New Zealand’s Transport Accident Investigation Commission (TAIC) has issued an investigation report into an incident where a crewmember was seriously injured onboard a bulk carrier on 23 June 2023.
The incident
On 5 June 2023, Poavosa Brave departed Port Pirie (Australia) on a voyage charter, bound for Tauranga with a cargo of wheat and beans. At 0618 on 14 June 2023, the vessel arrived and anchored at Tauranga roads. A pilot boarded at 0846 and at 1030 the vessel was secure alongside number 7 berth, Mount Maunganui. Over the next five days, the cargo was discharged and the voyage charter ended.
At 2100 on 19 June 2023, the vessel departed the berth and returned to Tauranga roads, where at 2233 it was brought up to anchor at number 3 anchorage. Whilst at anchor, a new voyage charter started. The crew was required to prepare the vessel for a full cargo consignment of logs. This included erecting sets of collapsible stanchions on the main deck.
At 0700 on 23 June, the bosun went to the bridge for a routine morning meeting with the master and the chief officer. The master told the bosun that the weather and sea conditions were not suitable for the crew to use the crane to pull up the collapsible stanchions, and that the job could be done after the vessel was alongside the berth. The deck crew then carried out alternative jobs, such as cleaning the crane housings and greasing the door handles.
At 1330, the bosun, three able-bodied seafarers (ABs), and one ordinary seaman (OS) went out on deck, to the starboard side of number 5 hatch, to pull up the stanchions. The bosun thought that the weather had eased and wanted to take the opportunity to train the crew. The bosun briefed the crew about how the stanchions would be pulled up. After going through the work plan step-by-step, the bosun went up to the driver’s cab to operate the crane.
At 1345, all the stanchions at the starboard side of number 5 hatch were upright and secured. At 1350, the chief officer, who had heard the crane running, came out on deck to tell the crew to stop the work. However, the stanchions were already upright and secured and the final task was to unhook the stanchion pull wire.
The bosun’s work plan was for the crew to unhook the pull wire after the crane hook was landed and stable on the deck next to number 5 hatch. However, the bosun mis-landed the hook on top of number 5 hatch. As the bosun started to reposition the hook from the hatch top to the deck, the chief officer told the crew to go up to the hatch top to unhook the pull wire. There was no communication between the chief officer and the bosun.
Shortly after 1350, as the bosun repositioned the crane hook and as the three ABs began to climb up to the hatch top, the vessel started to roll. As the vessel rolled, the suspended crane block started to swing. Two of the ABs, who were further away from the crane block, ran away from the reach of the crane block and hook. The third AB had climbed further up the hatch coaming and did not run away. The hook swung back and struck the third AB, pushing them up against the hatch coaming and hatch cover. They climbed back down the hatch coaming and sat down on the deck, injured. The other two ABs quickly moved their colleague away from the crane block.
Between 1403 and 1411, the master contacted the shipping agent and Port of Tauranga customer services to get help.
At 1412, the shipping agent phoned 111 and arranged for a rescue helicopter to deploy to the vessel. Emergency services dispatched a helicopter from Ardmore Airport within 20 minutes.
At 1510, the helicopter arrived at the vessel’s location and lowered a medic onto the deck. The medic assessed the AB’s injuries and at 1602 the injured AB was winched off the vessel and flown to Tauranga Hospital.
On 0051 on 24 June 2023, the injured AB was transferred to Auckland City Hospital for further treatment of their injuries.
On 9 August 2023, the injured AB was repatriated to the People’s Republic of China for their ongoing hospital care and recovery.
Why it happened
Under the operator’s safety management system the master and chief officer were responsible for safety assurance, including assessing risks and analysing the safety of planned work. The accident happened because the people involved didn’t know what each other were doing.
The master’s plan: At 0700, the ship’s master allocated tasks for the deck crew. The master instructed the bosun not to use the ship’s cranes, partly because weather and sea conditions were unsuitable for crane operations.
Bosun sets new plan – not communicated: By 1330 the conditions had eased and the bosun chose to start training the deck crew in using an on-board crane to hoist stanchions. The crew attended to the stanchions while the bosun drove the crane. But the bosun didn’t tell the master or the chief officer about the change of plan and didn’t seek the master’s authorisation to use the crane. The chief officer heard the crane operating, assessed the work as unsafe, and went to the deck.
Back to the Master’s plan – not communicated: seeing the crane block stationary on a hatch cover, the chief officer ordered the crew to retrieve it. But the chief officer didn’t tell the bosun. The crew obeyed the order but it was unsafe because the bosun was still working to his plan, driving the crane. The ship began to roll on a sea swell, causing the crane block and hook to swing off the hatch cover and strike the seaman.
Recommendations
In doing unauthorised work and not telling responsible officers, the bosun short-cut the abilities and authorities of the master and the chief officer to assess the safety of planned work.
Communicate the plan: The bosun should have told the chief officer and the master about the new work plan to use the crane. Those responsible officers could have prohibited the work or ensured everyone knew what they should do to stay safe.
Double-check the plan is still the plan: If the chief officer and bosun had talked about the bosun’s new plan, it’s very unlikely the chief officer would have ordered the crew into danger.
Speak up: The crew should have spoken up to alert the chief officer about the risk, but they followed orders and said nothing because the chief officer outranked the bosun
Lessons learned
- Safety depends on following lines of authority. It’s great to have a safety system that includes risk assessment and job safety analysis, but for that to work, responsible decision-makers need to be aware of all relevant information.
- If you’re making a call to step in and stop something because you see it as unsafe, take a moment.
- Determine how to step in safely; don’t introduce new hazards.
