The Norwegian Safety Investigation Authority (NSIA) published its report on the very serious accident regarding a fall overboard from the cargo ship Titran, that took place east of Stigen in Lurøy municipality, on 6 March 2022.
The incident
On Thursday 4 March, the cargo carrier ‘MV Titran’ left the port of Florø, setting course for Halsa in Meløy municipality to unload fishmeal at one of Ewos’s factories. On Sunday 6 March, as the vessel started nearing Halsa, the deck crew started routine preparations for unloading cargo on arrival. The vessel was passing through inshore waters, and the wind and wave conditions were calm.
At 10:43, three members of the deck crew went to the port side together to commence the work.
At approximately 10:57, one of the able seamen moved along the passageway on the starboard side of the main deck to start loosening cleats. The cleats holding the aft hatches had already been loosened earlier that morning, on both the starboard and port side. Around the same time, another able seaman and the deck cadet (hereafter referred to as the cadet) started loosening the sea fastening for the excavator.
The cadet loosened the port strap which was attached to the excavator bucket and placed it on the hatch deck. He then moved towards the port side, intending to climb down to deck level by cargo hatch 8. A CCTV2 recording from the ship shows that the cadet first climbed down onto the rail track, placing his right arm on the hatch deck for support. He then brought his left foot down, closer to the railings, but his foot slipped and he fell across the railings and overboard at approximately 11:00. None of the crew witnessed the fall. One of the able seamen was behind the excavator, and the other was on the starboard side of the main deck loosening cleats by hatch 4.
About 30 seconds after the cadet fell overboard, the able seaman who was behind the excavator came out onto the hatch deck, but he did not immediately notice that the cadet was missing. Approximately one minute after the fall, the able seamen who had been opening cleats on the starboard side crossed the hatch deck in the direction of hatch 8. The two of them continued the work of unfastening the remaining sea fastening around the excavator and bucket. At approximately 11:05, the excavator was started to help loosen its sea fastening, before the bucket was lowered to the hatch deck again at 11:10. At that time, one of the able seamen had started to loosen the wedges on top of the hatch deck.
At 11:12, the able seaman who had been operating the excavator walked around the hatch deck where the cadet had been working. He then approached the other able seaman, who was working a little further forward on deck, and asked him if he had seen the cadet, which he had not. The able seaman climbed down onto the main deck by hatch 6, in the same way as the cadet, and proceeded aft to check whether the cadet might have gone inside. The able seaman became concerned as it was unusual to leave the deck with a job half done without letting anybody know. The able seaman checked in several places in the ship and asked several of the crew, but nobody had seen the cadet.
He then reported to the captain that they could not find the cadet. Some of the crew were instructed to watch the water, while others continued to search on board the vessel.
At 11:22, the captain made a sharp turn to port, turning the vessel 180 degrees; see Figure 6. The captain then ordered the chief mate and deck officer to ready the MOB boat, so that it could be lowered quickly should the need arise.
According to the deck log, the captain notified the Norwegian Coastal Radio North (KRN) of a man overboard accident at 11:30. The radio station then transmitted a ‘mayday relay’.
Analysis
#1 Traffic on the hatch deck
The shipping company had not identified the risk of falling overboard from the hatch deck in connection with readying hatches. The shipping company and the crew considered such preparations a routine operation, and it was not defined as a high-risk operation. The shipping company’s safety management system therefore did not describe how traffic on the hatch deck was to take place, nor were specific safety measures defined. It was nonetheless known on board that the crew were meant to use dedicated ladders located at the front and aft of the hatch deck to move between the hatch deck and the main deck.
#2 Emergency report
The shipping company had introduced MOB procedures that included a scenario in which the time of the fall is unknown. Among other things, it highlighted the importance of searching for the missing person in the right area, as time is an essential factor for survivability in cold water. The procedure did not specify how the crew was supposed to pinpoint the exact time of the fall. It has subsequently emerged that CCTV was an important aid in determining the time at which the missing person fell overboard. CCTV should not be introduced as a safety measure to replace other measures, but may be used in an emergency situation to gain a better understanding of and more accurate information about the situation.
#3 The vessel’s design
The NSIA considers that the way the deck was designed, with a short distance from the outer edge of the cargo hatches to the railings at a considerably lower level was inexpedient in relation to the work to be performed and that it entailed a risk of falling overboard.
Furthermore, the investigation has shown that the crew’s use of this ’shortcut’ was a well-known practice. The NSIA considers it unfortunate that the design enables crew to move up and down on the hatches using the track and railings.
Probable cause
The incident happened as the deck crew were loosening cleats and other sea fastening to prepare the vessel for unloading in the next port. The cadet, who had loosened the excavator’ sea fastening, was moving down to the main deck via the rail track and railings when he lost his footing on the railings and fell overboard.
The crew and shipping company both considered readying the vessel for unloading a routine operation that did not require a risk assessment. Risk reduction measures had therefore not been considered or identified for this type of operation. No special safety measures had been introduced to prevent crew members falling overboard from the hatch deck, nor had sufficient measures been taken to reduce the consequences of falling overboard.
The risk associated with routine tasks becomes normalised in the individual over time, resulting in the risk gradually being ignored or not perceived. Shipping companies and other stakeholders must therefore consider the need for risk assessments and safe job analyses in all areas of operation that may entail risk, including those defined as routine operations.
What is more, the investigation found that:
- The shipping company had not identified the risk of falling overboard from the hatch deck in connection with readying hatches. The shipping company’s safety management system therefore did not describe how traffic on the hatch deck was to take place, nor were specific safety measures defined.
- The crew did not witness the missing person fall overboard. This made it difficulty for the crew to pinpoint the exact time when the incident occurred.
- The initial search area was set too far north before they received new information about the time and MOB position from the shipping company based on the CCTV footage. The NSIA believes it is essential for the crew of a vessel to clearly communicate any uncertainty about when a person fell overboard to the rescue services, so that the search area can be defined accordingly.
- There were no physical safety barriers against falling overboard from the hatch deck, only the railings on the main deck. The NSIA considers that the way the deck was designed, with a short distance from the outer edge of the hatch deck to the railings at a considerably lower level, was inexpedient in relation to the work to be performed and that it entailed a risk of falling overboard.
- If railings or other physical barriers along the hatch coamings are not operationally feasible, there will always be a risk associated with moving on the hatch deck. It will therefore not be possible to eliminate the risk involved in working on the hatch deck by means of operational measures only.
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