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Fatal injury caused by poor safety culture and probably also alcohol

A report by the UK’s Marine Accident Investigation Branch (MAIB) into the death of the Second Officer of the UK registered general cargo vessel Karina C blames poor safety measures and also suggests that alcohol consumption was a contributing factor.

The man was fatally injured when he was trapped between a stack of cargo hold hatch covers and a gantry crane used to move hatch covers. The ship was completing cargo operations and preparing to sail when the second officer, who was working on deck, climbed into a small gap between hatch covers and the stopped crane, probably to cross the vessel. Unseen by the crane operator, he was crushed when the crane moved, closing the gap.

The chief officer who was operating the crane immediately reversed the crane and the second officer fell onto the deck, where he received first-aid and cardio-pulmonary resuscitation from the deck crew and shore paramedics.

An emergency services doctor, who was informed that the second officer had fallen from the hatch coaming onto the deck, told the crew that the second officer probably died after having a heart attack. Based on the doctor’s initial assumption and the evidence provided by the vessel’s crew, the accident was not reported to the MAIB. Following receipt of the second officer’s post-mortem report and close examination of Karina C’s closed-circuit television recordings, the vessel’s managers, Carisbrooke Shipping reported the accident.

The accident occurred on the second officer’s birthday and his post-mortem toxicology report showed that he had a significant quantity of alcohol in his bloodstream. The investigation concluded that:

  • The second officer did not know the chief officer was about to move the crane and the chief officer did not know where the second officer was or what he intended to do because the deck operations were not being properly controlled or supervised and the deck officers did not communicate with each other.
  • The second officer’s judgment and perception of risk were probably adversely affected by alcohol.
  • Tiredness might also have adversely influenced the second officer’s actions.
  • The master did not adequately investigate or report the accident.
  • The safety culture on board Karina C was weak; company procedures were not followed, and several unsafe working practices were observed.
  • The company’s drug and alcohol policy was not being enforced.

Recommendations have been made to Carisbrooke Shipping to improve the safety culture on its ships and the level of crew compliance with established safe systems of work and to investigate alterations to crane movement warning systems.

Carisbrooke Shipping has now updated its gantry crane operating procedures and safety measures; updated its incident reporting policy; fitted additional emergency stops to all its gantry cranes; improved the profile of its employee confidential reporting system; and, reviewed and amended its alcohol policy to include frequent random testing of all crew and sanctions on masters in the event of policy breaches.

The report includes a statement from the Chief Inspector of Marine Accidents, “Ship’s decks are dangerous places and this accident could have been avoided if personnel operating Karina C’s deck that day had adhered to established safe working practices. The limited space available and ambient noise on deck mean that travelling gantry cranes, common on many operators’ vessels, can be particularly hazardous. Recently they have been involved in a number of fatal accidents and the MAIB is currently investigating another tragic death in similar circumstances. The accident on Karina C is a further case where excess alcohol consumption almost certainly contributed to the death of a seafarer”.