Investigation report: Before approaching loaded container ensure release of the spreader

The Japan Transport Safety Board focuses on a fatality which took place during container loading operations at the Nabeta wharf, Yatomi city, Aichi Prefecture, where a Stevedore lost their life after he got caught between two containers, and was then pronounced dead by a doctor.

The Incident

During loading operations, everyone was at their place; Stevedore A was on board around the port side of the passage between No. 07 and No. 09 of the container location number, whereas Stevedore B (wireless signal person) was onboard around the port side of C No. 09, and GC operator A was in the operation seat of the GC.

Stevedore B informed that the container had been grounded, through radio communication and the GC operator A responded to this information, and at that moment diverted his attention to the preparations for the next stage of loading container execution works.

He began hoisting the spreader with a hosting speed of 3 notch by the GC in the situation where the spreader twist locks had not been released from the upper 4 corner metal shoes’ parts of the Container, when he realized that there was something wrong with the hoisting of the container and stopped hoisting the container immediately.

Consequently, the container was suddenly pulled from the mid locks and was lifted up, swung to the aft side and bumped to the aft side container, which had already been loaded, resulting to the container damaged recessed part. Following, by the repercussion of the bumping, the container was swung to the fore side and bumped into the fore side container, which had also already been loaded.

After the whole incident, the other stevedores found Stevedore A caught between the container and the loader container. He tried to lean to the fore side container, stood and faced the aft side, but was injured leaving the container.

The report states that

nobody saw the precise moment when the accident occurred.

Probable Causes

#1 The investigation reveals that a probable cause of this accident was that Stevedore A was caught between the Container and the fore side container which had already been loaded.

#2 Also, another probable factor was the radio communication, as the GC operator A received the information by the radio and diverted his attention to the preparation for the next stage of container loading execution works when the container had just been grounded on board because GC operator A hoisted the spreader without noticing that the spreader was not released from the container.

#3 It is somewhat likely that Stevedore A had the role of locking the twist locks at the bottom fore side of the container when the container was loaded and grounded on board, because Stevedore A heard the information by the radio, then approached the container’s fore side and was caught between the container and the loaded container at fore side when the container was lifted and swung to fore side.

Safety Actions

Following the investigation report, Japan TSB concluded to the following measures to prevent the recurrence of a similar accident. In essence:

• GC Operator: Should be re-educated to ensure that he will be able to confirm the release operation of spreader twist locks from the container and the radio communication regarding unlocked spreader twist locks with checking the indication lamps in front of the operation sheet or on top of the spreader;
• Stevedore companies: Temporarily halt procedure of hoisting spreaders after the GC releases it from container onboard using hoisting speed at 1 notch, as well as when the GC is loading or grounding container.
• Stevedores: Be in line with the “Notice of loading container on board” manual to know how to secure themselves when the container is grounded onboard and then approach the container, after visually confirming the release of the spreader from container.
• Stevedores and GC operators: Improve communication amongst themselves / Avoid unnecessary communication when there is no relevant matter of discussion concerning loading containers and emergency information while the GC is grounding a container, hoisting a container or releasing the spreader from a container on board level.

The investigation recommends that

It is desirable that the indication lamps of the GC spreader are positioned where they can be easily seen from GC operation sheet. Rotary lamp light, etc. should be installed as well.

To learn more on the investigation report, click herebelow

See also:

1. UK MAIB Investigation report: Accessing a tug via the oil stage fenders can lead to fatal incident
2. Miss Roslyn Investigation report: Ineffective hull inspection and maintenance leads to capsizing