Accident Investigation report 19/2014
The UK MAIB has issued Accident Investigation Report No.19 ofthe fatality of an able seaman on board ro-ro cargo ship Tyrusland in Tripoli, Libya on 15 May 2013.
At1810on15May2013,ableseaman(AB)WilliamPenafielwascrushedbetween two cargo containers on the main deck of the ro-ro cargo ship Tyrusland. He did not survive the injuries sustained.
Tyrusland was berthed in Tripoli and the crew were working with an embarked teamofvehicledriverstodischargeacargoofcontainers.ABPenafielsrolewas to release and remove twistlocks during the cargo discharge operation. This task required him to work in close proximity to moving vehicles that were being used to handle the containers.
At the time of the accident, a full container was being handled using a fork-lift truck. The fork-lift truck driver was conducting a manoeuvre to avoid the container striking an adjacent stack of containers and to realign the container in preparation for loadingitontoawaitingtrailer.However,thedrivercouldnotseeABPenafieland was,therefore,unawareofhismovements.AsABPenafielattemptedtoremovea twistlock from the deck, the moving container collided with a static container, fatally crushing him in between.
The MAIB investigation found that the system of work employed by those involved inthecargohandlingprocesswasunsafeandthatABPenafielhadentereda hazardousareawithinsufficientsafeguardsinplace.
The investigation also found that there were weaknesses in the implementation of the companys safety management system (SMS) on board Tyrusland, particularly relating to risk assessments and SMS review processes. Although a risk assessment relating to working on deck existed, it did not identify and address the specifichazardofaworkerbeingcrushedbyamovingvehicleorcontainerduring cargo handling operations. The lack of appropriate risk assessments was an issuethathadbeenidentifiedpreviouslyinbothaninternalcompanyauditandan external audit conducted by the Maritime and Coastguard Agency (MCA). However, follow-up action by the company and the MCA in response to this issue was insufficienttopreventtheaccident.
This was the fourth accident, two of which were fatal, in less than a year involving UKflaggedshipsmanagedbyImperialShipManagementAB.Thecompany has since conducted a safety management review and has developed a plan for improvingproceduresandsafetycultureacrossitsfleet.TheMAIBhaspreviously made a recommendation1 to the MCA aimed at improving its processes for managing audits and follow-up action. In view of this recommendation and the action taken since by Imperial Ship Management, no recommendations are made in this report.
Conclusions |
Safety issues directly contributing to the accident that have been addressed
Other safety issues directly contributing to the accident
Safety issues not directly contributing to the accident that have been addressed
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Further details may be found by reading the UK MAIB report (please click at image below)