Transport Malta’s Marine Safety Investigation Unit has issued an investigation report into a fatality of a crew member on deck while rigging a portable cargo hold light at Iskenderun, Türkiye, on 08 September 2023.
The incident
On 08 September 2023, Drawsko was loading a cargo of grain, at the port of Iskenderun, Türkiye. During that night, the duty ordinary seafarer was tasked with rigging up portable lights in cargo hold no. 1. Several minutes later, however, the duty officer found the ordinary seafarer lying unconscious on deck, clutching a portable light.
Attempts to revive the ordinary seafarer, by the crew members as well as paramedics, were unsuccessful. The autopsy result revealed that the ordinary seafarer had died of cardiac arrest due to electrocution. The safety investigation determined that the portable light’s power plug had been incorrectly wired, resulting in the electrocution of the ordinary seafarer when he picked up the metal frame of the portable light. The MSIU has issued three recommendations to the
Company, designed to enhance safety when handling portable lights.
ANALYSIS
Aim
The purpose of a marine safety investigation is to determine the circumstances and safety factors of the accident as a basis for making recommendations, and to prevent further marine casualties or incidents from occurring in the future.
Cause of the accident
The MSIU was informed that there were no witnesses to the accident and therefore, the safety investigation relied on the crew members’ recollection of events, and the findings of the Turkish authorities’ forensic examination of the portable light. Since there were a number of possibilities as to why the accident may have occurred, the safety investigation analysed various possibilities, including whether the OS’ medical episode, on the previous day, had contributed to his demise. However, the medical log entries indicated that on the three occasions when his blood pressure was checked, the readings were normal. The second officer, who was designated as the vessel’s medical officer, had determined that the OS was not feeling well because of dehydration, given that the ambient
temperature was approximately 32 °C. Moreover, the second officer stated that at 0800 on 08 September, the OS had advised him that he was feeling better. Therefore, this hypothesis was not considered any further.
The third officer found the OS lying with the portable light clutched by both hands. Although he found the light unlit, he was unable to recollect whether the switch was on or off when he disconnected the plug. Since the portable light was incorrectly wired, when plugged in and switched on, it would not have worked. However, due to electrical leakage, if the unit’s metallic sections were touched by any person, it would have exposed them to electrocution.
Therefore, the following scenarios were considered:
- the OS had positioned the portable light on the cargo hatch coaming and then gone to insert the plug in the socket and switched it on. When he went back to check if the light was lit, he found it off, picked it up to examine it, and was electrocuted;
- he had first inserted the plug in the socket, switched it on and was electrocuted when he picked the portable light to place it on the hatch coaming.
However, if this was the case, he should have been found near cargo hold no. 2 instead of cargo hold no. 1; - he placed the portable light on the nearby cargo hold access hatch and then went to insert the plug in the socket and switched it on. When he came back to check if the light was on, he found it off, so he picked up the light and was electrocuted. However, if this was the case, he should have been found near the cargo hold access hatch; or
- he placed the light on the deck near the hatch coaming and then proceeded to insert the plug in the socket and switch it on. He then came back to position the light on the hatch coaming, found that it was off, and was electrocuted when he picked it up to examine it.
CONCLUSIONS
- The safety investigation concluded that the ordinary seaman died from cardiac and respiratory arrest due to electrocution when he picked up the
portable light. - The portable light’s plug was incorrectly wired; the live wire was connected to its earth terminal.
- The colours of the wires in the portable light’s cabling are considered to have likely contributed to the light being incorrectly wired.
- The portable lights were not part of a robust planned maintenance system where they would have been regularly checked.
Actions taken
During the safety investigation, the Company has taken the following actions:
- All portable floodlights have been removed from service and checked by the ship’s electrician. Floodlights with no issues have been returned for
service; - Training on commitment to safety, work planning, risk assessment and scope of duties has been offered on board;
- The operation and conditions of the cable and casing, insulation and earthing have been incorporated in the planned maintenance system on all
vessels within the fleet; - All Company vessels have been directed to check the condition of all the portable floodlights’ condition and tightness of the cable connections.
Vessels were also instructed to withdraw from service any floodlights which were not satisfactory and to discuss the outcome at the first safety
meeting on board; - An electrical installation inspection was carried out by the ETO (no malfunction detected);
- The Company’s SMS manuals have been updated to include the maintenance of the portable floodlights;
- A Company Safety Flash has been prepared and distributed among the Company’s fleet.
RECOMMENDATIONS
Polska Żegluga Morska P.P., (Polish Steamship Company) is recommended to:
13/2024_R1 – circulate the findings of this safety investigation to its managed and owned fleet.
13/2024_R2 – investigate the possibility of fitting RCD to vulnerable switch boards.
13/2024_R3 – consider the use of low voltage portable lights.
