The UK MAIB issued an investigation report on a fatal fall from height onboard the freight ferry ‘Seatruck Pace’, moored in Liverpool, in December 2018. The investigation identified that the assistant bosun must have crossed a temporary rope barrier on to a narrow section of deck between the ship’s side and the open ramp hatch. It was not known why he moved into this area; his allocated work did not require him to do so and he was not wearing fall protection equipment.
The incident
In the morning hours of 17 December 2018, a bosun onboard the Ro-Ro cargo ferry ‘Seatruck Pace’, moored at Brocklebank Dock, Liverpool, was working alone and preparing to paint the leading edge of the open ramp hatch cover.
At about 0820, crew in the cargo office and the two ordinary seamen in the lower hold heard a loud crash on the ramp and hurried to investigate.
The assistant bosun was found lying on the inboard side of the ramp in line with Frame 56, with a trestle lying on its side and across the lower part of his right leg.
He was on his back with his feet towards the lower end of the ramp, 12m from the forward end of the hatch opening above.
For reasons that could not be determined, the crewman crossed a temporary safety barrier guarding the edge of the open hatch and walked along a narrow deck edge between the ships side and the open hatch on which several trailer trestles were stowed.
The crewman’s fall was not witnessed, but it is evident that he had fallen at or about the same time as one of the trestles.
The second officer immediately raised the alarm. The bosun was conscious, but the chief officer quickly assessed that he had broken a leg and an arm.
Soon after, the ferry’s first-aid team, comprising the cook and two stewards, arrived at the scene. The emergency services were called at about 0825. At 0845, an ambulance with three paramedics arrived.
On 20 December 2018, the assistant bosun died. It was reported that he had suffered a stroke. Subsequent postmortem examination indicated that the cause of death was a traumatic brain injury.
Conclusions
- The assistant bosun crossed a safety barrier and then fell 4.5m from the main deck onto the ramp with the trestle.
- The task the assistant bosun had been allocated did not require access to the unprotected deck edge beyond the rope barrier, and it is not known why he entered the hazardous area.
- The risk of falling was apparent but was accepted by the assistant bosun, who had probably taken similar risks in the past.
The assistant bosun, who preferred to work unsupervised, had probably taken similar action in the past, recognising and accepting the risk of falling on the basis that ‘it would not happen to him.’
- Work practices adopted by other deck ratings during hatch cover maintenance 2 days earlier indicated that adherence to the vessel’s safety procedures was more a matter of routine and compliance than of understanding and conviction.
The documentation and procedures on board Seatruck Pace, such as generic risk assessments and PTWs, were comprehensive and assisted with providing safe systems of work on specified tasks…However, despite Seatruck’s focus on safety, it is evident from the circumstances of the assistant bosun’s fall and the earlier hatch cover maintenance that the crew’s adherence to the safety procedures was more a matter of routine and compliance, than of understanding and conviction,
…the report reads.
Actions taken
Following the incident, Seatruck Ferries Ltd has:
- Reminded its masters of the dangers of bypassing safety control measures and prompted them to review the safety of deck openings.
- Provided safety chains, fittings and warning signs for use on the temporary barriers rigged on the main vehicle decks of its ferries.
- Reviewed its risk assessment and PTWs concerning working at height.
- Introduced a procedure for recording the use of safety harnesses.
- Committed to ensuring that all masters and safety officers complete a Maritime and Coastguard Agency safety officers’ training course.
- Completed a ‘safety culture survey’ among its senior management, and senior managers have attended the Health and Safety Executive’s (HSE) ‘Behaviour Change – Achieving Health & Safety Culture Excellence’.
- Engaged HSE consultants with the aim of forming a safety culture steering group and implementing the HSE’s Safety Climate Tool.
- Undertaken to revise the SMS to highlight that specific items of equipment should only be used for their intended purpose, e.g. trailer trestles should only be used to support trailers.
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