Marine Safety Investigation Unit

MARINE SAFETY INVESTIGATION REPORT

Safety investigation into a stevedore fatality on board the

Maltese registered bulk carrier

TARSUS

at Port Rozi Anchorage, India

on 13 November 2013

201311/011

MARINE SAFETY INVESTIGATION REPORT NO. 29/2014

FINAL

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 safety investigation 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 13 November 2013. Its sole purpose is

confined to the promulgation of safety lessons and therefore may be 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, 2014.

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

CONTENTS ............................................................................................................................. iii

GLOSSARY OF TERMS AND ABBREVIATIONS ................................................................v

SUMMARY ............................................................................................................................. vi

1 FACTUAL INFORMATION .............................................................................................1 1.1 Vessel, Voyage and Marine Casualty Particulars .......................................................1 1.2 Description of Vessel .................................................................................................2 1.3 Deck Cranes................................................................................................................2

1.3.1 Operation of deck cranes ........................................................................................4 1.3.2 Safety features ........................................................................................................6 1.3.3 Crane jib emergency limit switch ...........................................................................6 1.3.4 Emergency stop button ...........................................................................................6

1.4 Maintenance and Inspection of Deck Cranes .............................................................7 1.4.1 Maintenance of crane no. 2 .....................................................................................7

1.5 Stevedores and Work Schedule ..................................................................................9 1.6 Ship’s Crew and Cargo Watch ...................................................................................9 1.7 Risk Assessment .......................................................................................................10 1.8 Environment .............................................................................................................10 1.9 Narrative ...................................................................................................................10 1.10 Post-accident Events .................................................................................................15 1.11 Autopsy Report .........................................................................................................15 1.12 Structural Damage ....................................................................................................15 1.13 Post-Accident Investigation by the Chief Engineer..................................................16

2 ANALYSIS .......................................................................................................................18 2.1 Purpose .....................................................................................................................18 2.2 Circadian Rhythm and Sleep Deprivation ................................................................18 2.3 Risk Assessment .......................................................................................................20 2.4 Findings by the Service Engineer .............................................................................20 2.5 Crane Operation at Port Rozi....................................................................................22

2.5.1 Slanting operation .................................................................................................22 2.5.2 Reporting of improper crane handling ..................................................................23 2.5.3 The bitter end of the luffing wire rope .................................................................25

2.6 Fatal Injury ...............................................................................................................25

3 CONCLUSIONS ...............................................................................................................28 3.1 Immediate Safety Factor ...........................................................................................28 3.2 Latent Conditions and other Safety Factors .............................................................28 3.3 Other Findings ..........................................................................................................28

4 RECOMMEDNATIONS ..................................................................................................29

LIST OF ANNEXES ................................................................................................................30

iv

LIST OF REFERENCES AND SOURCES OF INFORMATION

Crew members MV Tarsus

European Commission (2012). A wake up call. Research into the effects of

sleepiness on the cognitive performance of maritime watchkeepers under different

watch patterns, using ships’ bridge, engine and liquid cargo handling. Research

Report 2012. Retrieved on 03 April 2014 from

http://www.warsashacademy.co.uk/about/resources/final-horizon-report-final-as-

printed.pdf

IHI-WMMP Instruction Manual

International Maritime Organization (2001). Guidance on fatigue mitigation and

management. MSC/Circ.1014. London: Author

Managers MV Tarsus

v

GLOSSARY OF TERMS AND ABBREVIATIONS

AB Able seaman

Cm Centimetre

E East

ICU Intensive Care Unit

IHI Ishikawaiima-Harima Heavy Industries Co., Ltd.

kW Kilowatt

m Metre

mm Millimetre

MSIU Marine Safety Investigation Unit

N North

OOWs Officers of the watch

PPE Personal Protection Equipment

PMS Planned Maintenance System

RPM Revolutions per Minute

SMS Safety Management System

SWL Safe Working Load

T Tonnes

VTS Vessel Traffic Service

WMMP Wuhan Marine Machinery Plant Co. Ltd.

vi

SUMMARY

On 10 November 2013, the Maltese registered bulk carrier Tarsus anchored off Port

Rozi, India to load a cargo of coal from the barges. The crew prepared the vessel’s

cranes and connected the dual-folding grabs. The port stevedores boarded the vessel

and commenced loading at 14451. The cranes were operated by the stevedores.

On 13 November 2013 at 0450, the crane operator at crane no. 2, simultaneously

lifted the grab and the crane jib. He was guided by a signalman on deck, positioned

abreast of cargo hold no. 2. Whilst the hoisting wire rope lifted the grab, the luffing

wire rope had a contra-movement to the jib-up action and the crane jib started falling

down. The operator released the hoist and luffing lever controls and pushed the

‘power off’ button. Instantly, the hoisting wire rope stopped but the crane jib

continued to fall until it hit the air vent pipe on the main deck. The fall was arrested

by the vessel’s sheer stake. The luffing wire rope had unwound and the bitter end

slipped out of the luffing wire rope drum.

An AB who was on cargo watch escaped uninjured. However, the signalman was

lying beneath the crane jib, unconscious and bleeding from the head. The injured

signalman was administered first aid on board and transported by barge for medical

treatment ashore. He was admitted in the local hospital’s intensive care unit. The

signalman succumbed to his injuries on 14 November 2013.

Cognizant of the master’s submissions, the fact that the findings of the chief engineer

and the service engineer into the cause of the deck crane damage found no technical,

hydraulic or electrical failure, the Marine Safety Investigation Unit (MSIU) concluded

that the immediate cause of the accident and the subsequent fatal injury to the

stevedore was the falling of the jib beyond its operating limit.

The MSIU has made three recommendations to the managers of the ship and the

manufacturer of the cranes with the scope of enhancing safety during cargo

operations.

1 Unless otherwise stated, all times are ship’s time (UTC +5.5).

1

1 FACTUAL INFORMATION

1.1 Vessel, Voyage and Marine Casualty Particulars

Name Tarsus

Flag Malta

Classification Society DNV GL

IMO Number 9487213

Type Bulk Carrier

Registered Owner Tarsus Shipping Limited, Malta

Managers Genel Denizcilik Nakliyati A.S., Istanbul

Construction Steel (Double bottom)

Length overall 189.99 m

Registered Length 182.0 m

Gross Tonnage 31117

Minimum Safe Manning 18

Authorised Cargo Dry bulk

Port of Departure Jaigarh, India

Port of Arrival Port Rozi, Gulf of Kutch, India

Type of Voyage Coastal

Cargo Information Coal

Manning 24

Date and Time 13 November 2013 at 0450 (LT)

Type of Marine Casualty Very Serious Marine Casualty

Place on Board Ship – Freeboard Deck

Injuries/Fatalities One fatality

Damage/Environmental Impact No environmental impact. Damages to the

railing, crane jib and other fittings on the

freeboard deck.

Ship Operation Normal Service - Loading

Voyage Segment Arrival

External & Internal Environment Light breeze, calm sea. Mainly cloudy with good

visibility, air temperature 24 ºC.

Persons on Board 42

2

1.2 Description of Vessel

Tarsus was a 5-hatch, geared, self-trimming bulk carrier. She was registered in Malta

and was owned by Tarsus Shipping Limited. Tarsus was managed by Genel

Denizcilik Nakliyati A.S. of Turkey2. The vessel was built by Zhejiang Shipbuilding

Company Limited, China in 2008 and is classed by DNV GL.

Tarsus (Figure 1) had a length overall of 190 m, a moulded breadth of 32.26 m and a

moulded depth of 17.20 m. The vessel had a summer draught of 12.49 m and a

summer deadweight of 53208 tonnes.

Propulsive power was provided by a 6-cylinder MAN-B&W 6S50MC-C, slow speed

direct drive diesel engine producing 9480 kW at 127 rpm. This drove a single fixed

pitch propeller, giving a service speed of 14.70 knots.

Tarsus had satisfactorily completed Class and Statutory renewal surveys on

09 October 2013.

1.3 Deck Cranes

Tarsus was fitted with four IHI-WMMP electro-hydraulically driven cranes (Figure

2), each of 35 tonnes SWL capacity. The cranes’ working radii lie between 5 m and

28 m at crane jib angles of 82°and 20º from the horizontal respectively. The

maximum SWL in the grab operation mode was 28 tonnes.

The engine-room overhead crane, provisions crane and deck crane nos. 1, 2, 3 and 4

were thoroughly examined and load tested in Shanghai by a DNV surveyor. The

results were satisfactory. The ship’s cargo gear book was also endorsed. A

Certificate of Test and Thorough Examination of Lifting Appliances was issued on

09 October 2013.

2 The vessel’s name was changed to Tango following a change in ownership on 04 June 2014.

3

Figure 1: MV Tarsus

4

Figure 2: Crane and machinery room arrangement

1.3.1 Operation of deck cranes

The manufacturer’s Instruction Manual provided guidance on the preparation and

operation of deck cranes. The Instruction Manual recommended that prior to starting

the cranes, a number of checks had to be carried out including, level check of the

hydraulic/lubrication oil in the hydraulic pump/tank and the reduction gearbox, and

testing of the limit switches for the hoist, slew and crane jib movements. The

instruction label (Figure 3) in the Instruction Manual, and which was fitted in each of

5

the four crane cabins, warned the operator neither to hoist the load slanting nor

diagonally to prevent damage to the crane jib and its luffing wire rope.

Figure 3: Cautionary label in crane cabin

It was also stipulated that the controlling levers, hoist and luffing/slewing controls

(Figure 4) had to be in the neutral position before the electric motors were started.

Figure 4: Luffing and slewing control lever

The cranes are considered ready for cargo operations only after the recommended pre-

start checks were completed.

6

1.3.2 Safety features

In order to carry out cargo handling operations safely, each of the four cranes is fitted

with a safety device. The motion limit switches restricted hoisting between the upper

and lower limits of the crane jib. The slewing limit switches prevented the crane

running into any fixed obstacle. Moreover, the hoist and luffing differential switch

maintained adequate clearance between the crane jib head and the cargo hook. The

cranes were also fitted with interlock switches, which prevented the operation of the

cranes after the limit switches activated at the maximum and minimum angle of the

jib from the horizontal.

The relief valves in the hoist and luffing motor protected the winches from overload,

whereas valves in the slewing motors softened the mechanical shock. The relief

valves in the hydraulic system protected the pump from overload. When the pressure

on the relief valve exceeded a pre-set limit in the hoist, luffing or slewing, all crane

movements stopped.

1.3.3 Crane jib emergency limit switch

A crane jib emergency limit switch was fitted to stop the crane operation in the event

the luffing drum moved the crane jib down when the luffing lever was moved in the

crane jib-up position. Similarly, the crane movement would be stopped when the

luffing lever was moved up, the brakes are released and instead, the crane jib lowers

down as a result of loss of hydraulic pressure from internal leakages in the system.

1.3.4 Emergency stop button

In addition to the above safety devices, and in case of an emergency, the start/stop

button (Figure 5) also served as an emergency stop button. Activating it by pushing

the stop button would stop all crane movements during cargo operations.

7

Figure 5: Plan view of the crane cabin showing relative position of the crane stop button

1.4 Maintenance and Inspection of Deck Cranes

The Instruction Manual recommended periodic inspections and maintenance of the

deck cranes. A maintenance chart was appended to the Manual on the maintenance of

electric, hydraulic and machinery parts. The chart provided an overview of the

preparatory checks required on the cranes for cargo operations. The checks included

function of the limit switches and brakes, which were to be carried out by operating

the cranes without any load.

As part of the safety management system (SMS), the maintenance of cranes was

included in the Company’s planned maintenance system (PMS). Each maintenance

job was described in the PMS application.

1.4.1 Maintenance of crane no. 2

The crew had carried out monthly and three monthly checks on 12 October and 07

November 2013 respectively. On 17 April 2013, the brake tests were performed on

the hoist and luffing wire rope drums, and the slewing ring. During the Class and the

Statutory renewal surveys in October 2013, the ship’s cranes were tested and

thoroughly examined by the DNV GL surveyor. On 09 October 2013, a certificate

attesting the thorough examination and load tests was issued and the ship’s Cargo

Gear Book was endorsed (Figures 6 and 7).

8

Figure 6: Cargo Gear Inspection Endorsement by DNV surveyor

Figure 7: DNV Class test/thorough examination certificate

The crane operator’s cabin and equipment were last inspected on 12 October 2013

with satisfactory results. The luffing wire rope drum was checked on 20 August

2013, including the checking / re-screwing of the luffing wire rope fixed bolt (Figure

8) with a suitable spanner (Annex 1). The arrangement was found to be in good

condition.

Figure 8: Securing arrangement on the luffing wire rope drum

9

1.5 Stevedores and Work Schedule

The stevedores working on Tarsus comprised of a supervisor, eight crane operators,

eight signalmen and a cook. The stevedores lived on board and worked in shifts of 6

hours duty and 6 hours rest. During cargo operations none of the stevedores were

wearing personal protection equipment (PPE).

Deck crane no. 2 was operated by a 35 year old port worker who had indicated that he

had 15 years experience in crane operation of which, he had 4 to 5 years operating IHI

deck cranes. Documentary evidence indicated that the crane operator was due for

refresher training on 25 December 2009. No further evidence was submitted to

confirm that this refresher training was actually carried out. He was assisted by a 32

year old signalman who was reported to have five years experience working in the

port.

1.6 Ship’s Crew and Cargo Watch

All the officers and rating on Tarsus were Turkish nationals. The master, who was 59

years old at the time of the accident, held a Certificate of Competence issued under

STCW regulation II/2, and endorsed by the flag State Administration. He had been at

sea for over 36 years; 20 years of which serving as a master. He had been for six

years with the present Company. He joined Tarsus on 18 August 2013.

The chief mate, who was 31 years old, also held a Certificate of Competence issued

under STCW regulation II/2.

At Port Rozi, the officers of the watch (OOWs) were keeping the anchor and cargo

watches and a watchkeeping schedule was applied as follows:

Second mate 0000-0400 and 1200-1600

Chief mate 0400-0800 and 1600-2000

Third mate 0800-1200 and 2000-2400

An AB and a deckhand assisted the OOWs during their respective anchor/cargo

watches. The chief mate was responsible for the loading operations.

10

1.7 Risk Assessment

Documentary evidence showed that a formal risk assessment of cargo operations at

Port Rozi was done on 11 November 2013. The risk assessment team included the

master, the chief mate, the chief engineer, the first engineer and the bosun.

Communication failure, structural damage, and serious or fatal injuries were identified

as hazards. The safeguards to control hazards to an acceptable level were

implemented by the chief mate and the first engineer on 12 November 2013

(Annex 2). The formal risk assessment document also indicated that the necessary

checks on the deck cranes were carried out on 12 November 2013.

1.8 Environment

The weather on the morning of 13 November 2013 was light breeze with smooth seas.

The swell height was in the region of 0.1 m to 0.5 m and it had no effect on the

vessel’s rolling or pitching motion. The air temperature was 24 ºC. The vessel was

upright with trim of 0.48 m by the stern. The diurnal tide in the region ranged

between 1.0 m and 5.50 m.

1.9 Narrative

On the morning of 10 November 2013, Tarsus anchored off Port Rozi in the Gulf of

Kutch, West India. Following port clearance, draft survey and satisfactory

inspections of the cargo holds, Tarsus re-anchored to load coal in position

22° 39´N 070° 04´E, i.e. about five nautical miles from the port (Figure 9).

11

US Dept of State Geogrtapher

© 2014 Google

Image © 2014 TerraMetrics Image © 2014 CNES / Astrium

Data SIO, NOAA, U.S. Navy,

NGA, GEBCO

Figure 9: Anchor position of Tarsus just outside Port Rozi, Gulf of Kutch, India

The crew members prepared the cranes, opened the hatch covers and connected the

dual-folding grab to each of the ship’s four cranes. At 1430, barges loaded with coal

arrived and moored on the ship’s portside. The stevedores boarded the vessel and at

1445 commenced loading cargo holds nos. 2, 3, 4 and 5. All the cargo cranes were

operated by the stevedores, who were assisted by signalmen positioned on deck,

abreast of each cargo hatch. No bulldozers were available on the barges throughout

the cargo operation.

On 13 November 2013 at 0400, the chief mate took over the cargo watch from the

second mate. At the time, the vessel was upright with a slight trim by the stern. The

draft was 9.94 m forward and 10.42 m aft. The stevedores were loading cargo in

cargo holds nos. 1, 2, 4 and 5. It was dark but the deck lights provided adequate

luminosity. At 0430, the crane operator and the signalman assigned to

crane no. 2 took a short break for tea. At 0450, they returned and resumed loading.

The crane jib was reportedly positioned between 40° and 45° from the horizontal.

This position gave the loading grab a reach of 5 m to 7 m from the ship’s port side.

The grab was ready to be lifted from the barge, to be emptied into cargo hold no. 2.

The signalman standing near the aft air vent pipe signalled the crane operator to lift

12

the grab. The crane operator simultaneously moved the hoisting and the luffing lever

in crane jib-up position.

The AB on duty standing near the signalman recalled that soon after the grab had been

lifted to a height of about two metres from the barge, he heard a humming noise and

looked up. At about the same time, the crane operator noticed the crane jib’s contra-

movement. He immediately put the control levers to neutral position and pushed the

power off button. The hoisting wire rope instantly stopped. The crane jib, however,

continued to fall albeit slowly until it hit the air vent pipe on the main deck. The fall

was eventually arrested at the vessel’s sheer strake. The grab fell and rested on the

cargo in the barge’s hold (Figures 10, 11 and 12).

Figure 10: Crane jib after the accident

Figure 11: Grab position on the barge

13

Figure 12: View of damaged crane jib from the crane cabin

The luffing wire rope had unwound from the drum and the detached bitter end was

lost into the sea. The luffing wire rope strands were found open and the bitter end

securing arrangements were damaged (Figures 13 and 14). Although the AB was

uninjured, the signalman was found lying under the crane jib, unconscious and

bleeding from the head.

14

Figure 13: Damaged securing arrangement

Figure 14: Bitter end with strands open and loose

15

1.10 Post-accident Events

All cargo operations were immediately stopped and the injured signalman was given

first aid. However, since the nature of his injuries was very serious, the VTS at Port

Rozi instructed the vessel to transfer the injured stevedore ashore by one of the

barges.

At 0520, the injured signalman was transferred to the barge and transported ashore for

further medical treatment. On reaching Port Rozi, he was transferred by ambulance to

the hospital’s intensive care unit (ICU). Despite the medical care and treatment, the

signalman succumbed to his injuries on 14 November 2013.

1.11 Autopsy Report

A post-mortem examination was held on 14 November 2013. A 5 cm surgical stitch

wound was found on the frontal region of the head (forehead mid-line). Two small

abrasions were observed on the left cheek and below the left corner of the mouth. The

autopsy report concluded that the cause of death was a trauma caused by the severe

head injury.

1.12 Structural Damage3

The surveyors representing the interests of the owners, charterers and the stevedoring

company jointly surveyed the crane for structural damage. The survey was witnessed

by the master, the chief engineer and the chief mate. The following structural

damages were identified:

left and right arms of the crane jib (box frame) were buckled, deformed and

fractured at various locations;

the grab cable auto-tension motor was detached from the housing. The sheave

at the crane jib head was also detached and one of its sides bent;

the lighting cable and two pipe guards on the crane jib’s right arm were bent;

3 An inspection for any damages on the crane’s machinery was not carried out.

16

about one metre of sheer strake on the main deck was bent. Three tiered guard

rails and stanchions above the shear strake were broken and deformed;

two runner wire ropes sheaves on the crane jib head and flanges were bent;

the luffing wire rope securing clamps and bolts on the luffing wire rope drum

were detached and bent;

the luffing wire rope strands near the bitter end were opened up over a length

of about 2.50 m from the bitter end. Moreover, wire rope strands were opened

up in other locations; and

the air vent for void space no. 3 had been damaged and detached from its base.

1.13 Post-accident Investigation by the Chief Engineer

Following the accident, the chief engineer carried out a number of checks and tests on

the crane and forwarded his report to the ship’s managers. In his report, the chief

engineer stated that:

all limit switches were checked and found in order;

the pressure readings on the luffing hydraulic motor were found in compliance

with the manufacturer’s instructions;

the luffing wire rope drum was operated in both directions and the mechanism

worked properly. There were no abnormal noises or vibration;

the brakes were engaged and tested to verify that they locked tight around the

drum;

the machinery response from the operator controlling levers was satisfactory;

the luffing wire rope drum was operated using the luffing control lever at

small angles. The clearance between the brake band and the brake wheel was

found within limits; and

the luffing lever was operated both in crane jib-up and crane jib-down

positions at five second intervals. The machinery response was good. The

luffing brakes engaged and the hydraulic pressure at each lever movement

were found satisfactory.

17

The chief engineer reported that at Port Rozi, the crane must have been operated

beyond its recommended operating limits. He concluded that the cargo was pulled

slantingly and it’s limits were violated. The chief engineer stated that the harsh

movements on the controlling levers delayed and weakened the action of the brakes.

He also attributed the crane jib’s fall to excessive load caused by the slanting grab lift

and the operator’s erratic handling of the luffing lever.

18

2 ANALYSIS

2.1 Purpose

The purpose of a marine safety investigation is to determine the circumstances and

safety factors of the accident as a basis for making recommendations, to prevent

further marine casualties or incidents from occurring in the future.

2.2 Circadian Rhythm and Sleep Deprivation

The stevedore on Tarsus were divided into two gangs. They lived on board and

worked alternate shifts of 6 hours. A cabin space and toilet facilities were provided

by the ship. The operator on crane no. 2 was assigned a shift between the periods of

0200 to 0800 and 1400 to 2000. Since the barge movements were affected by tidal

waters in the port area, their arrival alongside the ship was unscheduled. Thus, in

addition to the scheduled six-hour rest, the operator had significant periods of free

time while on shift duties. The crane working hours and free time of the operator on

crane no. 2 are summarised in Table 1.

Table 1: Crane working hours and free time of crane operator no. 2

Crane working hours and free time of crane operator no. 2

(Total time on board 62 hours 20 minutes)

Date

Crane operation

(including tea

breaks)

Free time

(including

scheduled rest

period)

Remarks

10 November 5 hr 15 min 0 hr 15 min 1430: Boarded Tarsus

1445: Commenced loading

6 hr 00 min

11 November 4 hr 10 min

7 hr 50 min

11 November 2 hr 30 min

9 hr 30 min

12 November 4 hr 20 min

7 hr 40 min

12 November 5 hr 45 min

6 hr 15 min

13 November 2 hr 50 min 0450: Work stopped due to crane jib

accident

Total Hours 24 hr 50 min 37 hr 30 min 62 hr 20 min

19

The analysis was carried out in the light of potential issues with the biological clock

and circadian rhythm. The biological clock is perfectly synchronised to the traditional

pattern of daytime wakefulness and night-time sleep. There are two times of low

alertness in each 24 hour period (0300-0500 and 1500-1700). The working patterns

of the stevedores, crane operators and signalmen conflicted with their biological

clock. Moreover, a recent research project4 on seafarers showed that sleepiness levels

were higher in the 6 on - 6 off system and consistently peaked between 0400 and

0800; and the off-watch disturbance (noise, vibration, etc.) produced significant high

levels of tiredness.

Wakefulness builds up a sleep requirement and prolonged wakefulness results in sleep

deprivation5. Though common in the everyday working life, sleep deprivation

induces fatigue and adverse changes in cognitive performances through decreased

alertness and slow response in simple monotonous tasks.

However, the intermediate periods of free time during and between scheduled crane

operations, which ranged from a minimum of 6 hours to up to 9.50 hours, were also

considered. These periods were utilised for meals, shower, social activities and sleep.

As indicated in Table 1, the crane operator had worked 24.83 hours out of the 62.33

hours, which he had been on board. He therefore had well over 37 hours of free time.

On the morning of 13 November, before reporting on duty at 0200, he had a rest

period of 6.25 hours. In the previous 24 hours, he had rested 13.92 hours. After 2.5

hours of crane operation, he stopped for a 20 minute break.

Though the MSIU could not establish the operator’s quality or duration of sleep, it

was apparent from the available evidence, however, that the operator was not unduly

fatigued or overwhelmed by the circadian rhythm or, potentially, micro sleep6 when

he resumed work at 0450 shortly after the tea-break.

4 Project Horizon – A wake-up call. Research Report 2012. A European Commission part-funded

multi-partner research initiative to investigate the impact of watch keeping patterns on the cognitive

performance of seafarers.

5 Sleep is a physiological need during which restores energy.

6 Micro sleep means sleep of typically 10 to 15 seconds duration.

20

2.3 Risk Assessment

The ISM Code requires vessels to make a risk assessment on safety of operations and

to determine and implement control measures necessary to ensure safe operations.

Tarsus’ SMS included a formal risk assessment procedure. During the on-site

investigation and collection of evidence, no document on risk assessment was

submitted to the safety investigator.

However, during the course of the safety investigation, the managers obtained a copy

of SMS Form 034001 dated 11 November 20137 on risk assessment for crane

operations at Port Rozi from the vessel’s master. The document identified a number

of hazards, with mitigating safeguards put in place on 12 November 2013, a day

before the accident8.

It was deduced that since all cranes were recently examined and load tested by a

DNV GL surveyor a few weeks before the accident, a sudden crane jib fall was not

considered as a probable hazard and therefore not included in the risk assessment

exercise.

2.4 Findings by the Service Engineer

At Ningbo and Shanghai, China, a service engineer from WMMP attended the vessel

to carry out an investigation into the cause and extent of the damage.

During the course of the crane inspection, the service engineer found that the brake

liners were in good condition and free from any oil traces, which therefore eliminated

the possibility of brake slippage. The thickness of the liner was within the allowable

limits and the clearance between the brake and the brake wheel was 1.1 mm, which

was also within the maximum allowable limit. This also meant that the brake holding

capacity was not compromised by these two factors. The service engineer also

checked the limit switches of the luffing wire rope system and found them in good

working order. The operation of the luffing control levers and luffing brakes was also

found satisfactory.

7 Cargo operations had started on 10 November 2013.

8 The Risk Assessment Form made no reference to stevedores working on board without wearing the

necessary PPE.

21

Thus, whilst the limit switches were found in good working order, the safety

investigation had to determine why the crane jib transited the lower operating

boundary (i.e. 20° from the horizontal) without the fall being arrested by the brake.

Although the hydraulic motor running pressure was good, damage to the reduction

gear from the reaction force of the crane jib falling on deck was suspected. The

hydraulic motor was dismantled and no damage was found. However, the reduction

gear had sustained severe damages. Parts of the teeth were broken and found in the

luffing wire rope drum. A new reduction gear and flange were ordered and eventually

fitted. The connection between the luffing wire rope drum and the reduction gear was

checked and the crane jib (box frame) was repaired. A new wire rope was installed

and the limit switches re-adjusted. The crane was run for hours and the system was

thoroughly checked. Finally, a load test was carried out with satisfactory results.

At the end of a thorough investigation, the service engineer found abnormalities

neither in the hydraulic system, limit switches, nor in the luffing brakes. In his

conclusion, however, he attributed the likely cause of the crane jib fall to the hoisting

of the load in a slanting manner by the operator.

Since no technical explanation was submitted in support of the service engineer’s

conclusion (as presented in his report – Annex 3), the MSIU requested further

clarifications from the manufacturers, namely:

whether the damage to the luffing reduction gear was the result of the crane jib

fall or whether the crane jib’s fall was caused by the damaged reduction gear;

to confirm whether the engineer’s findings on the crane damage were clear

indications of a slanting hoist and if so, whether the damage could have been

caused by a single slanting load or multiple loads;

to clarify the consequences in the event of crane mishandling and whether

mishandling can lead to a failure of the crane’s mechanical and/or electro-

hydraulic system, resulting in a crane jib fall; and

to advise on the possible technical reasons for the crane jib not to stop falling

even if the control levers were neutral and the ‘emergency stop’ button

pressed.

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Notwithstanding a series of emails, by the end of the Consultation Period, the MSIU

had not received a reply to these queries, which were aimed to explore the technical

link (hydraulic and mechanical) between the fall of the crane jib and possible hoist

slanting during the cargo operations (either at Port Rozi or even in previous ports).

2.5 Crane Operation at Port Rozi

2.5.1 Slanting operation

The master stated that the stevedores were verbally instructed to operate the deck

cranes safely and to stay clear of the cargo operational area. The master’s orders in

the logbook instructed the watch keepers to ensure safe and orderly crane operations.

Moreover, each crane cabin was provided with instructions on the operation of cranes,

with specific warning to the crane operators not to drag or to lift the grab slantingly.

After the accident, the master asserted that the accident had occurred due to the

jerking of the crane and the dragging and slant lifting of the cargo. The master also

suggested that the hoist might have snagged on the barge9. He pointed out that the

bitter end of the luffing wire rope had come off the luffing wire rope drum and that

this was indicative of the damage caused by the operator’s handling of the crane

beyond its permissible limits. As already indicated elsewhere in this safety

investigation report, the chief engineer, who had carried out various checks and tests

after the accident, also attributed the cause of the accident to the violation of the

crane’s operational limits by imposing excessive load on the crane through slanting

cargo hoists.

At the time of the accident, the vessel was upright with a trim by the stern of 0.48 m10

.

The crane jib was reported to be at an angle of about 40° to 45° from the horizontal.

In this position, the grab would have reached 5 m to 7 m from the ship’s side. At 20°

(working limit), the crane jib reach would have a maximum slewing radius of 28 m,

giving a reach of 12 m over the ship’s side (Figure 15). Therefore, within the working

limits of the crane jib, the grab could have easily covered the full 7 m beam of the

barge. Moreover, the barge could be moved up and down under the hoist. The weight

9 An inspection of the barge, however, did not reveal protrusions or obstructions, which could have

snagged the hoist.

10 The vessel’s trim was not considered to have been a contributory factor to this accident.

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of the grab with coal at 21 tonnes was well within the maximum permissible limit of

28 tonnes. Therefore, whilst slanting of the grab can neither be confirmed nor

excluded, the reach of the crane jib and the shifting of the barge in the fore and aft

direction would have obviated the need for slanting hoist. However, the MSIU

neither had evidence which would indicate that the barge was moved in the fore and

aft direction, nor that the cargo was shovelled directly under the grab.

Figure 15: Crane jib’s operating limits

2.5.2 Reporting of improper crane handling

It transpired that none of the watch keepers had reported poor crane handling, lifting

or attempting to lift the grab slantingly during the cargo operation although it was

claimed that the operators were verbally cautioned by the duty officer and the watch

keeper. The AB who witnessed the accident made no reference to the mishandling of

the crane. Since the start of the cargo operations on 10 November 2014, a log entry

was neither made by the watch keepers nor any protest (other than the one made after

the accident) was lodged by the master on poor and / or rough handling of the crane.

The reporting of crane misuse was analysed from a safety perspective by the MSIU

and in terms of the safety management of the system. Given that evidence did not

indicate that the alleged misuse of the crane was immediately reported to the master

or the chief mate, it may be deduced that any of the crew members who witnessed the

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cargo operations (and therefore was a potential informant), may have not immediately

seen the value in making this report; the MSIU has been made aware that deck

equipment is commonly not operated in accordance with the manufacturers’

directions in a number of ports around the world.

If this was the case, then the issue may be of an inaccurate distinction between

successful/unsuccessful behaviour and correct/incorrect behaviour on the crane

operator’s side. If slanting hoist was indeed being practiced, then until the accident

happened, the results were perceived successful and the cargo operations were

deemed positive, which may be seen as a measure of successful cargo operations.

This is however, neither necessarily correct nor in accordance with the manufacturer’s

instructions.

On the other hand, any slanting of the crane jib would have actually been a risk-taking

exercise, which therefore, would have been accepted. In terms of a safety

investigation, the matter remains an issue on the social and commercial value of the

activity being conducted and whether the potential of an accident was foreseen by the

crane operator and / or the crew members.

Even so, the fact that after the accident there was a claim of slanting of the crane jib,

and knowing very well that slanting is specifically mentioned in the Instruction

Manual, but no records of any reports were made and / or no action was taken prior to

the accident, was suggestive that there was a limited understanding on board on the

critical importance of reporting safety occurrence in order to stay ahead on the way

the nature of risk may change and possibly, leading to an accident.

It may be also indicative that whereas the safety management system required that

safety occurrences are reported (e.g. near accidents), the interpretation given to a

number of occurrences is that these are not ‘safety occurrences’ at all, more so if, as

described above, the outcome is perceived to be positive. Therefore, what may be

classified as an excellent opportunity for an organisation to enhance ‘organisational

learning’, can be an unreportworthy event for the crew member on board, who may be

busy doing his job during a cargo operation.

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2.5.3 The bitter end of the luffing wire rope

It was definite that the luffing wire rope did not part but slipped off its bitter end.

Available documentary evidence indicated that at some point in time, the luffing wire

had stripped off its bitter end on the luffing wire drum under shock load conditions.

The findings of the chief engineer and the service engineer were also taken into

consideration. It would seem that on the basis of these findings, a possible technical,

hydraulic or electrical fault had to be eliminated, unless it was of an intermittent

nature which went undetected after the accident. However, according to the master’s

explanation to the safety investigator, the luffing wire came off the bitter end of the

wire luffing drum and that this indicated that the crane jib was operated at angles

beyond the permissible limits during the cargo operations.

The nature of the damage on the luffing wire rope drum (Figure 13) at the bitter end,

i.e. deep scratches in the luffing wire rope drum’s side wall and a bent holding down

bolt also indicated that the securing arrangement fastening the luffing wire rope to the

drum must have been excessively stressed.

In view of the master’s explanation above, the findings of the chief engineer and the

manufacturers’ representative. and given that the bolt on the bitter end of the luffing

wire drum had been satisfactorily tightened using a suitable spanner on 20 August

2013, the MSIU could not rule out that the luffing wire rope had been stressed during

the loading operation with the consequent damage to the fastening arrangement. It

has to be specified that the rigging geometry and the bitter end securing arrangement

were neither intended nor designed to withstand shock loads.

2.6 Fatal Injury

Although the injured signalman was found under the crane’s jib, it seemed unlikely

that he was hit by the crane jib itself. The crane operator pointed out that the position

where the injured signalman fell, provided adequate standing room between the deck

and the crane’s jib. Without any witness, it was not possible to precisely establish

what had actually caused the injury to the signalman.

However, considering a single (covered by surgical stitches) wound on the frontal

region of the head (forehead midline) and the position where he was found, it was

26

possible that the signalman may have sustained fatal injuries from the uncontrolled

luffing wire rope but more likely from the broken pieces of the smashed air-vent pipe.

Figure 16 indicates numerous broken pieces spread under the crane’s jib and at the

location where the injured signalman was found.

Figure 16: Metal debris under crane jib and location of injured signalman

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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.

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3 CONCLUSIONS

Findings and safety factors are not listed in any order of priority.

3.1 Immediate Safety Factor

.1 The immediate cause of death was trauma to the head following the fall of the

crane jib on the main deck.

3.2 Latent Conditions and other Safety Factors

.1 Available evidence did not indicate that pre-starting checks were carried out in

the presence of the stevedores.

.2 Available evidence indicated that the hazards or preventive measures during

the operation of the cranes were not confirmed by the stevedores.

.3 The nature of the damage on the luffing wire rope drum at the bitter end, the

luffing wire rope and a bent holding down bolt indicated that the securing

arrangement fastening the luffing wire rope to the drum must have been

excessively stressed.

.4 According to the master’s explanation, the luffing wire came off the bitter end

of the wire luffing drum and that this indicated that the crane jib was operated

at angles beyond the permissible limits during the cargo operations.

3.3 Other Findings

.1 The MSIU was not provided with a technical explanation from the crane

manufacturers as to how the slanting of the grab could have led to this failure.

.2 No evidence was submitted to confirm that this slanting of the grab operation

was logged in the ship’s logbook.

.3 The reach of the loading grab covered the full width of the barge.

.4 An inspection of the barge did not reveal any protrusions or obstructions

which cold have snagged the grab or the hoisting wire rope.

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.5 Following the accident, both the chief engineer and the service engineer found

the safety limit switches and the luffing wire rope drum brakes in good

working condition.

.6 The mass of the lift of the grab (with coal) was within the manufacturer’s

permissible limits.

.7 The environmental conditions had no adverse effect on the operation of the

crane.

.8 The formal risk assessment and the risk control measures were implemented

after the cargo operations had started.

4 RECOMMENDATIONS

In view of the conclusions reached and taking into consideration the safety actions

taken during the course of the safety investigation,

Genel Denizcilik Nakliyati A.S. is recommended to:

29/2014_R1 Retrofit audible and visual alarms, which will activate automatically

when the stop button is pressed on the deck cranes fitted on ships under its

management.

29/2014_R2 Conduct safety meetings with crew members to define ‘safety

occurrences’ and highlight the importance of reporting them to the vessel

management team.

IHI-WMMP is recommended to:

29/2014_R3 Fit audible and visual alarms on new deck cranes, which activate

automatically when the emergency stop button is pressed.

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LIST OF ANNEXES

Annex 1 Job Sheet

Annex 2 Risk Assessment Form

Annex 3 Service Engineer Report

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Annex 1 Job Sheet

32

33

Annex 2 Risk Assessment Form

34

Annex 3 Service Engineer Report

35

36

37

38

39