Safety Alert: MAIB report on fatal crush on RoRo cargo vessel

 

The UK Marine Accident Investigation Branch (MAIB) has published a report into the fatal crush accident during cargo operations on board a roll-on/roll-off cargo vessel.
Summary.

20 July 2021, the bosun of a roll-on/roll-off cargo vessel was fatally crushed while working on the vessel’s vehicle deck. The vessel was alongside loading semi-trailers. A tractor unit pushed a semi-trailer into a corner space, marshalled by the bosun in their assigned role as banksman. The accident was not seen by the driver, who disconnected the tractor unit and drove away. Shortly afterwards, two crew members found the bosun trapped between the rear of the semi-trailer and the vessel’s structure.

Safety Issues
• The banksman was fatally crushed while standing in an unsafe area in the path of an approaching semi-trailer.
• The tractor unit driver did not monitor the banksman’s position because they were relying on other visual cues to manoeuvre the semi-trailer and had assumed the banksman would keep out of the path.
• The bosun did not act as expected and instead stood on an unprotected walkway that had been painted inside the vehicle lane.
• The loading operation was unsupervised because the bosun had become involved in marshalling, and the crew did not continuously monitor one another’s positions on the vehicle deck.
• Neither the port nor the vessel’s manager had developed a safe system for loading high-risk stowage spaces.
• The accident reflected routine and widespread divergence from safe working practices on vehicle decks in the ferry industry because the local procedures and guidelines did not reflect how people worked, and there was no common standard.
• The vessel’s managers had an insufficiently robust approach to organisational learning and continuous improvement.
• There were shortcomings in the standards of tractor unit driving at the port, resulting in a tacit acceptance of some unsafe practices that had become ‘normal’.
• There was no national occupational driving standard for tractor unit drivers.

Chief Inspector’s Remarks

We include here a quote from the Chief Inspector of Marine Accidents which sets out MAIB’s position very clearly on management of vehicle deck risks. We have selectively highlighted some points:
“This accident serves as a tragic reminder of the inherent dangers of people and vehicles operating within the same area. Ferry vehicle decks continue to be a hazardous environment and while the risks are well known this has not prevented the deaths of several crew and port workers across Europe, some of which are documented in this report. This investigation again exposes routine divergence from safe working practices on vehicle decks due, in part, to procedures and guidelines that do not align with or reflect actual work practices.
The companies involved in this accident have taken numerous actions to improve safety following this accident, including an extensive review of vehicle deck practices, but despite these efforts, tragically, another crew member was fatally crushed earlier this year in a similar accident on board the ferry Laureline. It is not enough to develop procedures that look good on paper; they must be practicable, followed, and properly supervised.
It is no longer tenable for the industry to continue operating in the current manner and decisive action is needed to protect workers on ferry vehicle decks. Consequently, I have recommended that industry organisations develop a unified Code of Practice for vehicle deck safety on roll-on/roll-off vessels and that regulators review and amend their codes and guidelines to align with industry derived best practices.”

 

CLICK HERE FOR THE PDF OF THE FULL REPORT

Link to the full report:
https://www.gov.uk/maib-reports/crush-incident-on-board-ro-ro-cargo-vessel-clipper-pennant-with-loss-of-1-life