The Irish Marine Casualty Investigation Board (MCIB) published its report on the merchant vessel “Arklow Clan”, on which, whilst lowering the handrails, the Second Officer lost his footing, falling around 3.6 metres from the walkway to the quay below. As a result of the impact the Second Officer sustained serious injuries to both his legs, necessitating an extensive period of hospitalisation, multiple surgeries, and rehabilitation.
The incident
The vessel departed in a ballast condition from the port of Immingham, Lincolnshire, UK on 10 August 2021. The Pilot boarded at 10.15 hrs, before disembarking at 12.40 hrs. The vessel then proceeded on passage north towards Aberdeen, Scotland.
On departing Immingham the Second Officer reported to the Bridge at 12.00 hrs, for the 12.00 hrs to 16.00 hrs watch. He felt well rested after having a full night’s sleep the night before whilst the vessel was moored alongside in port; a total of 18 hours rest in 24 hours. During the short voyage to Aberdeen the weather was favourable, with variable winds of a maximum of Beaufort Force three, good visibility and slight seas. The benign weather conditions and sea passage allowed the Second Officer two further periods of uninterrupted rest; eight hours after completing his afternoon watch on 10 August 2021 and then a further eight hours rest after finishing his night watch which lasted from 00.00 hrs to 04.00 hrs on 11 August 2021.
The vessel passed the Aberdeen Fairway Buoy at 09.30 hrs and anchored at 09.45 hrs awaiting the boarding of a pilot. The Second Officer reported for duty on the bridge again at 12.00 hrs and for the duration of his watch the vessel lay at anchor. The crew commenced heaving anchor at 16.20 hrs and by 16.50 hrs the Pilot was onboard.
“Arklow Clan” proceeded into the port and the Albert Basin which lies at the southern section of the Inner Harbour. After completing a starboard swing the vessel manoeuvred portside alongside Pacific Wharf. The handrails were in the upright position throughout the approach. High-definition closed circuit TV (CCTV) footage evidenced weather conditions consisting of drizzle, a south westerly breeze (blowing the vessel on to the dock), calm seas, cloudy overcast skies and good visibility in daylight conditions. Four large offshore vessels moored on the opposite side of Albert Basin to “Arklow Clan” provided a degree of lee from the wind. At the time of the incident no other vessels were manoeuvring in the Basin and the vessel lay steadily alongside the dock.
The Second Officer was responsible for aft mooring operations, and he was assisted by an AB. The vessel was moored with two headlines, two stern lines and two springs, and it was all fast, port side to, by approximately 17.40 hrs. The vessel was scheduled to commence loading a cargo of scrap metal in bulk the following morning on 12 August 2021; no cargo operations were planned overnight.
The vessel is equipped with four full body harnesses to provide fall protection when working at height (aloft). The vessel’s Safety Management System (SMS) contained Company Standing Orders (SO) detailing standard operating procedures. Working at height was covered in section 2.27 of SO – Part 2 – General:
A safety harness, safety line and where appropriate a fall arrestor, must be used at all times by any person working aloft or working over side. No person shall work over side when the vessel is underway. The use of safety gear should only be used for its intended purposes
The SMS did not state the requirement for a risk assessment and permit to work to be completed prior to crew commencing lowering the handrails. The general practice onboard “Arklow Clan” was that crew did not don safety harnesses prior to lowering the handrails and on this occasion no harnesses, risk assessment or permit to work were in use. No toolbox talk was carried out prior to starting the lowering operation.
Almost immediately after completing mooring operations, starting at approximately 17.40 hrs working from aft and moving forward on the port side of the vessel, the Second Officer and AB 1 commenced removing the five nuts and bolts for each handrail section, each working on alternate bolts. AB 2 followed behind lowering the handrails with a rope. The witness accounts differ as to the exact sequence of events which followed. At around 17.49 hrs the Second Officer recalled standing up from the crouched position and losing his footing, in a bid to steady himself he grabbed the nearest handrail, but as the nuts and bolts had been removed the handrail gave way, causing him to fall overboard. AB 1 and AB 2 recalled observing the Second Officer leaning against a loosened handrail, before losing his balance and falling overboard.
The net result was the same, at 17.49 hrs the Second Officer found himself falling towards the tarmacked quay below, a height of approximately 3.6 m. In a spilt second, he made the decision to rotate his torso and take the impact with his legs extended.
Analysis
#1 Code of Practice and Relevant Legislation
Health and safety onboard Irish Registered vessels is highly regulated through legislation and guidance, including the provisions for safely working at height under the 2006 Regulations and Chapter 17 COSWP. Full body harnesses and lanyards were provided onboard “Arklow Clan”, but the systems in place to ensure their correct usage were inadequate. The absence of an appropriate risk assessment, permit to work for the operation or “toolbox talk” (crew safety briefing) was the main contributory factor to the incident. If these three control measures were in operation as required under the 2006 Regulations, then in all likelihood the crew would have recognised the potential dangers of the operation and would have donned the harnesses prior to lowering the handrails.
During Arklow Shipping’s own investigation it was identified that 16 Arklow Shipping vessels were not fitted with a safety wire on the walkways. These deficiencies have been rectified, but nevertheless, it is surprising that the risks associated with fitting lowerable handrails were not adequately identified during any Port State, Flag State or Classification Society Inspection on the 16 vessels in the Arklow fleet. Provision of a safety wire is a logical control measure and its absence appears to have been overlooked across the fleet during numerous surveys.
#2 Culture and Compliancy
Onboard “Arklow Clan” it was common practice not to wear harnesses when dropping the railings. This culture and compliancy does not appear to be limited to the vessel, as an incident regarding lowered walkway handrails also occurred onboard “Arklow Vanguard”.
The lack of safety wires onboard 16 other vessels in the Arklow fleet is persuasive evidence that the risks associated with handrail lowering operation were not appreciated by the crews or the vessel operator. In other words, the lack of a wire was not reported or deemed to constitute a hazard. A culture had developed that harnesses were not required for the handrail lowering/raising operation. The lack of reported incidents associated with the operation may have created a degree of complacency amongst crews as to the dangers associated with the operation.
Procedures for lowering the handrails continue to be included in Arklow fleet training, with Fleet Training Officers and Superintendents confirming procedures are being followed during ship visits. Examples of permits to work, “toolbox talks” and risk assessments covering the handrail operation were provided during the investigation, indicating a cultural change led by Arklow Shipping’s senior management.
Probable cause
The root cause of the incident was a failure to follow safe systems of work applicable for working at height including adequate risk assessment, completion of a permit to work and “toolbox talks”. These deficiencies were quickly identified post incident by Arklow Shipping and rectified.
Full body harnesses were available onboard the vessel and had they been correctly used the incident would have been avoided
MCIB stated.
In addition, the Second Officer was not suffering from excessive fatigue, but fatigue associated with working at night and keeping the 12 to four watch may have caused him to momentarily lose concentration.
Recommendations
The Minister for Transport should issue a Marine Notice to remind all crews and vessel operators of the potential dangers of working at height and their obligations to follow existing legislation and guidance in order to reduce any risks.
This includes ensuring the task is risk assessed, subject to a permit to work, that crew are provided with a “toolbox talk” prior to commencing the task and the appropriate PPE is available.
Crew must be provided with training in the correct use of PPE and the PPE must be subject to regular inspections and recorded in a planned maintenance system, as per International Safety Management (ISM) Code (applicable to passenger ships and cargo vessels over 500 Gross Tonnes).
explore more at mcib’s accident report
