Transport Malta has published an investigation report to share lessons learned from a fatality onboard the motor tanker Amur Star in 2023. The incident occurred due to the tipping of loose steel plates onto a crew member. The report aims to address the safe stowage of heavy steel plates and raise awareness of this particular hazard.
On 21 November 2023, while the motor tanker Amur Star was en route to Immingham, United Kingdom, the electrician found the second engineer unconscious, trapped by steel plates in the steering gear compartment. The stack of heavy steel plates, stored vertically and free from its lashings, tipped over on him, possibly due to the natural movement of the vessel in a seaway. The safety investigation concluded that the second engineer was alone in the steering gear compartment.
Course of events
Amur Star was due to complete discharging its cargo of gasoline at Bremen, Germany, around midnight on 20 November 2023. In anticipation of its departure soon afterward, the chief engineer advised the second engineer that, along with the third engineer and oiler, he would man the engine control room (ECR) during the estimated six-hour outbound pilotage. The second engineer was to attend the engine-room at the usual time in the morning and continue with the normal sea routine of manning the engine-room during the day, along with the electrician.
There were no planned maintenance jobs discussed, apart from the second engineer assisting the chief officer during the cargo tanks cleaning, if required. Discharging was completed at 2154, and the vessel departed its berth in ballast and under pilotage at 2354, bound for Immingham, UK. The pilot disembarked at 0630 on 21 November, and by 0642, the vessel was fully away on sea passage. Shortly afterward, the master handed the navigation watch to the officer of the watch (OOW), so he could prepare the departure reports and transmit the cargo documents. At about 0800, seeing that all was well on the bridge, the master went to his cabin to rest.
In the meantime, soon after full away, the chief engineer released the third engineer and the oiler to rest. He also prepared the auxiliary engines and inert gas (IG) system for cargo tank washing. Cargo tank cleaning commenced at about 0730 by the bosun, an AB, and a cadet, with the chief officer remaining in the cargo control room (CCR). By about 0810, satisfied that all was well with the cargo tank cleaning process and the IG system, the chief engineer went into the engine-room, where he met the second engineer and the electrician in the workshop. From the entrance, he told the second engineer that he was going to his cabin to rest. He asked the second engineer to continue assisting the chief officer during the cargo tank cleaning.
The electrician continued to assist the second engineer to cut the top of a 200-litre oil drum and drain the residual oil into a bucket upon completion. At about 0830, the second engineer and the electrician went to the galley to discuss the outstanding work on the dishwasher. After about 10 minutes, the second engineer left the galley to return to the engine-room. Around the same time, the cargo tank cleaning was completed, and the deck crew members started to strip the cargo tanks.
At about 0930, the electrician completed his work in the galley and returned to the ECR to put his tools away and record the work carried out. On his way, he met the chief officer, who asked him about the second engineer’s whereabouts, as she was unable to find him. The electrician replied that he was not aware of where he was. After recording his work, the electrician looked around in the engine-room for the second engineer but could not find him.
He kept looking for him, proceeding to the steering gear compartment. There, he found the second engineer unconscious and trapped between the spare parts shelving and several steel plates that appeared to have tilted on him. He immediately went to the ECR, called the bridge for assistance, and then went to the CCR to inform the chief officer of the matter. The time noted was about 0935.
The third officer on watch immediately informed the crew members working on deck, the master, and the chief engineer. The chief officer and one AB, together with the electrician, arrived first on scene and attempted to lift the plates off the second engineer but could not do so because of the heavy weight.
The bosun and one of the cadets were the next crew members to arrive on site and immediately assisted their colleagues to lift the plates, one by one. Before the last plate was removed, the AB slid next to the second engineer and supported him so that he would not fall while the last plate was being removed. The time was about 0942. The second engineer remained unresponsive, and after the last plate had been removed, the AB laid the second engineer on the deck and, along with the chief officer, started to administer cardiopulmonary resuscitation (CPR).
The master and the chief engineer arrived on scene within a few minutes, and after assessing the situation, the master went to the bridge to seek medical advice. He also instructed the second officer to take the oxygen cylinder to assist. The chief engineer remained on site and assisted with the first aid.
The master arrived on the bridge at 0950 and called the Designated Person Ashore (DPA) to inform the company of the emergency. At about 0955, the master contacted German Bight VTS, reporting the medical emergency and requesting permission to turn back. At about 1003, VTS advised the vessel to steer a course of 140° towards River Weser. The master then contacted Telemedical Maritime Assistance Service (TMAS) at about 1006. The first helicopter, Rescue 21, was tasked to assist at 1033. Similarly, Hans Hackmack and Bernard Grube, two 23-metre lifeboats, were also dispatched to the vessel to provide the necessary assistance.
Rescue 21 arrived first on scene at 1108, with one paramedic and an operational communications officer lowered on the the vessel in position 54° 01.6’ N 007° 18.1’ E. Following an initial assessment, the second engineer was shifted into the engine-room, where there was more space for the resuscitation efforts to continue. Northen Rescue 01, another helicopter tasked at the same time as Rescue 21, arrived on scene at 1124 with additional equipment and two medics. On board, the three medics and the operational communications officer continued the resuscitation attempts on the second engineer.
At 1142, it was thought that a low pulse was detected, however, by 1148, the medical team leader declared that the second engineer had passed away. The death of the crew member was also confirmed by an emergency physician from the NHR Air Rescue Service, who was flown to the vessel by helicopter and lowered on board by winch to assist the other physician, who had been lowered on the vessel before.
The two lifeboats that had almost reached the vessel were released to return to base. At 1234, both medical teams signalled that they were ready to be picked up. The first team was picked up by Rescue 21 at 1239, and the second team, together with the second engineer’s body, were picked up by Northern Rescue 01 at 1306. The vessel was then instructed to proceed to the Neue Wesser Reede Anchorage, where it dropped anchor at 1448 to complete formalities with the local authorities, following which the vessel resumed its voyage towards Immingham on 22 November 2023 at 2112.
The invesigation report concludes the following:
- The second engineer was injured when a stack of steel plates tipped over, trapping him against the store shelving in the steering gear compartment.
- The lashing intended to secure the stack was found slackened.
- No maintenance was planned for the day and the work was unplanned.
- The second engineer was working alone and there was no system in place for him to sound the alarm for assistance.
- The safety investigation identified several weaknesses and limitations in the arrangement. For instance, in order to select and take out a steel plate from the stack, the complete lashing arrangement had to be released.
- There was no information which indicated that the crew members had cues, which would have suggested to them that there was a level of unacceptable risk related to the stack of steel plates, and which had to be addressed.
- The stowage position and lashing arrangements of the steel plates did not allow for the use of either a hoist or lifting clamps to transfer / shift the plates safely.
- The stowage of steel plates on board is not an uncommon practice within the maritime industry, encountered by crew members and shore personnel alike.
In view of the key findings from safety analysis conducted the following recommendations are made:
- Incorporate Safety Guidelines into SMS: Ensure the company’s safety management system (SMS) includes clear guidelines, procedures, and necessary risk assessments for the safe handling of heavy items, emphasizing the avoidance of one-person operations for such tasks.
- Horizontal Storage and Use of Lifting Equipment: Whenever possible, store steel plates horizontally in a designated area equipped with appropriate lifting tools to facilitate safe handling.
- Safe Racks for Vertical Storage: For vertically secured plates, construct purpose-built racks designed to safely store and enable the handling of heavy steel plates without endangering crew members.