On January 6 2019, while the container vessel Harrier was moored at the Nabeta wharf with the master and the 17 crewmembers, seven stevedores were loading containers to the vessel.

The stevedore and a GC operator were conducting cargo handling operations, loading containers.

During the operation, a stevedore, serving as an assistant wireless signal person and communicating the conditions of unloading and loading containers by radio apparatus, was hoisting the spreader with a hoisting speed of 3 notch by the GC in the situation where the spreader twist locks had not been released from the upper 4 corner metal shoes’ parts of the Container.

The stevedore realized that there was something wrong with the hoisting of the Container and stopped hoisting the Container immediately.

Then, the container was pulled from the mid locks and was lifted up, then was swung to aft side by the impact of being pulled and lifted by the GC and bumped to the aft side container, which had already been loaded and was damaged. By the repercussion of the bumping, the Container was swung to the fore side and bumped into the fore side container (C No. 07), which had also already been loaded.

This resulted to the stevedore being stuck between the container and the loaded container, and was then found dead from the other stevedores.

After the incident, the Japan Transport Safety Board issued an investigation.

  • Probable Causes
  1. Stevedore A was caught between the Container and the fore side container,which had already been loaded, because the Container swung due to the impact of being pulled suddenly from the mid locks which secured the Container on board.
  2. The GC operator A received the information by the radio and diverted his attention to the preparation for the next stage of container loading execution works when the Container had just been grounded on board, because GC operator A hoisted the spreader without noticing that the spreader was not released from the Container.
  3. Stevedore A had the role of locking the twist locks at the bottom fore side of the Container when the Container was loaded and grounded on board, because Stevedore A heard the information by the radio, then approached the Container’s fore side and was caught between the Container and the loaded container at fore side when the Container was lifted and swung to fore side.

Following the investigation, the Board resulted to the Safety Actions below:

#1 Review of the contact process from GC operator to Stevedore on board when GC loads containers;

#2 An introduction of temporary stop procedure of spreader after the GC releases the spreader from the container and hoists the container from a vessel.

#3 Reeducation of the GC operator to ensure the release operation of spreader twist locks from the container and the radio communication regarding unlocked spreader twist locks with checking the indication lamps in front of the operation sheet or on top of the spreader.

#4 Stevedore companies should take temporary halt procedure of hoisting spreaders after the GC releases it from container on board using hoisting speed at 1 notch, as well as when the GC is loading or grounding container.

#5 Stevedores should observe the ‘Notice of loading container on board’ of the Manual, keep themselves at safe position when the container is grounded on board, and then begin to approach the container only after visually confirming the release of the spreader from container.

#6 Better communication between stevedores and GC operators.

#7 The indication lamps of the GC spreader are positioned where they can be easily seen from GC operation sheet.


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