RMI issued an investigation report on a crew fatality, after fall from height, onboard the product tanker PORT STANLEY, while at Guangzhou Wenchong Shipyard, China, in May 2019. The investigation highlighted an ineffective safety culture onboard, while the ship was in the shipyard.
The incident
On 21 May 2019, the RMI-registered product tanker PORT STANLEY was at the Guangzhou Wenchong Shipyard at Guangzhou, China, undergoing repairs.
During the afternoon, the Able Seafarer Deck (ASD) 1 fell shortly after he entered the No. 2 starboard cargo oil tank (COT) to conduct an inspection. He was found on the tank top lying on his back, unconscious, breathing, and bleeding from his mouth and the back of his head.
The ASD1 did not respond to first aid provided by the ship’s crewmembers. He was evacuated from the tank and taken ashore for medical treatment.
The Death Certificate reported that the ASD1 died due to serious brain and skull injuries.
Probable causes
-Causal factors that may have contributed to this very serious marine casualty include:
- the access ladder for the No. 2 S COT was obstructed by the ventilation duct and electrical cable that passed through the tank dome next to the vertical ladder and across the first platform;
- ineffective supervision and oversight by the Fleet Superintendent who was responsible for implementing the Company’s drydocking procedures;
- ineffective supervision and implementation by the Master and Chief Officer (C/O) of the safe work practices onboard the ship;
- ineffective onboard hazards identification and communication;
- the apparent ineffective safety culture on board PORT STANLEY while the ship was in the shipyard in May 2019; and
- the impact that the change of lighting may have had on the ASD1’s vision as he entered the No. 2 S COT.
-Additional factors identified during the Administrator’s investigation include:
- uncertainty by the Master and C/O regarding whether the Company’s enclosed space entry procedures were applicable while PORT STANLEY was in the shipyard;
- the Pumpman entering the No. 2 S COT after an Ordinary Seafarer (OS) 1 told him not to, as permitted by the Company’s “Stop the Job” policy; and
- the Pumpman and Officer of the Watch (OOW) entering the No. 2 S COT to assist ASD1 without determining if there was an unsafe condition inside the tank or if the atmosphere was safe for entry.
Actions taken
In response to this very serious marine casualty, the company has taken the following Preventive Actions:
1.The company sent a Safety Circular with the lessons learned during its preliminary investigation that was discussed during a safety stand down on all ships in its fleet. These lessons learned included:
- the need for all job safety assessments, risk assessments, and Toolbox Talks to be conducted while a ship is in the shipyard to ensure that all potential hazards to personal safety are identified and control measures implemented;
- the need to plan all work efficiently; and
- ensuring that all work planning is documented on an ADM 37.
2. A case study based on this incident was prepared for use during crewmember seminars, Superintendent Safety Briefings, and pre-joining briefings for Masters and C/Es.
3. A drydocking safety campaign was undertaken that included:
(a) reviewing and revising the Company’s drydocking procedures. Changes were made to the Fleet Superintendent’s daily drydock report and revisions to the checklists for the initial drydocking meeting and the site safety assessment. Changes were also made to the shipyard evaluation and assessment form;
(b) requiring attendance when possible by a member of the Company’s Health, Safety, Environmental, and Quality staff or a Marine Superintendent to provide additional oversight when a ship first enters drydock and to reinforce Company expectations regarding the onboard safety culture; and
(c) developing a drydocking safety assurance eLearning course for Superintendents and seafarers.
Recommendations
1. It is recommended that the Company review and, as necessary, revise:
- its enclosed space entry procedures to clearly establish whether they are applicable while a ship is in the shipyard;
- its Enclosed Space Entry Permit and risk assessment to address whether the means of accessing an enclosed space is free of obstructions;
- its enclosed space rescue training considering the lessons learned from this incident;
- its “Stop the Job” policy considering the lessons learned from this incident; and
- its procedures for monitoring and assessing the performance of Fleet Superintendents and ships’ senior officers with respect to their compliance with the Company’s safe work procedures.
2. It is recommended that the Company carryout an awareness campaign directed toward shore staff and ships’ crewmembers addressing the importance of conducting thorough risk assessments to ensure ship operations and daily tasks are conducted safely. It is recommended that consideration also be given to conducting periodic refresher training for shore staff and all officers working on ships in the company’s fleet to reinforce company expectations for conducting risk assessments.
3. It is recommended that the company review and, if deemed necessary, revise how shore staff and ships’ senior officers communicate the company’s commitment to safety with ships’ crewmembers, to enhance safety culture onboard ships in its fleet. It is also suggested that periodic refresher training addressing safety communications be held for shore staff and senior officers.
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