UK MAIB, in its latest Safety Digest edition, presents a case in which the ship’s side gate was opened making the turntable lowered before the gangway was in a position to be secured, causing AB to trip and fall through the turntable opening and overboard from the ship. Lessons learned highlight how important is Risk Assessment to be reviewed on a regular basis to ensure that they remain appropriate for the task being completed.
The incident:
A ship had berthed alongside and was now secure with all moorings in place. The engines were shut down, and the crew commenced deploying the gangway to provide a safe means of access to and from the ship
During this operation, an AB was using a boat hook in an attempt to guide the gangway into the correct position. The AB was stretching at the limit of his reach when the hook became detached from the gangway.
This caused the AB to lose his balance and stumble. Consequently, his left foot came into contact with the gangway turntable, causing him to trip and fall through the turntable opening and overboard from the ship. The AB was a very lucky man; he fell free from the ship, and entered the water between the ship and the quay. The estimated height of the fall was 4.5 metres. Although not wearing a Personal Buoyancy Aid, the AB was able to remain afloat and make his way to a quay wall ladder, and then to climb up to the quay. He sustained only a minor injury (a scratch to his left hand).
Although it was considered a routine task, the deployment of the gangway was a controlled operation with a documented procedure, which was subject to a risk assessment (RA) and a lifting plan. Furthermore, there was a formal requirement for the OOW to have manoverboard procedures in place. The gangway rigging procedure required three crew members, including a trained crane operator.
The manoverboard procedures required a lifebuoy and buoyant lifeline to be available at the gangway position. All of these requirements were met at the time of the incident. The gangway was lifted into position using the ship’s crane. A tag line was secured at each end of the gangway to be used to steady it until it had been slewed round and lowered into position.
At the start of the operation, it became apparent that the tag line at the far end of the gangway had become entangled and that the gangway was the wrong way round to be secured to the turntable. The AB was attempting to overcome this by use of a boathook to manoeuvre the gangway. After the incident, a CCTV recording showed that the gangway was being slewed at speed; a factor which is likely to have contributed to the incident.
There was a requirement, highlighted in the RA, for personnel to wear buoyant work vests if they were less than 1 metre from the quay edge when manoeuvring the gangway. Buoyancy aids were not considered necessary on board the ship because the ship’s side rails were deemed to be a suitable barrier to falling overboard. However, on this occasion, the ship’s side gate had already been opened and the turntable lowered before the gangway was in a position to be secured.
Lessons Learned
1. Annex 1.2 of the Code of Safe Working Practices for Merchant Seamen highlights that RAs should be reviewed on a regular basis to ensure that they remain appropriate for the task being completed. If elements of the task change (in this case opening the ship side gate and lowering the turntable) additional controls may need to be introduced, i.e. the wearing of a PBA.
2. The provision and use of a PBA for any work carried out from an overside position or in an exposed position where there isa reasonably foreseeable risk of falling or being washed overboard, is required under The Merchant Shipping and Fishing Vessels Personal Protective Equipment Regulations 1999 (Merchant Shipping Notice 1731 (M+F)).
3. For a work procedure and its associated RA to be effective, they must be understood by all participants and all steps pertaining to the task must be followed. If something is not as it should be, stop and reassess the situation.
Source: UK MAIB
