper who was asked to assist in loading the ash bag into a cage lift was severely injured when the cage lift he accessed to free the ash bag, which had wedged itself, gave way, trapping and crushing his leg and lower body. Despite immediate medical assistance on board and medical care ashore at a local hospital, the wiper later died from complications arising from his injuries.

Why it happened 

The cage lift got wedged when an ash bag shifted during hoisting due to horizontal bars not being in place, which were fitted to prevent cargo from spilling out from under the gate during loading. The incinerator supervisor was unaware that the chain on the cage lift was slack when he isolated the power, rendering it unsafe for access in any attempt to free the wedged ash bag. The wiper entered the cage to free the ash bag, unaware of the potential risks.

On the morning of 22 February 2024, the Bahamian flagged passenger ship Silver Nova, with 530 crew and 629 passengers onboard, was on passage from Fortaleza, Brazil, to Macapá, Brazil, as part of the Amazon leg of its Grand Voyage South America itinerary. Weather conditions for the voyage were favorable, and the journey was operating according to schedule. This was the vessel’s maiden Grand Voyage South America cruise over a 71-day period, having recently entered service in August 2023 in Italy. Crew were carrying out work as normal on deck and below, including planned maintenance, scheduled service intervals, and daily routines, such as managing recyclable and non-recyclable waste onboard.

The responsibility for waste management onboard lay with an incinerator supervisor (IS) and an incinerator operator (IO). Both the IS and IO had undergone specific shipboard training in the use of all auxiliary equipment, including the incinerator and lifting equipment, and had been duly signed off by the chief engineer as experienced and competent members of the engineering department. Both were responsible for ensuring that waste accumulated onboard was collected and segregated for recycling. Any dry waste, such as cardboard, paper, wood, and dried food, was shredded into 25mm pieces before being fed into the incinerator. Once the ash from the incinerator was cooled, it was loaded into large one-ton bags and shipped ashore when the vessel was alongside.

The cooled ash stored in bags requires a fraction of the space onboard compared to conventional methods of compacted and baled waste on pallets or stored in cages. These ash bags are then transferred to an upper deck by means of a cage lift to a holding area for removal when unloading takes place in port. Following the conclusion of the morning toolbox meeting at 08:00, held in the engine control room (ECR), the IS and IO made their way up to Deck 2, where the garbage handling area was situated. On arrival, they began separating waste for incineration and other waste that would be recycled later, which would then be transferred to the provision handling area further aft of the garbage handling area, ready for removal.

At around 10:20, following a coffee break and the completion of sorting and shredding waste for incineration, they proceeded down to Deck 00 (zero-zero) to transfer the cooled ash from the previous day’s incineration into ash bags. En route, they passed a wiper who was on his way back to the engine room and asked him to assist with lifting the ash bag into the cage lift. Due to the nature and size of the one-ton ash bags in use, overfilling them would pose a problem for the IS and IO when lifting and moving them. As a result, they routinely filled the bags approximately a third full, with a weight of around 300 to 350 kilograms.

The weight of the ash bag, coupled with the confined area in which to operate a manual pallet truck and the proximity of the discharge chute to the entrance of the cage lift, made the transfer into the cage difficult for two crew members. As a result, a third person was often called upon to assist (Figure 3). The cage lift was a custom-built unit designed to fit the allocated space and area in which it was to operate.

At 10:24, the IS called the cage lift down from Deck 2 to Deck 00 by engaging the switch on the main control box situated on Deck 0. Although access and working space were limited, the IS and IO, accompanied by the wiper, managed to manoeuvre the bag resting on the pallet truck into the cage lift. The ash bag proved difficult to position due to its weight and placement, so the IS and IO made their way back up to Deck 0. The IS opened the access gate with an over-ride key he had taken from the ECR, and with the use of some bale hooks, they both climbed onto the top frame of the cage. Leaning through, they gathered up the handles on the ash bag in the cage below to try and move it centrally.

Whilst they were both lifting and taking the strain, the wiper pushed the ash bag from below to try and centre it into the cage lift before removing the pallet truck to allow the cage door to close. Shortly before 10:29, following several attempts, the cage lift door was finally closed by the wiper on Deck 00. The IS made his way down to lock the rear access gate before proceeding up to Deck 0, where he closed and locked the front access gate. He then made his way over to the lift controls situated diagonally opposite the lift.

On reaching the control panel, the IS began hoisting the cage up to Deck 2, while the IO connected an empty ash bag to the discharge chute and the wiper repositioned the manual pallet truck out of the way and clear of the cage entrance. As the lift cage made its way up and through the deckhead on Deck 0, the IS noticed that the cage was no longer rising. He then realized that the ash bag had moved and wedged itself between Decks 0 and 1. At this point, the IO and wiper were making their way up from the lower deck.

Several attempts were made by the IS to dislodge the lift by lowering and then lifting the cage, but these proved unsuccessful. At 10:32, the IO and wiper left Deck 0 and made their way up to Deck 1 to investigate further. The IS called up through the lift space, stating that he would try again to dislodge the bag by hoisting and lowering it. The IS called again for feedback, but the IO stated that it was not moving, at which point the IS ceased operating the lift, isolated the controls, and activated the emergency stop before making his way up to Deck 1.

Upon realizing that the bag was the issue, the IS asked the IO to retrieve a steel pole from the store on Deck 2 so it could be used to push the bag from the sides of the cage in an attempt to lever or push it free. Meanwhile, the wiper had made his way to the rear of the cage on Deck 1 to see if he could open the cage door and manually move the bag to free it.

The IO returned with the pole, and along with the IS, they attempted to hook a tie handle to move the bag. The wiper then summoned the IS to open the rear access gate so the ash bag could be accessed. The IS opened the gate following a discussion with the wiper and returned to the IO at the front. The wiper then entered the cage lift to free the bag.

At 10:35, the wiper, who was standing with one leg inside the cage on the edge of the pallet and his other leg on the deck, was manhandling the ash bag when it suddenly dislodged. The cage plummeted more than 2 meters toward Deck 0. The wiper’s upper leg, pelvis, and lower abdomen were crushed and trapped between the deckhead on Deck 0 and a support bar on the upper section of the cage lift.

The IS turned back and saw what had happened. He immediately left the scene to call for help. Within a minute, the second engineer, accompanied by a fitter and another engineer, attended the scene to assess the extent of the injury. The second engineer rushed back to the ECR and notified the chief engineer and bridge, where the ship’s emergency code alpha alarm was sounded, alerting the ship’s surgeon and medical team. The second engineer then returned and began securing the cage.

With the full complement of medical staff now in attendance, the ship’s surgeon instructed the engineers to secure the lift to allow for a safe extraction of the severely injured wiper. Using a strop and chain block, the second engineer isolated the cage, preventing movement, and facilitating a safe extraction.

Almost half an hour after securing the cage lift and rigging a harness and hoist, the wiper was safely recovered from the cage and positioned on the deck a couple of meters away so that the medical team could attend to him. Following emergency medical care onboard by the ship’s surgeon and his team to stabilize the wiper’s condition, he was transferred later that day by air to a hospital’s emergency care unit in Belém, Brazil. After five weeks in intensive care, the wiper died from complications arising from his injuries.

Conclusions:

• The wiper sustained serious injuries when the lift he entered fell, trapping and crushing his lower body.
• The wiper entered the gate of the cage lift to free the ash bag, which had wedged itself during hoisting.
• The horizontal bars were not lowered prior to loading and closing the cage lift, causing the bag to shift during hoisting.
• Although the power to the cage lift had been isolated, neither the IS, IO, nor the wiper were aware of the slack in the chain.
• The manufacturer’s instructions on the importance of lowering the horizontal bars during lift operations were not clearly marked on the cage lift.
• A breakdown in communication between the IS, IO, and the wiper resulted in their failure to ensure all safety features and securing arrangements of the cage were maintained according to the manufacturer’s guidelines.
• The design, installation, and proximity of the cage lift to the ash chute forced the crew to adapt their tasks and workspace to fulfill their duties. This overlooked the importance of designing tasks, workstations, tools, and equipment to match workers’ physical capabilities and limitations.

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