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Marine Safety Investigation Unit
MARINE SAFETY INVESTIGATION REPORT
Safety investigation into the serious injury
to a crew member on board
the Maltese registered bulk carrier
BARGARA
in the port of Fangcheng, China
on 23 January 2012
201201/028
MARINE SAFETY INVESTIGATION REPORT NO. 21/2012
ii
Investigations into marine casualties are conducted under the provisions of the Merchant
Shipping (Accident and Incident Safety Investigation) Regulations, 2011 and therefore in
accordance with Regulation XI-I/6 of the International Convention for the Safety of Life at
Sea (SOLAS), and Directive 2009/18/EC of the European Parliament and of the Council of 23
April 2009, establishing the fundamental principles governing the investigation of accidents
in the maritime transport sector and amending Council Directive 1999/35/EC and Directive
2002/59/EC of the European Parliament and of the Council.
This report is not written, in terms of content and style, with litigation in mind and pursuant to
Regulation 13(7) of the Merchant Shipping (Accident and Incident Safety Investigation)
Regulations, 2011, shall be inadmissible in any judicial proceedings whose purpose or one of
whose purposes is to attribute or apportion liability or blame, unless, under prescribed
conditions, a Court determines otherwise.
The objective of this safety investigation report is precautionary and seeks to avoid a repeat
occurrence through an understanding of the events of 23 January 2012 misleading if used for
other purposes.
The findings of the safety investigation are not binding on any party and the conclusions
reached and recommendations made shall in no case create a presumption of liability
(criminal and/or civil) or blame. It should be therefore noted that the content of this safety
investigation report does not constitute legal advice in any way and should not be construed
as such.
© Copyright TM, 2012
This document/publication (excluding the logos) may be re-used free of charge in any format
or medium for education purposes. It may be only re-used accurately and not in a misleading
context. The material must be acknowledged as TM copyright.
The document/publication shall be cited and properly referenced. Where the MSIU would
have identified any third party copyright, permission must be obtained from the copyright
holders concerned.
MARINE SAFETY INVESTIGATION UNIT
Malta Transport Centre
Marsa MRS 1917
Malta
iii
CONTENTS
GLOSSARY OF TERMS AND ABBREVIATIONS .................................................. iv
SUMMARY ................................................................................................................... v
1 FACTUAL INFORMATION ................................................................................. 1 1.1 Vessel, voyage and marine casualty particulars ................................................... 1
1.2 Description of vessel ............................................................................................ 2
1.3 Environmental conditions ..................................................................................... 3
1.4 Vessel‟s trade and cargo information ................................................................... 3
1.5 Training of the AB ................................................................................................ 5
1.6 Safety management system .................................................................................. 5
1.7 Narrative ............................................................................................................... 7
1.8 The BLU Code and Manual ................................................................................. 9
1.9 The STCW Code ................................................................................................ 10
2 ANALYSIS ........................................................................................................... 12 2.1 Aim ..................................................................................................................... 12
2.2 Circumstances of the accident ............................................................................ 12
2.2.1 Cargo and the cargo hold .......................................................................... 12
2.2.2 Crew preparedness .................................................................................... 12
2.2.3 Communication ......................................................................................... 13
2.2.4 Presence of signalling men ....................................................................... 14
2.2.5 Risk assessment ......................................................................................... 15
3 CONCLUSIONS ................................................................................................... 18 3.1 Immediate Safety Factor ..................................................................................... 18
3.2 Latent Conditions and other Safety Factors ....................................................... 18
4 ACTIONS TAKEN ............................................................................................... 19 4.1 Safety actions taken during the course of the safety investigation ..................... 19
iv
GLOSSARY OF TERMS AND ABBREVIATIONS
AB Able Bodied Seaman
B&W Burmeister and Wein
BC Solid Bulk Cargoes
BLU Bulk Loading and Unloading
BST Basic Safety Training
BV Bureau Veritas
CSS Code of Safe Practice For Cargo Stowage and Securing
DWT Deadweight
IMO International Maritime Organization
IMSBC International Maritime Solid Bulk Cargoes
ISM Code International Safety Management Code
Kg hl-1
Kilogramme per hector litre
Km hr-1
Kilometre per hour
LT Local Time
MT Metric Tonne
NSW New South Wales
PWCS Port Waratah Coal Services
SMS Safety Management System
SOLAS International Convention for the Safety of Life at Sea, 1974 as
amended
STCW International Convention on Standards of Training, Certification
and Watchkeeping for Seafarers, 1978, as amended
TEU Twenty Foot Equivalent Unit
v
SUMMARY
On 23 January 2012, the Maltese registered bulk carrier MV Bargara was discharging
its Canola cargo at Berth 11 at Fangcheng port in China. At about 1330, the AB on
duty went down into cargo hold no. 3 to loosen up areas of the cargo to facilitate the
unloading. The mechanical grabber in use to unload the Canola cargo, and which was
being operated by a shore crane operator, caught the AB from his legs.
As a result of this accident, the 25 year old AB suffered severe injuries and
consequently lost both his legs.
The safety investigation identified safety issues related to risk awareness, risk
acceptance and communication.
On the basis of the actions taken by the Company in the wake of the accident, no
recommendations have been made to Bargara‟s ship managers.
1
1 FACTUAL INFORMATION
1.1 Vessel, Voyage and Marine Casualty Particulars
Name Bargara
Flag Malta
Classification Society Bureau Veritas
IMO Number 9261360
Type Bulk Carrier
Registered Owner Selene Owning Co. Ltd.
Manager(s) TMS Bulkers Ltd.
Construction Steel
Length overall 225.00 m
Registered Length 218.17 m
Gross Tonnage 40437
Minimum Safe Manning 16
Authorised Cargo Bulk cargo
Port of Departure Chiwan, China
Port of Arrival Fangcheng, China
Type of Voyage Coastal
Cargo Information Canola seed
Manning 22
Date and Time 23 January 2012 at 1325 (LT)
Type of Marine Casualty or Incident Serious Marine Casualty
Location of Incident Fangcheng, China
Place on Board Cargo hold
Injuries/Fatalities One crew member injured
Damage/Environmental Impact None
Ship Operation Discharging at berth
Voyage Segment Arrival
External & Internal Environment During ongoing cargo operations, the weather was
clear with a temperature of about 9°C. Northerly
breeze and clear skies with good visibility.
Persons on Board 22
2
1.2 Description of Vessel
Originally named Song Hua, the vessel is a single hull bulk carrier built at Hudong
Zhonghua Shipbuilding Co. in China (Hull number 1288A). She was delivered to her
owners in January of 2002. Bargara has an overall length of 225 m and a beam of
32.26 m.
Bargara has seven cargo holds of almost equal length, fitted between frames 44 and
245 and located forward of the accommodation superstructure (Figure 1). The cargo
holds‟ hatch covers are of the side rolling type, stowing at the side of the hatch. The
main propulsion is provided by a single Burmeister and Wain (B&W) 5S60MC two-
stroke, single acting, diesel engine that delivers 8,550 kW. The main engine drives a
single, fixed pitch propeller, which gives the ship a service speed of about 15 knots1.
Bargara is registered under the Maltese flag, owned by Selene Owning Co. Ltd. and
managed by TMS Bulkers Ltd. The vessel is classed with Bureau Veritas (BV).
At the time of the accident, the vessel had a crew of 22. All the crew members were
Filipino nationals except for the master, who was Greek, and the electrician and fitter,
who were both Romanian. All the crew members were qualified to serve on board the
ship in accordance with the flag State Administration requirements.
Figure 1: MV Bargara main deck
1 One knot, or one nautical mile per hour equals 1.852 km hr
-1.
3
1.3 Environmental Conditions
At the time of the accident, the weather was clear with a visibility of 14 nautical miles
and good natural light. The sea state was moderate, with a temperature of 5 C. There
was a northerly breeze and the outside temperature was 9 C.
1.4 Vessel’s Trade and Cargo Information
On 18 January 2012, Bargara sailed from Chiwan, China and arrived at Fangcheng,
China on the following day at 2200. The vessel had been carrying Canola seeds as
indicated in Table 1.
Table 1: Cargo distribution on board
* Metric Tonnes
Cargo discharge operations started on 20 January at 1410.
Fangcheng Port (marked B in Figure 2) is located at the northern bank of Beibu Gulf,
southern part of Guangxi deepwater harbour at the furthest south-western end of the
coastline on China mainland. Fangcheng Port has 35 berths, 21 of which can
accommodate vessels of more than 10,000 DWT. The maximum design berthing
capacity is 200,000 DWT, with an annual throughput capacity of 30 million tonnes.
The dedicated container berth handling capacity is 200,000 TEU annually.
Hold 1* Hold 2* Hold 3* Hold 4* Hold 5* Hold 6* Hold 7* Total*
7,5756 9,070 9,075 9,075 9,075 9,075 8,497.20 61,442.20
4
B
A
Map data © 2012 Google, Kingway, MapIT, MapKing, Mapabc, SK M&C, Tele Atlas, ZENRIN
Figure 2: Loading and discharge ports
Baraga was carrying 34,222 mt of Canola seed in bulk. Canola seed is genetically
derived from rapeseed and although its nutritional values are substantially different
from rapeseed, visually and dimensionally it is very similar; however, it differs in
texture. Canola seed has dark brown matt colour, it is generally spherical in shape,
about 2 to 4 mm in size (Figures 3 and 4). The texture is rather dull and rough. The
volumetric grain weight of Canola seed is about 65 kg hl-1
. Canola is not considered
to be a hazardous cargo.
Figure 3: Canola seed Figure 4: Canola seed shape and texture
5
Canada is the major producer and exporter of Canola seed. It produces over six
million tonnes per year and exports more than 50% of its annual crop. The United
States produces an average of one million tonnes of Canola seed per annum, while
Australia produces another two million tonnes of Canola seed per year and exports
worldwide about one million tonnes per annum.
1.5 Training of the AB
The injured AB was issued with a Seafarer‟s Registration Certificate as an Ordinary
Seaman on 17 August 2010. He had also been issued with a certificate as
navigational support on 13 March 2008. The AB had received training in Basic
Safety Training and Instruction in Personal Survival, Fire Prevention and Fire
Fighting, Elementary First Aid, and Personal Safety and Social Responsibility, and
Proficiencies in Survival Craft and Rescue Boat.
The AB also met the required standard of competence to undertake task, duties and
responsibilities listed in column one of tables A VI/1, A VI/1.2, A VI/1.3 and
A VI/1.4 of the STCW Code. He was also certified as having successfully completed
training as required by Regulation II/4 of the STCW Convention in „Navigational
Watch Keeping‟.
Before embarking on Bargara, the AB undertook further training in the Philippines
between 31 August and 06 September 2011. He successfully completed training in
„Port State Control Awareness‟, and „Anti Piracy Awareness Training‟. During the
same period, he was also certified as having attended a „Bridge Watch Keeping and
Procedure Awareness‟ and a „Pre Departure Orientation Seminar‟.
The AB had served on another vessel between 22 September 2010 and 18 June 2011.
He embarked on Bargara on 13 October 2011.
1.6 Safety Management System
The Company‟s Safety Management System Manual made specific reference to
access into cargo holds during cargo operations. In particular, it specified that
…the Master is responsible at all times for the safe loading and discharge of his vessel
and he shall confirm to the terminal this control in the form of the loading or discharge
plan.
6
It further stated that
…should, for any reason it become necessary for crew members to enter into cargo
holds during operations, cargo operations in the affected hold must be stopped and
permission obtained from the terminal before entry is made. In order to ensure the
safety of all crew members during operations, the following procedure should be
strictly adhered to.
BEFORE ENTRY
The terminal supervisor shall be advised …and must agree, in writing to this operation.
The Master, upon receiving written consent, shall evaluate all the risk…
The Chief Officer shall ensure that all shore cargo handling equipment is removed
from the hold…
A deck Officer with a radio shall be designated to remain at the point of entry
throughout the time…
The Company procedures related to “crew entering cargo holds – during cargo
loading” and adopted by TMS Bulkers Ltd., were circulated to respective masters,
chief mates, safety and deck officers as Safety Bulletin No. 243 – 10/2009. The
Safety Bulletin clearly stated that “No entry into cargo hold is allowed during cargo
operation”. The Bulletin also instructed masters to laminate and post on all cargo
hold entrances the notice that was issued by Port Waratah Coal Services (PWCS) of
NSW Australia (Figure 5).
Figure 5: Warning notice at one of the cargo hold access points
7
1.7 Narrative2
On 19 January 2012, Bargara arrived at Fangcheng Port, China and was made all fast
port side alongside at Berth 11 (Figure 6) to discharge about 34,222 mt of Canola seed
in bulk from its cargo holds nos. 1, 3, 5 and 7. The discharge operations started on the
following day at 1400, using shore cranes and grabs (Figure 7). Discharge operations
were uneventful and on 23 January at about 0820, hatch covers for cargo holds nos. 1,
3, 5 and 7 were opened.
At 0835, all four cargo holds were ready for the cargo discharge operations to resume.
Two gangs started work at 0900, discharging cargo from cargo hold no. 3. Work was
temporarily suspended at 1140 for break. At 1200, the second mate, together with an
AB reported for duty and proceeded to cargo hold no. 3. At 1240 discharge
operations were resumed.
Figure 6: Bargara during unloading operations at berth 11
Figure 7: Wharf cranes alongside Bargara
2 Unless otherwise stated, all times are local.
8
The shore cranes rigged with a mechanical grabber (Figure 8) were operated by local
port workers.
Figure 8: The use of the grabber in one of the cargo holds on board Bargara
At one point in time, while the grabber was on the jetty side, the duty AB went down
inside cargo hold no. 3 to loosen Canola seeds that were entrapped between the
transverse frames of the cargo hold. The second mate remained on the main deck3. A
long scraper was normally used to loosen any entrapped cargo, which would have
caked between the frames. The AB understood that the second mate was supervising
the operation from the main deck. He claimed that it was also agreed that the second
mate would warn him before the grabber is swung over the side and lowered into the
cargo hold so that he would take adequate cover before the grabber reached the cargo
surface.
At about 1325, the grabber was lowered into the cargo hold while the AB was still
trying to loosen up the entrapped Canola grain. Whilst he was breaking loose the
cargo, the AB looked up and noticed the grabber approaching from above without any
notice. The AB tried to keep clear of the grabber, which landed on the surface of the
cargo, very close to his back. As the grabber opened, the AB was drawn inside with
the grain as a result of the unstable nature of the cargo. Both his legs were caught by
the grabber as the latter closed and the crane started to hoist it up.
3 The injured crew member claimed that there was a rope inside the cargo hold, which served as a
lifeline to be tied around the waist of anyone accessing the cargo hold. However, there was no
evidence that the injured AB was tied around the waist at the time of the accident.
9
The second mate heard the AB screaming and when he realised what had happened,
he signalled to the crane driver. The grabber was subsequently lowered onto the
cargo and the AB released. The second mate alerted the master of the accident. First
Aid was administered to the AB and an ambulance was called, which transferred the
injured crew member to a nearby hospital. Following the necessary surgical
intervention, the AB survived the accident. Notwithstanding all the medical
assistance received on board and ashore, the AB lost both his legs from the knees as a
result of the severe injuries sustained.
Whilst the master had not authorised the AB to enter the cargo hold during the cargo
discharging operations, the second mate claimed that he had only made a passing
comment to the AB about the blackened caking cargo.
The AB claimed otherwise and explained that this particular access to the cargo hold
was not a one-off entry. He explained that he had to go inside the cargo hold through
the manhole and crew members had also received instructions from the ship to loosen
the cargo when the grabber was out of the cargo hold4. He also explained that it had
been agreed that the duty officer would supervise the cargo hold and notify him
before the grabber approached the cargo hold.
1.8 The BLU Code and Manual
The Code of Practice for the Safe Loading or Unloading of Bulk Dry Cargo Carriers
(BLU Code) stipulates procedures to be adopted by the ship and the terminal. Section
3.3.1.12 specifies that on receipt of the ship‟s initial notification of its ETA, the
terminal should give the ship advance information on the proposed cargo handling
operations or changes to existing plans for cargo handling.
The Code also specifies in section 4.1.1 that the master is responsible at all times for
the safe loading and unloading of the ship, the details of which should be confirmed to
the terminal representative in the form of either a loading or unloading plan. In
addition, it is stipulated that it must be ensured that there is an agreement between the
master and the terminal representative at all stages and in relation to all aspects of the
loading or unloading operations.
10
The establishment of communication arrangements between the ship and the terminal
(thereby facilitate prompt response), are emphasised as an important procedure.
Appendix 3 to the Code requires both the master and the terminal manager to
establish communication methods, working language, radio channels and exchange
phone numbers.
On the same matter, the BLU Manual in section 6.1.2 specifies that “…monitoring
and effective communications between terminal and ship must be maintained at all
times” whilst in section 6.1.3 it continues “…hold cleaning arrangements are normally
specified in the relevant charter party”. At a lower hierarchical management level, the
Manual further reinforces the need to establish good communications between the
ship and the terminal by stating that unloading operators should have an appropriate
understanding of how to “ensure that good communications are maintained between
the unloading operator and the designated ship‟s officer...assess the risk arising from
cargo sticking in frames and on hopper sides and facilitate, if possible, its safe
removal without risk to the safety of terminal personnel and ship‟s crew members.”
The Manual also recognises that moving equipment and vehicles, and operation of
mobile plant in ship‟s cargo holds are hazards that may be encountered at the
ship/shore interface during loading and/or unloading of solid bulk cargoes.
Risk assessment (RA) related to carriage of solid bulk cargoes is highlighted in the
International Maritime Solid Bulk Cargoes (IMSBC) Code, which requires that a
preliminary assessment of any potential hazards in the space to be entered is carried
out by a competent person.
1.9 The STCW Code
Cargo handling is also addressed in the STCW Code in Table A-II/2, (Function Cargo
Handling and Stowage). Crew members at management level are required to have the
knowledge, understanding and proficiency in “loading and unloading operations, with
special regard to the transport of cargoes identified in the Code of Safe Practice for
Cargo Stowage and Securing.”
4 In his submission to MSIU, the master denied that any crew member had ever been instructed to
enter the cargo hold during the cargo operations.
11
The Code also specifies the importance of effective communication, healthy working
relationships between ship and shore terminal personnel, and establishing procedures
for the safe handling of cargo in accordance with the provisions of the relevant
instruments, such as the IMSBC Code.
12
2 ANALYSIS
2.1 Aim
The purpose of a marine safety investigation is to determine the circumstances and
contributory causes of the accident as a basis for making recommendations, to prevent
further marine casualties or incidents from occurring in the future.
2.2 Circumstances of the Accident
2.2.1 Cargo and the cargo hold
Bargara was a single hull bulk carrier. Typically, due to stiffening and frames on the
inside of cargo holds, granular cargo, such as Canola seed, becomes caked and gets
trapped between the frames and stiffeners. With an empty cargo hold, it is difficult to
reach these areas. For this reason, the AB went into cargo hold no. 3, while it still had
about 70% of cargo. Maintaining a steady foothold would have been very difficult.
2.2.2 Crew preparedness
The Master held a Safety Management Meeting on the 27 November 2011 and one of
the agenda items was “Safety Bulletin No. 243 – 10/2009”. It was reported that the
Master emphasised the danger and cautioned that no entry into cargo holds was
allowed during cargo operations. The names of the injured AB and the second mate
involved in the accident did not appear on the list of participants.
At the time of the meeting, the second mate had not yet joined the vessel and it can
only be hypothesised that the Safety Management Meeting minutes were discussed
during the handover session when he embarked. Although the injured AB was on
board, it is highly probable that he was on duty during the Safety Management
Meeting. Whilst it is an onboard practice to post the meeting agenda on the notice
boards in both messrooms, there was no possibility to ascertain that it would have
been read by all crew members. Moreover, the agenda would not have contained the
specific details of the meeting and the only plausible source of information for these
crew members would be the Meeting minutes. There was no mention of the AB ever
asking for the minutes of this Meeting. Notwithstanding these uncertainties, there
was no evidence to indicate that the absence of the crew members from the Meeting
was a direct cause of the accident.
13
2.2.3 Communication
Effective communication is paramount in hazardous situations. It is one way of
ensuring that a task is safely conducted, taking into consideration the defined
circumstances. Not only; but effective communication is directly related to situation
hazards and complexity i.e. the more a situation is perceived to be hazardous and
complex, the higher the importance for clearer communication between actors
involved in the matter. Even more, the room for manoeuvring in optimising system
performance becomes limited in hazardous situations; which again escalates the
importance of communication.
Evidence indicated several levels of inadequate communication, which directly or
otherwise had a bearing on the dynamics of the accident. Moreover, certain features
of the ship also contributed to the inadequate level of communications. For instance:
the safety notice posted on the cargo hold hatch coaming was ignored. This
is not an uncommon phenomenon and there are studies which indicate that
safety notices are easily ignored within days they are posted;
any instructions given by the second mate to the AB may have not been clear
enough and were possibly misinterpreted;
access to the cargo holds during cargo operations may have happened in the
past with no adverse consequences that would have either deterred the crew
members from repeating the practice, or necessitated a report to be lodged
with the Company;
no VHF communication was available to the AB inside the cargo hold. The
AB could have found the radio useful to raise the alarm as soon as he noticed
the grabber approaching in the cargo hold;
in the onset to the accident, the second mate was not in the line of sight of the
crane driver and the AB;
access to the cargo hold during cargo operations was affected without a
permit of entry signed by the master;
14
possible steep hierarchal chain of command may have been present where the
ratings accepted orders from their superiors irrespective of the requirements
in the SMS Manual5;
it is possible that the second mate was distracted by the activity on board
without noticing that the grabber was in position and being lowered in the
cargo hold where the accident happened;
there were no discussions between the vessel (master) and the terminal about
the operations due to a language barrier. The master only wrote a Letter of
Protest after the accident had happened6;
potential language barrier between the crew members and the crane operator;
and
absence of a signalling man on the deck who could have either raised the
concern that a crew member has climbed down the cargo hold or
communicated with the crane driver in a more effective way.
Irrespective of whether the entry into the cargo hold was the initiative of the injured
AB or the result of instructions from the second mate, the need for effective
communication was sidelined. It may be hypothesised that the entry into the cargo
hold was deemed by the crew members not to be a too complex matter and therefore,
an entry plan was not deemed to be a necessity.
2.2.4 Presence of signalling men
The accident happened on 23 January 2012, which coincided with New Year‟s Day in
the Chinese calendar. There was no indication as to whether Fangcheng Terminal
was understaffed on the particular day. Since the commencement of the cargo
discharge operations on 20 January 2012 until the day of the accident three days later,
the discharging operations were performed without signalling men. It was only after
the accident occurred that signalling men were posted at each discharging cargo hold.
5 In his submission, the AB specified that he went down into the cargo hold against his wish and had
objected to the second mate. The AB‟s concern was the absence of a signalling man on the main
deck. He reiterated that he had agreed with the second mate for the latter to signal the crane
operator himself should the need arises – a task, which was not fulfilled. Gaining access into the
cargo hold meant overriding established safety management system procedures.
6 In fact, the ship-shore checklist was signed by the master and the agent on behalf of the Terminal.
15
The absence of the signalling men implied several other safety related issues, which
were not necessarily directly related to the accident per se, i.e.
the master had not made an agreement with the terminal representative in
relation to all aspects of the discharge operation and the SMS Manual prior to
the commencement of the cargo operations as required by the BLU Code.
The crew members had difficulty to establish effective communication with
the Terminal due to language barrier. In fact, all communications with the
port were done through the ship‟s agents, being the only person able to speak
both English and Chinese;
whilst no signalling men were appointed by the Terminal, the vessel
proceeded with the cargo discharge operations, which indicated that either
signalling men were perceived to be ineffective or else the cargo discharge
operations were considered to be paramount over the presence of the
signalling men; and
the SMS manual required a person to be designated to oversee the cargo
operation and to be stationed on deck above the cargo hold at all times, to
watch the safety of the persons working in the cargo hold and to ensure that
cargo operations in the particular cargo hold are temporarily suspended if any
person is required to enter the cargo hold. This procedure was not followed.
2.2.5 Risk assessment
A form prepared by the shipper, and which met the requirements of SOLAS 1974
Convention, regulation VI/2, the Code of Safe Practice for Solid Bulk Cargoes
(BC Code), and the Code of Safe Practice for Cargo Stowage and Securing (CSS
Code), specified that the cargo being shipped by Bargara was non-hazardous grain.
This document was presented by the managers to MSIU after a formal request was
made for a copy of the risk assessment carried out before the cargo operations were
initiated. The document provided was not a risk assessment, and it may be concluded
that because the cargo was classified as non-hazardous, no risk assessments were
deemed necessary by the crew members and therefore no written assessments were
performed.
16
The above safety issues may bring into question the effectiveness of the training and
implementation of the safety management system on board. However, these need to
be seen in the light of the prevailing situation at the time.
Considering the availability of safety notices and literature on Bargara (even if these
are considered to be soft barriers), it may be submitted that the acceptance of risk and
exposure to hazards were the result of particular social components on board,
interacting with attitude and behaviour, thereby influencing the safety outcome.
Therefore, the particular factors identified above, interacting with crew members‟
personal predispositions (which were also influenced by these particular factors) had
an impact on the way the events developed, with risk materialising into an accident.
The acceptance of the crew member to access the cargo hold during the cargo
operation (irrespective of whether this was the result of instructions from above or a
personal initiative), reflected a situation of a hazardous trade-off between compliance
with safety rules and support of efficient performance.
As such, this was considered to be a matter related to organisational factors on board
– matters, which would go beyond the request for additional training, slogans, and
safety posters. This was considered to be so because research studies indicate that
there are several hazards that are classified as universally hazardous – in other words,
hazards inherent within the system and are readily accepted by operators (in this case
the crew members) in close proximity of the hazards. Universal hazards may not
necessarily change or influence safe behaviour because of their general acceptance7.
Then, as already mentioned above, personal attributes play an important role in
acceptance of risk; a phenomenon, which has also been researched in several safety-
critical domains. The safety investigation did not come to the conclusion that the
AB‟s entering into the cargo hold was a reflection of cavalier attitude. Rather, risk-
taking is not an uncommon tendency and is influenced by the perception of the gained
advantages in effort time8.
7 Evidence suggested that the only perceived risk was the hanging grabber approaching the open
cargo hold. The potential inherent danger of the cargo as not appreciated enough. The force of the
cargo whilst being drawn inside the grabber when the latter opened may have not been anticipated
and its effect was only appreciated once the crew member was drawn towards the grabber.
8 In the absence of any disapproval from the officers at management level and no history of accidents
as a result of risk-taking, the latter becomes incorporated into the normal way of work, thereby
eroding the safety margin between the real danger zones of the operations.
17
THE FOLLOWING CONCLUSIONS AND SAFETY
ACTIONS SHALL IN NO CASE CREATE A
PRESUMPTION OF BLAME OR LIABILITY.
NEITHER ARE THEY LISTED IN ANY ORDER OF
PRIORITY.
18
3 CONCLUSIONS
Findings and safety factors are not listed in any order of priority.
3.1 Immediate Safety Factor
3.1.1 The crew member suffered serious injuries to his lower extremities after
he accessed the cargo hold during cargo operations and was caught by the
grabber discharging the cargo;
3.2 Latent Conditions and other Safety Factors
3.2.1 The injured AB and the duty officer were not re-briefed on the pertinent
Company‟s latest Safety Bulletin even though they were both aware of the
company‟s instructions vis-à-vis access into the cargo hold during cargo
operations;
3.2.2 The crew member accepted the risk of entering the cargo hold during the
cargo discharge operations;
3.2.3 The crew member was unaware that the grabber had approached the cargo
hold and consequently was unable to take a timely action;
3.2.4 It was not possible for the crane operator to see the injured crew member
inside the cargo hold partly because of the height of the hatch coaming,
the level of cargo inside the hold, and also because of the location of the
injured crew member inside the cargo hold;
3.2.5 Until the accident happened, there was no designated watch appointed
from the shore terminal to oversee the cargo operations;
3.2.6 The access into the cargo hold during the cargo operations went against
the procedures prescribed in the SMS manual;
3.2.7 There was no effective communication between the AB inside the cargo
hold, the second mate on the main deck and the crane operator ashore.
19
4 ACTIONS TAKEN
4.1 Safety actions taken during the course of the safety investigation
The Company investigated the accident in terms of Section 9 of the ISM Code. The
identified safety issues were discussed internally, following which, actions were taken
to adequately address the matter.
The Company reported that all the vessels under its management were notified of the
accident through the Company Fleet Advisory System. Subsequently, masters
reviewed the accident with their deck officers and ratings that are normally directly
involved in cargo operations, addressing in particular:
the enhancement of supervision by the duty deck officers during cargo
operations; and
effective communication between the duty deck officers and the ratings.
During the in-house pre-joining familiarisation course, TMS Bulkers Ltd. is now
specifically addressing:
onboard practices vis-à-vis the Code of Safe Working Practices for Merchant
Seamen;
the Company‟s Permit to Work System;
the Company‟s documented SMS procedures for the „Entry into cargo holds
during cargo operations‟;
the Company Safety Bulletins and Circulars – in particular the one related to
entry into cargo holds; and
the Company posted warnings / signs outside each cargo hold.
TMS Bulkers Ltd. has also increased the frequency of internal ISM audits on board all
their managed vessels in order to improve the identification of any potential problems
of a similar nature within its fleet.
