Falling into cargo hold

The Swedish P&I Club Monthly Safety Scenario for June 2014

The Swedish P&I Club published its Monthly Safety Scenario for June 2014 regardingthe danger of partially open hatches and falling into cargo hold.The Swedish Club publishes on a monthly basis a new “Monthly Safety Scenario” (MSS) to assist owners in their efforts of complying with the maritime regulations.

It was an early morning in winter. There were patches of ice on the deck and on the cargo hatch covers. The container vessel was alongside and cargo operations had started. The starboard outboard cargo hatch cover for hold 5 had been removed and placed on the quay. A couple of containers were then loaded into the cargo hold. After this some other holds were to be loaded before coming back to hold 5. The hold was left partially open.

A couple of hours after loading had started, a terminal supervisor came onboard the vessel and complained that crew members had walked on a partly open cargo hatch while a container was hanging above. The OOW said he would discuss this with the crew at the next safety meeting.

At 06.00 there was a change of watch and AB (able seaman) Smith started his 6-hour watch. Also on watch was the third officer who was the OOW with two OS (ordinary seamen) and Smith. One OS was doing the ISPS watch at the gangway while Smith and the other OS monitored the cargo operation. The OOW was in the ships office. Around 07.00 Smith informed the OOW that cargo operation had begun in hold 4. At this time there was not much happening so the OS went for breakfast. Smith said he would join him in about ten minutes but that he just wanted to examine cargo hold 5 to see that everything was OK and that there was no cargo damage.

Between each cargo hold there was a protected walkway and to access the cargo hatch cover it was necessary to climb up a short ladder from the main deck. The guardrails on either side of the walkway were fitted with safety barriers, which could be lifted to gain access.

To get a better look into the cargo hold Smith opened up the safety barriers and walked onto the cargo hatch cover, which was partially removed. When the AB was close to the edge he slipped on some ice.

About 15 minutes later when the OS had finished breakfast he meet the OOW by the gangway who asked if he had seen Smith. He replied that he had not seen Smith for about 15 minutes. Both men started to search for Smith. After ten minutes they found Smith lying at the bottom of cargo hold 5, just beneath the open hatch cover.

The OOW told the stevedores to call for an ambulance. The ports ambulance soon arrived soon at the scene and the master informed vessel traffic service. About ten minutes later the crew had assembled a team who entered the cargo hold and they found that Smith had no pulse. Smith was wearing all the required personal protective equipment. Five minutes later the ambulance paramedics entered the cargo hold. They tried to revive Smith but were unsuccessful and pronounced him dead.

There were no temporary guardrails onboard the vessels that could be fitted to hatch covers and it was impossible to secure any fall prevention harness. The vessels SMS had addressed the risks of falling into an open hold and working on deck under icy conditions, but the particular risks from walking on a partially open hatch cover had not been considered.

This Monthly Safety Scenario includes the following questions for incident investigation and further discussion on the accident

1. What were the immediate causes of this accident?

2. Is there a chain of error?

3. Is there a risk that this kind of accident could happen on our vessel?

4. How could this accident have been prevented?

5. What sections of our SMS would have been breached, if any?

6. Is our SMS sufficient to prevent this kind of accident?

7. If procedures were breached why do you think this was the case?

8. What are the procedures if someone walks on the cargo hatch covers during a cargo operation?

9. Do we have a risk assessment onboard that addresses these risks?

10. How is the risk of falling into a cargo hold addressed in our SMS and risk assessment?

11. If a hatch cover is partially removed does our risk assessment address this?

12. If not, should this be implemented and how should it be implemented?

13. Do we have guardrails that fit if a cargo hatch cover is partially open?

14. What are the procedures for walking under anything suspended in the air?

15. Do we correct an identified issue with any safety equipment or breach of safety procedures immediately?

16. What do you think is the root cause of this accident?

Source: The Swedish P&I Club / Monthly Safety Scenario