A UK Marine Accident Investigation Branch (MAIB) has issued an investigation report on a fall from height onboard a bulk carrier in Syros which resulted in the death of crewman on 17 April 2023.
The incident
On 25 March 2023, the Cayman Islands registered bulk carrier Equinox Seas arrived at the ONEX Syros Shipyards S.A. facility on the island of Syros, approximately 50 nautical miles southeast of Athens, Greece, for a period of scheduled maintenance.
On 17 April 2023, a fitter on board Equinox Seas entered the fan room on the starboard side of the ship’s funnel, where an engine room fan had been removed. The fitter fell 10m down the open ventilation trunk to the engine room below. The fitter was recovered from the base of the ventilation trunk and moved to a local hospital, where he died from his injuries.
The investigation concluded that:
- The fitter passed a tape barrier placed across the entrance to the fan room access by the shipyard, possibly due to a reduction in alertness because of the time of day the accident occurred.
- The response to the accident by all the organizations involved was both timely and effective.
- The management of safety on board Equinox Seas in a ship repair setting, and the coordination of activities, was poor.
- Guidance on the management of safety on board ships in a ship repair facility was either unavailable or not widely promulgated, and the responsibility for safety was poorly understood.
Safety issues directly contributing to the accident that have been addressed or resulted in recommendations
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The barrier controls in place in the fan room were insufficient to mitigate the risk of falling from height, resulting in the fitter sustaining fatal injuries when he fell approximately 10m down the ventilation trunk.
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The specific risks associated with the fan removal were not assessed, putting staff at risk from those hazards present in the fan room.
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The intensity and diversity of shipyard work can create a wide range of hazards, requiring an enhanced awareness of safety to mitigate risk.
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Safety on board Equinox Seas was not effectively managed during the entire stay at the shipyard facility.
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Ineffective communication and coordination between the shipyard and ship’s staff meant that deficiencies in the management of safety on board Equinox Seas were not addressed.
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The fragmented organization on board contributed to the suboptimal management of safety while Equinox Seas was at the shipyard.
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Relevant industry guidance on the management of safety in a shipyard environment was not incorporated into the working practices of the shipyard.
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The availability of relevant shipyard safety guidance from the P&I Club, of which Equinox Maritime was a member, was limited on board Equinox Seas.
Other safety issues directly contributing to the accident
The accident occurred during the afternoon dip in alertness experienced as a natural consequence of circadian rhythm.
Safety issues not directly contributing to the accident that have been addressed or resulted in recommendations
The Code of Safe Working Practices for Merchant Seafarers did not contain any guidance related to the risks created or amplified on ships in a shipyard environment.
Other safety issues not directly contributing to the accident
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The fan’s electrical isolation did not mitigate the risk of electric shock.
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Although unlikely to have affected the outcome, the fitter was not wearing the personal protective equipment required by the safety management system of Equinox Maritime at the time of the accident.
Actions taken
Actions taken by other organizations
The Maritime and Coastguard Agency has initiated a work item to consider developing guidance to highlight the hazards specific to, and amplified by, ships undergoing maintenance in ship repair facilities. This guidance is to be considered for inclusion in future amendments to the Code of Safe Working Practice for Merchant Seafarers.
Equinox Maritime Ltd has updated its SMS to incorporate:
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A shipyard safety checklist detailing matters related to safety provisions and communication/coordination with the shipyard.
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Crew safety training before entering a shipyard, specifically raising awareness of hazards encountered during maintenance in a ship repair facility.
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Requirements for safety meetings before and during dry dock periods.
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The inclusion of safety matters in daily work planning meetings between the ship’s management and the shipyard, with the need to minute such meetings.
Recommendations
ONEX Syros Shipyards S.A. is recommended to:
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Update its safety management and communication procedures to ensure that risks created by the work carried out in its shipyards are effectively managed and coordinated with the relevant ship’s crew and that the delineation of responsibility for safety on board is clearly understood between all parties.
