Lessons learned: Steel plates should not be stowed in a vertically

What happened?

Several steel plates measuring approximately 300cm x 130cm x 1cm and a total mass of approx.1800 kg were stowed in a vertical position in a corner of a steering gear room of a ship. The plates were used as material blanks for the on-board production of spare parts. To prevent the plates from tipping over, the stock of plates leaning against a railing was fixed in place with a steel cross strut mounted horizontally at waist height. The two ends of the cross brace, which served as an anti-tip device, were each pushed onto a threaded rod welded to the railing and locked in place with a nut. Opposite the stack of plates was a wall shelf at a distance of approx. one meter.

On the day of the accident, one plate was to be removed from the plate supply for a repair assignment. In order to handle the heavy plates, several crewmembers were required. As these crewmembers still had work to do on deck, only one crewmember initially went into the steering gear room and made preparations for the upcoming work assignment. In this context, he already disassembled the anti-tip device. As a result, the plate stack lost its “stability” and felt against the wall shelf. The crew member standing between the stack of plates and the wall shelf was caught by the stack of plates and pressed against the wall shelf at abdominal level. The accident victim suffered fatal injuries.

Why did it happen?

• The stowage of the steel plates in an upright position entailed the latent risk of a single plate or the stack tippiing over as soon as the anti-tipping device was removed.
• The design of the storage area and the anti-tip device were not intended to allow a single plate to be safely removed from the stock. Removing the anti-tip device inevitably not only enabled access to one plate at a time (with the dangers that this alone entails), but also made the entire stack of plates unsecured.
• The cramped condition of the stowage area in the corner of the steering gear room, did not allow the accident victim to escape the tipping plate stack.
• The accident victim was apparently unaware of the dangers he was creating by removing the anti-tipper.
• There was not specific risk assessment in place for the handling of steel plates. The activities in question, their technical and organizational framework conditions and the accident prevention measures to be derived from them were not covered by the Ship Safety Manual.
• The accident victim carried out the tasks – in an remote area of the ship – without the presence of second person (work allone). There was no continuous or at least sufficient closely meshed supervision or monitoring of his task.
• Despite working alone, the accident victim was not equipped with a UHF radio. It was therefore not possible to call for help by radio or to use such a connection so that the supervisor could maintain contact with the colleague working alone at regular intervals.
• The remote accident site was not equipped with camera surveillance (CCTV). There was therefore no (at least theoretical) possibility of taking note of the accident from the engine control room, for example.inj
• There are no classification society regulations governing the stowage and securing of steel plates carried on board seagoing vessels as spare part blanks.
• The way in which steel plates are stowed and secured is not an aspect to which particular attention is paid during port state controls.

Lessons learned

• Steel plates carried on board for repair purposes should, if possible, not be stowed in a vertical position. If this is unavoidable, racking systems should be used that allow the safe removal of individual plates from the stowage.
• When selecting the storage area, care must be taken to ensure that it must be possible to use lifting gear and other technical equipment for the safe handling and transportation of the steel plates, both there and in the area of the access route.
• The handling of steel plates by crewmembers is an extremely dangerous field of activity both in port and at sea. It must therefore be the subject of a careful risk assessment. The relevant results of this assessment and the measures required to prevent accidents and minimize risks must be described in detail in the ship safety manual and implemented in everyday life on board. Particular focus must be placed on the topics of “technical and spatial requirements”, “instructions”, “responsibilities”, “required personnel” and “monitoring”.
• When working alone, crewmembers should be equipped with UHF-radios.
• Remote areas on ships, where lone work regularly takes place, should be equipped with camera surveillance (CCTV).
• Since accidents involving steel plates carried on board for repair purposes repeatedly lead to tragic accidents, the technical aspects of storing and securing such plates should be made the subject of classification society regulations.
• Port state controls should (randomly) examine whether the specific way in which steel plates are stored and secured is actually suitable for safe handling of these plates by the crew in technical and work organization terms.

Who may benefit?

Shipping companies (in particular: ISM officers, technical ship management), ship’s commands, ship crews, classification societies, shipyards, port state control authorities