In its latest Loss Prevention guidance on gangways, the Shipowners Club describes a case of an injury to an elderly passenger disembarking from a tourist craft operating in north-eastern Australia. The Club highlighted a poor implementation of safety management system.
The incident
The craft itself was of unusual construction, being a semi-submersible vessel designed to allow passengers to view coral reefs through windows in the lower deck below water level.
The incident occurred after the vessel had returned to the dock.
The passenger and her husband had not disembarked with the main body of passengers as they had remained on board to search for a lost piece of camera equipment.
Having found the missing item, they ascended to the main deck and moved towards the gangway.
To do so they had to negotiate a change in level on the upper deck where there was a 27cm step. In doing so, the lady stumbled and fell, breaking her ankle.
Observations
The raised section of the upper deck was covered to within 6cms of the step by a black plastic mat.
The lower level and the 6cm strip along the edge of the higher level was painted with white non-skid paint.
The result was that the edge of the step was difficult to see. There were no handrails and no warning notices or other visual warnings.
Although crew members had been assigned to assist passengers at the gangway close by, none were assigned to help passengers negotiate the change of levels in this area.
Lessons learned
This accident should never have been allowed to happen. Our investigations revealed that crew members assigned to the gangway had observed passengers stumbling on the step on numerous occasions.
If the company had implemented a safety management system, the crew members would have had a means of reporting their observations and appropriate measures could have been taken to minimise the risk to passengers.
Those measures could have included painting the edge of the step in high visibility paint of contrasting colour, placing appropriate warning notices in the vicinity, fitting a handrail and stationing crew members to assist frail passengers in negotiating the change in level.
Alternatively, it might have been possible to replace the step with a ramp.
