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Marine Safety Investigation Unit
SAFETY INVESTIGATION REPORT
201406/001
The Merchant Shipping
(Accident and Incident Safety
Investigation) Regulations,
2011 prescribe that the sole
objective of marine safety
investigations carried out in
accordance with the
regulations, including analysis,
conclusions, and
recommendations, which either
result from them or are part of
the process thereof, shall be
the prevention of future marine
accidents and incidents
through the ascertainment of
causes, contributing factors
and circumstances.
Moreover, it is not the purpose
of marine safety investigations
carried out in accordance with
these regulations to apportion
blame or determine civil and
criminal liabilities.
NOTE
This report is not written 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 report may therefore be
misleading if used for purposes
other than the promulgation of
safety lessons.
REPORT NO.: 10/2015
June 2015
MV Johann Oldendorff
Serious injury to crew member
in position 17° 31’N 126° 54’E
03 June 2014
SUMMARY
At about 1410 on 03 June 2014,
the
mobile
scaffolding
stage/ladder in the cargo hold of
Johann Oldendorff toppled over
inside one of the vessel’s cargo
hold. Consequently, the AB
working on the scaffolding
platform was seriously injured.
Suspecting spinal injuries, the
master diverted the vessel
towards the Philippine coast for
medical assistance.
The
following morning, at 0830, the
injured AB was air lifted by
helicopter and transferred to a
hospital in Manila.
The MSIU found that at the
time of the fall, the safety
harness/lifeline was detached
and the scaffolding stage/ladder
was being pushed by the crew.
Moreover,
the
safety
investigation revealed that no
risk assessment was made
before the task was initiated
and consequently not all risks
were identified and evaluated.
Considering the actions taken
by the vessel’s managers, the
MSIU
has
issued
no
recommendations.
© Copyright TM, 2015.
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 reused accurately and not in a
misleading context. The
material must be
acknowledged as TM
copyright.
MV Johann Oldendorff
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.
MV Johann Oldendorff
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201406/001
On 02 June 2014, the deck crew
commenced washing the cargo holds with
high pressure washing machine. A 6.60 m
high aluminium scaffolding stage/ladder
was rigged to reach the upper sections of
the cargo hold, almost half-way to the
topside tanks (Figure 1).
FACTUAL INFORMATION
Vessel
Johann Oldendorff, a 34612 gt bulk carrier
was built in 2014 and is registered in Malta.
She is owned by Arkadia Shipping Inc.,
managed by Oldendorff Carriers GmbH &
Co Kg, Germany and classed by
Nippon Kaiji Kyokai. The vessel’s length is
199.90 m and her loaded draught is 13.03 m.
Propulsive power is provided by a 6-cylinder
MAN-B&W 6S50ME-B9, slow speed direct
drive diesel engine producing 8130 kW at
108 rpm. This drives a single fixed pitch
propeller, with a service speed of 15 knots.
At
the
time
of
the
accident,
Johann Oldendorff was on her maiden
voyage from Nontong, China to Cape
Flattery, Australia.
Figure 1: Crew members working on the
scaffolding stage/ladder
Crew
Johann Oldendorff’s
Minimum Safe
Manning Certificate required a crew of 14.
There were 21 crew members at the time of
the accident. The crew members were from
the Russian Federation, Sri Lanka, Indonesia,
Ukraine, and the Philippines.
The assembly of the scaffolding
stage/ladder, which was carried out by the
crew members, was supervised by the chief
mate and the bosun. At all times, the
scaffolding was secured by the wheelbrakes and four 2.7 m aluminium outriggers
(two on each side). The crew members
confirmed that the wheel brakes were only
released when it was required to shift the
equipment to another area inside the cargo
hold. A safety line was also rigged across
the hatch coaming to secure the crew
member’s safety harness.
The injured crew member was a 40 year old
AB from Indonesia. He had joined the
company in 2001 and was promoted to the
rank of able seaman in 2010.
The working language on board was English.
Environment
The weather was clear and the air
temperature was 31°C. There was a six knot
Westerly wind and a 0.50 m swell from the
Southwest.
On 03 June 2014, the crew resumed
washing in cargo hold no. 1. As for the
previous day, the AB on the scaffolding
stage/ladder was wearing a safety helmet
and a pair of safety shoes. A safety harness
was attached to the lifeline, which ran
across the hatch opening. The AB was
assisted by two deck crew members who
shifted the scaffolding stage/ladder as
required under the supervision of the bosun.
Narrative
On 31 May 2014, Johann Oldendorff left
Nantong Shipbuilding Yard in China, on a
ballast voyage for Cape Flattery in Australia.
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At about 1410, the crew released the wheelbrakes and closed the outriggers, in
preparation to shift the scaffolding
stage/ladder. Unknown to the bosun and the
other crew members below, the AB had
disconnected the safety harness. As the crew
started pushing the scaffolding stage/ladder,
it tottered and toppled over (Figure 2) with
the AB falling down to the cargo hold from a
height of about 6.0 m.
condition was frequently monitored and
reported to CIRM. On 04 June 2014, at
0830, the injured AB was evacuated by
helicopter for treatment in Manila.
Injured AB’s diagnosis
The injured crew member was admitted to
hospital on the same day he was evacuated
from the ship. He was diagnosed to have
suffered injuries to his spinal column,
fractures of one rib, a lacerated wound, and
contusion hematoma on both kidneys. The
AB also suffered from moderately
extensive muscle strain and partial tears.
The injuries necessitated two spinal
surgeries and sessions of physiotherapy.
Safe working practice
Safe working practice was addressed in
Document PR-SE-05, which was an
integral part of the Company’s Safety
Management System on board. In addition
to placing the onus on the master and other
crew members with respect to safe working
practice, the document addressed a number
of general and specific precautions, which
had to be taken by the crew members.
Figure 2: Scaffolding stage/ladder after the
accident
Post-accident events
The accident was reported to the bridge and
both the master and the second mate rushed
to the injured AB and administered first aid.
The document addressed the situation
where crew members were expected to
work at a height. It made specific reference
to either wearing a safety harness with a
lifeline or other fall arresting devices.
Supervision of the work by a responsible
person was also a requirement.
At 1437, the master altered course to the
nearest coast in the Philippines for medical
assistance. In the meantime, the Company’s
emergency response team was also informed
and the master was directed to call the
MRCC in Manila. As helicopter assistance
was not immediately available, the
Philippines Coast Guard arranged for a boat
to evacuate the injured AB. However, in
order to ensure a more timely response, the
managers arranged for a private helicopter to
transfer the AB ashore.
The document, however, made no specific
reference to work on scaffolding.
Aluminium scaffolding stage/ladder
The aluminium scaffolding stage/ladder in
use at the time of the accident was
manufactured by a company in China and
certificated to ISO 9901:2008 quality
standard (Figure 3).
Following medical advice from the Centro
Internazionale Radio Medico, Rome (CIRM),
the AB was given pain killers and carefully
transferred to the ship’s hospital.
His
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201406/001
5.
After moving or assembly, the scaffold
wheels should be braked and locked.
6.
After working, make sure the scaffold
dismantle from up to down, all the parts
and components should be delivery one
by one which by hand or by rope, even
by other tools and ways (sic).
Evidence indicated that the scaffolding
stage/ladder was neither damaged nor
unsafe for use.
ANALYSIS
Figure 3: ISO 9001:2008 Certificate
Aim
The purpose of a marine safety
investigation is to determine the
circumstances and safety factors of the
accident as a basis for making
recommendations, and to prevent further
marine casualties or incidents from
occurring in the future.
The scaffolding stage/ladder came with a
configuration list and a drawing on the
assembly procedure (Figure 4).
Effects of environmental conditions on
the vessel
The vessel’s motion in the prevailing
weather conditions was not reported to be
excessive or to the extent that it jeopardised
the health and safety of the crew members.
Environmental conditions were therefore
not considered to be a contributing factor to
the accident.
Figure 4: Drawing showing assembly procedure
The scaffolding stage/ladder also carried a
document on its operational limitations/use
as indicated below:
1.
Don’t use defective or damaged parts.
2.
Please follow the installation sequence
and the permissible load of scaffolding.
3.
4.
Safety concerns
Falls from heights are a common cause of
injuries and even loss of lives. Accident
data also indicated a number of common
factors, including:
Failure to recognise a problem;
It is strictly prohibition to suspense (sic)
heavy goods around scaffold, and avoid
two people up and down the ladder at
same time.
Failure to ensure that safe systems
of work are followed;
Inadequate information, instruction,
training or supervision provided;
and
Please make sure all the workers come
down from the scaffold platform before
moving.
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been assembled in accordance with the
manufacturer’s instructions, it is very likely
that the equipment was unstable when it
was pushed by the crew members to a
different area inside the cargo hold.
Failure to use appropriate safety
equipment.
The contributing factors in other accidents,
researched by the MSIU, were also relevant
to this case although for instance, it is not
entirely clear to the MSIU as to why the
safety harness had been disconnected by the
AB.
Risk identification and evaluation
It may be submitted that in order to clean
the upper section of the cargo hold, the
crew members had no alternative but to use
the scaffolding stage/ladder available on
board.
It was concluded that the immediate cause of
the accident was the shifting of the
scaffolding at a time when the AB was still
on the upper level. The safety investigation
identified three possible causes to this
inappropriate approach:
1.
The crew members were unaware of
the manufacturer’s requirement not to
shift the scaffolding stage/ladder,
when a person was on it;
2.
The approach taken would have saved
time and avoided the need to have the
crew member coming down and then
climb up again; and / or
3.
The procedure may have already been
carried out on a number of occasions
without an accident.
Working at a height would have required
proper planning and the job assessed for the
potential risks involved. Section 4.9 of
Document
PR-SE-05
required
risk
assessments to be carried out in cases of
hazardous or dangerous non-routine jobs. It
was not clear whether the crew members
were previously engaged in cargo hold
washing (hence a routine job falling outside
the scope of this requirement). However,
even if that was the case, there was still an
option for a risk assessment to be carried
out prior to taking other dangerous work, if
deemed necessary.
Considering that the crew members were
familiar with the safety management system
on board the ship and hence the instructions
mentioned above, it may be concluded that
they were convinced that the safety
precautions taken would have sufficed and
deemed that no risk assessments were
necessary.
Evidence indicated that prior to the accident,
the AB on the scaffolding stage/ladder and
the other crew members below were not
properly supervised, particularly at the
moment of shifting the equipment.
This was a procedural lapse on the part of
one of the crew members. At the time of the
accident, the crew member responsible for
the supervision of the task was reportedly
handling water-hoses and neither observed
the shifting of the scaffolding stage/ladder
with the crew member on the upper level, nor
did he notice the disconnected safety harness.
The lack of a formal risk assessment meant
that the crew members were unable to
consider all the hazards related to this job,
which would have encompassed the shifting
of the equipment when someone was still
on the upper platforms1.
Moreover, the manufacturer’s instructional
documents on the scaffolding stage/ladder
were not available on the ship and the crew
members were unaware of its limitations and
assembly procedure. Whilst it is unclear as
to whether the scaffolding stage/ladder had
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5
Given that the AB had a safety harness, it was
suggestive that an ‘informal’ risk assessment had
been carried out and there was a degree of
awareness of the risk of a fall from a height.
This did not necessarily mean, however, that the
awareness was complete and accurate.
201406/001
CONCLUSIONS
1.
2.
3.
4.
SAFETY ACTIONS TAKEN DURING
THE COURSE OF THE SAFETY
INVESTIGATION2
The immediate cause of the accident
was the shifting of the scaffolding at a
time when one crew member was still
on its upper platform.
Following the accident, the Company
adopted a number of safety actions with the
aim of preventing similar future accidents:
The safety harness was detached and
therefore was unable to serve its
purpose.
Adopted safe working instructions on
the use of scaffolding stage/ladder in
the vessel’s QSE system;
The crew and the bosun did not notice
that the AB had disconnected the
safety harness from the safety line.
Circulated a safety instructional
document on working with scaffolding
stage/ladder on all vessels under its
management;
Three possible causes related to the
inappropriate approach taken by the
crew members were:
Unawareness
of
the
manufacturer’s requirement not to
shift the scaffolding stage/ladder,
when a person was on it;
Saving on time and avoid having
the crew member coming down
and then climb up again; and / or
The procedure may have already
been carried out on a number of
previous occasions without an
accident.
5.
The AB on the scaffolding
stage/ladder and the other crew
members below were not properly
supervised.
6.
The manufacturer’s instructional
documents on the scaffolding
stage/ladder were not available on the
ship and the crew members were
neither aware of the equipment’s
limitations nor of the assembly
procedure.
7.
The crew members were convinced
that the safety precautions taken
would have sufficed and deemed that
no risk assessment was necessary.
8.
The Company’s safe working
procedures of personnel working
from a height were not complied
with.
Prohibited the shifting of scaffolding
stage/ladder when persons are aloft the
scaffolding stage/ladder; and
Ensured that a responsible person sees
that no crew member is on the
scaffolding stage/ladder when it is
unsecured or being shifted.
RECOMMENDATIONS
In view of the actions already taken by the
managers, the MSIU did not issue any
recommendations.
2
MV Johann Oldendorff
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Safety actions should not create a presumption
of blame and / or liability.
201406/001
SHIP PARTICULARS
Vessel Name:
Johann Oldendorff
Flag:
Malta
Classification Society:
Nippon Kaiji Kyokai
IMO Number:
9684471
Type:
Bulk carrier
Registered Owner:
Arkadia Shipping Inc.
Managers:
Oldendorff Carriers GmbH
Construction:
Steel
Length Overall:
199.9 m
Registered Length:
197.0 m
Gross Tonnage:
34612
Minimum Safe Manning:
14
Authorised Cargo:
Dry bulk
VOYAGE PARTICULARS
Port of Departure:
Nantong, China
Port of Arrival:
Cape Flattery, Australia
Type of Voyage:
International
Cargo Information:
In ballast
Manning:
21
MARINE OCCURRENCE INFORMATION
Date and Time:
03 June 2014 at 1410 (LT)
Classification of Occurrence:
Serious Marine Casualty
Location of Occurrence:
17° 31’N 126° 54’E
Place on Board
Cargo hold
Injuries / Fatalities:
One serious injury
Damage / Environmental Impact:
None
Ship Operation:
On passage
Voyage Segment:
Transit
External & Internal Environment:
Clear weather and six knot Westerly wind.
Southwesterly swell of 0.50 m high
Persons on board:
21
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