The Government of Luxembourg’s Administration of Technical Investigations (AET) issued an investigation report on the fatal occupational accident onboard the chemical oil tanker Nabucco on 26 June 2017. The Chief Officer was working alone on the platform of the accommodation ladder, when he fell from the accommodation ladder platform between the vessel and the quay into the water.
The incident
On 26 June 2017, at 19:20, the Nabucco was all fastened and berthed port side alongside Associated British Ports (ABP) Terminal number 1 jetty in Saltend, Hull, UK. Two means of access were established. One gangway was installed to enable access in low water situation and the port side accommodation ladder was established for high water situations.
At around 22:50 the means of access were required to be changed as the tide was on the ebb and the accommodation ladder needed to be stowed away. The gangway was prepared for accessing the vessel.
The Chief Officer was working alone on the platform of the accommodation ladder and at 23:03 he fell from the accommodation ladder platform between the vessel and the quay into the water. Despite intense search actions, the body of the Chief Officer was only discovered on 5 July 2017 some 30 km downstream.
Conclusions
- The vessel was running late on schedule because:
-The loading had to be performed with the ship’s cranes instead of the cranes on the jetty that were inoperative;
-The ship’s gangway had to be moved by crane from the aft of the manifold to the forward end of the main deck to be installed, as jetty number 1 was partially blocked by ongoing works.
-The accommodation ladder had to be rigged from the aft end of the main deck as the gangway was deemed too steep for safe access to the ship during high-water.
- Due to the ebb tide, the C/O took the decision to stow the accommodation ladder himself, which was not a regular task for him on board the vessel, and to perform the task alone. This was not in accordance with the existing procedure, which required a second person supervising the operation.
- The C/O was not wearing a lifejacket and a safety harness while performing the task of stowing the accommodation ladder. This was not in accordance with the existing procedure.
- While removing the stanchions, the C/O fell from the upper platform into the water. He sustained a head injury and likely died from drowning.
- Tiredness of the C/O, combined with an increased workload and stress level due to time constraints may have played a contributing role in the accident.
- Tests performed after the accident found that the accommodation ladder worked as per design.
- Safety procedures defined in the operator’s SMS were not adhered to by the crew at different levels of responsibility, impeding the safety on board the Nabucco and weakening the safety culture.
Recommendations
AET recommends that the vessel operator evaluates its current level of SMS implementation together with all involved parties and, in respect of the results of the evaluation, takes corrective actions, where deemed necessary, to improve both the effectiveness of its SMS system and the level of safety culture onboard its vessels.
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