The Hong Kong Marine Department provides lessons learned from an incident where the chief engineer and crew members attempted to replace hydraulic oil on a ship in the Inland Sea of Japan, leading to a fatal fall.
The incident
When the ship was sailing in the Inland Sea of Japan, the chief engineer of the ship led eight crew members, including the C/C, to replace the hydraulic oil of the shipboard windlass. In order to facilitate the transfer of oil drums into the windlass hydraulic pump room, the bolted hatch had to be opened. The hatch was fitted on the forward transverse bulkhead between the hold and the pump room.
While attempting to pry the cover of the hatch with a steel bar, the C/C lost his balance and accidentally fell into the adjacent opening from the forward starboard platform and plunged to the bottom of the hold. The accident inflicted a serious head injury on the C/C, causing heavy bleeding and rendering him unconscious. The C/C was subsequently airlifted by a rescue helicopter and transferred to a shore hospital for medical treatment. Unfortunately, the C/C was declared dead upon arrival at the hospital.
The investigation identified that the contributory factors leading to the incident were that the senior management team (SMT) of the ship did not adhere to the job assignment requirements outlined in the shipboard safety management system (SMS), and the SMT failed to follow the requirements stipulated in the “Code of Safe Working Practices for Merchant Seafarers” (the Code) when assigning the oil replacement work to the C/C, which included opening the bolted hatch. The SMT did not adhere to the procedures for working aloft under the shipboard SMS; the C/C and his team members were not aware of the risk of falling into the hold when working on the forward starboard platform in the hold without wearing proper personal protective equipment (PPE); and the risk assessment for the oil replacement work and the safety training on board for ship crew were ineffective.
Lessons learned
In order to avoid the recurrence of similar accidents in the future, ship management companies, all masters, officers, and crew members should note the following items:
- strictly follow the requirements of the shipboard SMS and the Code when assigning new tasks to ship crew, particularly those requirements related to the safety of working aloft;
- strictly follow the shipboard SMS procedures for working aloft to ensure safety, including proper use of PPE, rigging of safety nets, issuance of permit-to-work, and effective risk assessments; and
- ensure effective shipboard training to enhance ship crew’s safety awareness of the risks of working aloft and necessary preventive measures for personal safety.
