Transport Malta MSIU issued an investigation report on a serious injury to a crew member onboard the tugboat Spinola while replacing a rescue boat cover at Timber Wharf, in April 2020. The investigation highlighted that a risk assessment was not considered necessary for this task.
The incident
Spinola’s rescue boat cover required replacement and two crew members from tugboat Lieni were tasked with the job.
To facilitate the task, one crew member working a general-purpose hand (GPH) stepped on the unprotected outboard side of the rescue boat. At this time, he attempted to slacken the tension on the lifting slings holding the rescue boat.
As soon as he operated the yellow handle, the rescue boat swung outboard, struck the crew member, and threw him onto the wharf.
The safety investigation concluded that the crew members did not have the intention to slew the rescue boat.
Conclusions
The task assigned to the crew members was considered by the Company to be straight forward and simple. As the rescue boat’s cover was normally handled during drills and training activities, a risk assessment was not considered as necessary for this task,
…the report reads.
- The davit’s slewing mechanism was activated accidentally, causing the rescue boat to swing outboard, dragging the GPH along with it, and resulting in a fall to the wharf.
- A risk assessment was not considered necessary for this task.
- The crew members decided to lower the release hook and disengage the rescue boat because they did not notice that the cover could be undone by unzipping it;
- On two occasions, the GPH moved to the outboard side, where guard rails were not fitted.
- A safety harness had not been worn when the work shifted to the outboard side of the rescue boat.
- A safety helmet had not been worn by the GPH during this task.
- As soon as it became evident that pulling the first handle had no effect, the second available handle was pulled, resulting in an unexpected slewing movement of the rescue boat.
- The crew members were not entirely familiar with Spinola’s rescue boat davit operation.
- During training sessions and drills involving the launching of rescue boats, only the engineers actuated the davit’s controls and it was always carried out from the local control station.
- The ball valve (15) in the slewing system was always kept open to facilitate readiness of the rescue boat. This meant that ball valve (15) became an ineffective (functional) barrier, against an accidental slewing of the davit.
Actions taken
In order to avoid similar occurrences in the future, the Company has:
- carried out an exercise with its employees to review their knowledge and address any issues found with them;
- implemented a training programme/plan for both crew and shore-based personnel, to ensure that all its employees were trained accordingly;
- mapped a training gap analysis for its personnel and carried out in-house and third-party training;
- reviewed all risk assessments that were relevant to this accident;
- reviewed risk assessments of other tasks where a similar potential scenario could arise.
Recommendations
The MSIU has issued three recommendations to the Company designed to ensure familiarity with the rescue boat’s launching system and reduce the hazards while preparing the boat for launching/recovery. Specifically, the company is recommended to:
- Apply either reflective tape or black & yellow warning tape on the cover zipper.
- Fix comprehensive rescue boat launching procedures in the vicinity of the rescue boat.
- Consult with the flag State Administration and the Classification Society on the installation of a remote operating mechanism, at the rescue boat launching position, for the slewing system ball valve (15).
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