UK Marine Accident Investigation Branch (UK MAIB) has published an investigation report into a serious injury to a crew member onboard the survey and supply vessel Kommandor Orca that occurred in August 2022.
The incident
On 16 August 2022, the second officer of the UK-registered survey and research vessel Kommandor Orca sustained crush injuries to his lower left leg while operating one of the rail-mounted deck cranes. His leg became caught in the crane’s rack and pinion traversing mechanism when he moved the crane aft for a lifting operation. A helicopter transferred the second officer to the hospital, where his leg required amputation below the knee.
The investigation found that the crane was not being used in accordance with the manufacturer’s operating manual and that the crew had used the local crane controls designed for emergency use only. There were no instructions on board for the use of the crane beyond those stated in the manufacturer’s operating manual. The crew’s inappropriate use of the crane controls had become normalized behavior and was adopted for convenience.
The owner of Kommandor Orca, Hays Ships Ltd, has introduced measures to prevent a recurrence.
Analysis
Overview
The 2/O’s lower left leg was crushed while he operated a rail-mounted crane with unguarded rotating machinery using its local controls. Operating the crane from the local controls in the pedestal was unsafe. The method of crane control used by Kommandor Orca’s crew was contrary to the method stated in the manufacturer’s manual, and the hazards of working at height and operating unguarded machinery had not been identified in the vessel’s risk assessment.
This section of the report will consider why the crane was operated in an unsafe manner with none of the associated risks being recognized.
The crane operation
The manufacturer’s manual stated that the crane was to be remotely controlled from either the bridge station or the wireless remote control unit on the deck, and that the local hydraulic controls were for emergency use only. The starboard crane could have been operated using the wireless remote or the bridge control position. However, the inability to use the wireless remote control on the port side crane due to a fault, the visibility constraints of the bridge control, and the need to mobilize the remote controls led the senior officers and crew to seek the simplest solution and operate both cranes using the local controls. In the absence of permanent and legible signs, the crew had labeled the crane’s local controls with duct tape and marker pen, which neither questioned nor alerted anyone to the fact that this was not the usual method of operation.
Kommandor Orca’s 2/O was following his training when he operated the crane’s local controls from an exposed position at height and without safeguards. His position, with his left foot on the inboard bulwark and his right foot on the crane drive motor casing, was stable until he needed to step down from the bulwark as the crane moved aft. When the crane mechanism dragged his boilersuit into the unguarded rack and pinion gear, he lost his balance backwards and continued to hold on to the travel control lever. The added pressure that this applied to the lever was an automatic reaction, which in turn increased the crane’s speed and dragged the 2/O’s leg further into the pinion gear.
Safety management
Kommandor Orca had been in cold lay-up with no significant maintenance before the company purchased it. Consequently, the senior officers and crew had the complex task of commissioning all the ship’s equipment and learning its operation without the benefit of a handover of the previous crew’s knowledge. It is likely that the senior officers and crew applied their own experience of ship systems instead of referring to the manufacturer’s manuals and instructions.
The crane operation training was conducted by the senior officers, so the crew might have assumed they were being instructed in the correct methods. However, the requirement to operate the crane while working at height with no guardrails or restraints and near the unguarded rack and pinion gearing was a clear sign that the process was flawed. The crew indicated that they had the freedom to challenge on-board practices, but they did not do this for the operation of the cranes. This demonstrated either their acceptance of senior officers’ instructions or no recognition of unsafe acts or unsafe conditions.
Vessel-specific procedures for crane operations were not documented in Kommandor Orca’s SMS. This was a significant omission as the cranes were frequently used pieces of deck equipment. The creation of vessel-specific procedures was not deemed necessary by the crew, who followed the generic instructions in the SMS. This omission was not identified in the internal or external ISM audits.
Management of deck operations and risk assessment
The shipboard risk assessment process had not identified the hazards of working at height or the crane’s unguarded rotating machinery, indicating a selective or naive view on safety. Kommandor Orca’s day-to-day paperwork was in order, its crew were dressed appropriately, and the ship was clean and tidy; however, the methods used to operate the crane showed that the crew were either unable to recognize basic safety violations or chose to ignore them for expedience.
The master, C/O, and 2/O were experienced officers. When this experience was coupled with their professional training, it should have provided them with a greater level of safety awareness. Neither the C/O nor 2/O recognized the hazards of operating the crane using the local controls as part of the lifting plan, permit to work, or during their pre-work toolbox talk discussions on the morning of the accident. That the crane was operated in the same way by every crew member indicated a weak approach to safety on board the vessel.
Conclusions
- Kommandor Orca’s 2/O was following his training when he operated the crane’s local controls from an exposed position at height and without safeguards. As a result, when he moved his position, he became entangled in the unguarded drive mechanism, overbalanced, and his leg was crushed before the crane stopped moving.
- Operating the crane from the local controls in the pedestal was unsafe. The method of crane control used by Kommandor Orca’s crew was contrary to the method stated in the manufacturer’s manual. The crane was not designed to be operated from the local position other than in an emergency and so no personnel platform, guardrails, or machinery guards were fitted.
- None of the shipboard risk assessment process, vessel’s lifting plan, or the company’s procedures had identified the hazards of operating the crane using the local controls and the associated risks of working at height or being exposed to the crane’s unguarded rotating machinery, indicating a selective or naive view on safety.
- The vessel had been in cold lay-up before its purchase 11 months before the accident, and there was no handover from the previous company’s crew. As a result, the cranes’ flawed operating procedures and subsequent on-board training were developed without sufficient reference to the manufacturer’s operating manual. Consequently, neither the bridge station nor portable wireless remote control units were used. The training provided to the crew in operating the crane’s local controls led to it being used in an unsafe manner.
- Kommandor Orca’s SMS did not include ship-specific crane operating procedures and principally covered generic crane and lifting operations that referenced applicable regulations and guidance. This omission was not identified during subsequent ISM Code audits.
Action taken
Actions taken by other organizations:
The Maritime and Coastguard Agency issued Kommandor Orca with a full SMC on 23 December 2022, with no defects identified.
Hays Ships Ltd has:
- Mandated the use of the bridge station and wireless remote control units when operating the rail-mounted cranes.
- Provided its crews with instruction in lifting operations by an approved training organization.
- Undertaken a full review of its SMS and amended the sections on crane operations and cargo handling.
- Fitted Kommandor Orca with bulwark guardrails, rack and pinion guards, and a crane emergency stop to enable safe access to the local controls for maintenance or in the event of a remote control unit failure.
- Supported the injured 2/O with the intent to continue his employment in a suitable capacity.
