UK MAIB report: Unsafe working practices during lifting operation

The incident

A port stevedore on board the Gibraltar registered general cargo vessel Cimbris was fatally crushed when he became trapped between the vessel’s gantry crane and a cargo hatch cover during cargo discharge operations at the Antwerp Bulk Terminal, Belgium.

No one saw the stevedore position himself between the moving gantry crane and the hatch cover, but his likely intent was to assess the progress being made by his team working in the hold.

The chief officer did not have a full view of the crane’s path from his control position and, contrary to the vessel’s documented procedures, a second crew member was not used to act as a lookout or banksman.

The hatch cover lifting operation was not properly planned, adequately supervised, or executed in a safe manner. Communication between the ship’s crew and port stevedores was poor and the safety culture demonstrated by both was weak.

The vessel’s manager, Briese Dry Cargo GmbH & Co. KG, has taken action to improve its guidance on the safe conduct of gantry crane lifting operations and the port stevedore federation, Centrale der Werkgevers aan de Haven van Antwerpen, has reviewed its safety procedures for stevedore operations.

Findings

• The stevedore coordinator was fatally crushed between the gantry crane and number 11 hatch cover because he placed himself in the path of the moving crane and the crane did not stop.
• The stevedore coordinator almost certainly knew the gantry crane was moving but was probably confident that he could achieve his objective and move out of its path.
• The ship’s gantry crane operator did not stop the crane because he did not know the stevedore coordinator was on the crane track.
• The cargo hatch cover lifting operation was not properly planned, supervised or executed safely; a lookout or banksman was not used and stevedores were working under the suspended load.
• The levels of safety culture demonstrated by the ship’s crew and among the port workers was weak and unsafe acts and conditions were widespread.

Recommendations

In light of the situation, the following recommendations have been made to Briese Dry Cargo GmbH & Co. KG and Centrale der Werkgevers aan de Haven van Antwerpen:

• Take appropriate actions to improve the level of safety culture on board Cimbris and its other managed vessels.
• Take appropriate actions to improve the level of safety culture among its registered workers.
• Review compliance with safe working practices on board customer vessels, to better ensure the safety of its registered workers and vessel crews.

VIEW UK MAIB ACCIDENT REPORT HERE