Transport Malta investigated the fatal fall from height of a crew member in an enclosed space onboard the bulk carrier MV SEAFARER. Following the accident, the company reviewed the enclosed space access arrangements and issued a fleet safety information bulletin to all vessels highlighting the procedure and the need to provide safe means of access.
The incident
On 08 May 2020, the Maltese-registered bulk carrier Seafarer departed Istanbul, Turkey in ballast for Port Cartier, Canada.
On the morning of 12 May, the electrical technical (ETO) rating was tasked to prepare and layout a portable electric lantern at the entrance of the access trunk hatchway between cargo hold nos. 1 and 2, to the pipe tunnel. At about 0850, the ETO rating was seen on the main deck carrying portable light equipment. He was wearing PPE i.e., a safety helmet and shoes, gloves and a working overall.
About 30 minutes later, at 0920, the second engineer called the ETO rating on the portable radio. Receiving no response, the second engineer sent the oiler to look for him. The oiler was unable to find the ETO rating on deck and hence, decided to look for the oiler in the engine-room.
Returning to the engine-room, he met the master and informed him about the ETO rating. The master, who was on his way to check the progress of the pipe repairs, proceeded to the access trunk hatchway between cargo hold no. 1 and 2.
Climbing down the vertical ladder, the master observed a safety helmet, a broken portable light and one shoe on platform C. He also noticed fragments of the portable light on platform D. Further down on platform E, he saw the ETO rating, lying motionless.
The chief engineer and the repair team, who were working close-by in the pipe tunnel, were called-in by the master. No vital signs were detected.
The Company was immediately informed and following advice by Med Solutions International, the body was retrieved from the space. The seafarer was then diverted to Cagliari, Italy for forensic / clinical autopsy. The autopsy report concluded that the sustained fatal injuries were consistent with a fall from a height.
Conclusions
- The autopsy concluded that fatal injuries sustained by the ETO rating were caused by a fall from a height;
- It is likely that the ETO rating either missed a step, lost his grip or balance while climbing down the vertical ladder;
- The fixed lighting system in the pipe tunnel and access trunks was not working;
- Fatigue and alcohol/drug were excluded as a contributory factor to the fall;
- The pipe tunnel had been ventilated and measured for toxic gases and oxygen deficiency and determined safe for entry;
- The ETO rating was expected to lay out the portable light outside the access trunk hatchway and wait for the oiler.
Actions taken
Following the accident, the company conducted an internal investigation and took the following actions within its Safety Management System:
- The internal investigation report, analysis and its findings were circulated amongst the fleet vessels and brought to the attention of joining crew members;
- A Safety Information Bulletin was promulgated, stressing the importance of toolbox talks, clear specific instructions, and ensuring that they are understood by personnel before commencing any job;
- All vessels were required to conduct an additional safety meeting to discuss this accident and safety procedures for entering enclosed spaces;
- Where the requirements of tank entry permit could not be fully complied with, a risk assessment is being required to be carried out to identify additional risks involved. Moreover, before entry, the responsible officer is required to ensure that all risk mitigation measures identified in the risk assessment are implemented;
- Entry into an enclosed space alone or without proper supervision is being strictly forbidden. A two-person entry into the enclosed space is now required, with a stand-by crew member at the entrance to act in the event of an emergency. The stand-by crew member is required to be in direct contact with persons inside the enclosed space and with the navigating bridge or control room as required;
- Duty officers on the bridge and in the cargo/engine control room are to be made aware of the enclosed space entry operations. Access to rescuers and rescue equipment shall always be ensured;
- When ascending or descending ladders, the three-contact point rule (two hands and a foot or two feet and a hand on the ladder) must be applied, with the use of a safety harness and safety line, except where their use is not possible. Moreover, the area must be well illuminated and free of obstruction to prevent the risk of trips and slips.
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