Download Report

Marine Safety Investigation Unit
SIMPLIFIED SAFETY INVESTIGATION REPORT
201406/020
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.
© 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.
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 Fantastic
REPORT NO.: 14/2015
June 2015
MV FANTASTIC
Serious injury to crew member
in position 05° 37.8’N 097° 54.3’E
16 June 2014
Course of events
Fantastic was enroute to Hazira,
India from Tanjing, Indonesia
with 55,000 metric tonnes of
coal in bulk. On 16 June 2014,
at approximately 0800 (LT),
whilst navigating the Malacca
Straits, the chief mate and an
able seaman (AB) proceeded on
deck to secure the freefall
lifeboat. The vessel was heading
to the Western coast of India and
the master had requested
additional lashing due to the
monsoon season in the area.
Just
before
the
accident
happened, the chief mate was
positioned on the lifeboat
embarkation platform, holding
the lifeboat’s lifting block. The
AB was tasked to operate the
hydraulic control levers fitted to
the lifeboat’s davits on the poop
deck level. The chief mate and
the AB were not in direct line of
sight, although it was not
impossible to see one another.
The third mate was standing
nearby, watching the two crew
members.
1
The ‘hydraulic control station’ at
the foot of the lifeboat’s davits is
fitted with two levers, connected
to hydraulic spool valves. The
left hand (i.e. aft control lever in
relation to the ship) operates the
winch. The right hand lever
(forward lever) operates the
hydraulic control to swing in /
out the lifeboat’s davits (for
recovery purposes).
After the chief mate and the AB
positioned themselves in their
respective points, the former
instructed the AB to heave up
the lifting block. The AB briefly
operated the lever and heaved up
the block, waiting for directions
from the chief mate.
During the process, the chief
mate ordered the AB to lower
the lifting block, instructing him
to stop a while later. Eventually,
the chief mate instructed the AB
to lower it even further. Instead,
the AB heaved up the block.
Consequently, the chief mate’s
fingers were caught between the
201406/020
the lifting block and the lifeboat’s davit
(Figure 1), resulting in a severe injury.
Fixed part of the
lifeboat davits
Area where chief mate’s
finger was injured
Lifting block
Figure 1: Lifeboat davits’ lifting block
Extent of reported injuries
The injuries which the chief mate suffered to
his fingers were serious and required
immediate medical assistance ashore.
However, they were not life threatening. The
chief mate was eventually landed ashore in
Indonesia and treated in a local hospital
before he was repatriated. As a result of the
injuries, the chief mate lost part of his third
finger and a sustained a fracture in another.
Condition of the equipment and
familiarisation
Documentary evidence from the ship
suggested that the AB was familiar with the
operation of life saving equipment. The
‘Ratings Familiarization Check List’ – SMS
Form No. 303003, indicated that the AB had
received his familiarisation training on 28
May 2014. The safety officer was the chief
mate.
It was also noticed that the responsibility of
the AB in the muster list was to operate the
lifeboat’s davits and the unlashing of the
lifeboat. There was therefore no doubt that
the AB was familiar with the equipment being
used at the time of the accident. Moreover, as
explained above, he had already followed the
orders of the chief mate twice before the
accident happened.
Probable cause of the accident
The AB claimed that just before the third
operation of the hydraulic lever, he thought
that he had heard the chief mate asking him
to hoist the lifting block again. In the
absence of contradictory evidence, it was
concluded that the probable cause of the
serious injury was one-way communication
between the chief mate and the bosun.
MV Fantastic
2
201406/020
The safety investigation did not come across
any evidence which suggested that the
equipment malfunctioned or was not well
maintained.
Thus, malfunction of the
hydraulic control system was ruled out.
mate and the AB was context and mutual
understanding – a communication type where
it is taken for granted that the receiving end
of the instructions has understood the
intentions.
Closed-loop communication only happens
when verbal instructions are repeated by the
receiver to confirm to the originator that they
have been well understood1. Closed-loop
communication increases the likelihood to
identify verbal instructions which would not
have been understood.
Effective communication
It had been established that the two crew
members, being of the same nationality, had
no language barriers. Moreover, as indicated
elsewhere, the lifeboat securing operation
had already started and no problems had been
experienced until the accident happened.
There were no indications that the chief mate
communicated simultaneous instructions in
the direction of the AB. However, because
the communication loop was not closed, the
two crew members did not share a mental
model – even more so, the AB had no
situation awareness of the position of the
block because he was standing on the poop
deck where the controls were fitted.
As indicated in Figure 2, it is very probable
that the chief mate and the AB were not in a
direct line of vision.
Chief mate
Third mate
SAFETY ACTIONS TAKEN DURING
THE COURSE OF THE SAFETY
INVESTIGATION2
AB
Control levers
Genel Denizcilik Nakliyati AS has issued a
safety alert to its bulk fleet, bringing to the
attention of the crew members serving on
board the details and findings of the internal
investigation carried out in terms of Section 9
of the ISM Code.
Figure 2: The accident site
Effective communication is essential in any
domain for the reduction of erroneous
actions. This is also applicable during
situations which are not classified as
emergency situations and hence are not
necessarily time-critical. Whilst it is very
probable that a pre-task briefing was not
required for this task (because it was
perceived to be a rather simple), it was
evident, however, that communication was
mono-modal,
i.e.
one
channel
of
communication – verbal.
Moreover, the communication procedure
during lifeboat drills and recovery of the
lifeboat has been revised and communicated
to the fleet.
The new procedure now
provides clear instructions on the operation
of the lifeboat davits winch and the
communication methods between the
responsible officer and the winch operator
Evidence suggested that rather than closedloop, the communication between the chief
MV Fantastic
3
1
For instance, closed-loop communication normally
happens on the bridge when the vessel is in manual
steering and therefore a helmsman is at the wheel.
2
Safety actions should not create a presumption
of blame and / or liability.
201406/020
RECOMMENDATIONS
As a result of the safety actions taken by the
Company, no recommendations have been
made.
MV Fantastic
4
201406/020
SHIP PARTICULARS
Vessel Name:
Fantastic
Flag:
Malta
Classification Society:
DNV - GL
IMO Number:
9456329
Type:
Bulk carrier
Registered Owner:
Fantastic Shipping Ltd.
Managers:
Genel Denizcilik Nakliyati AS
Construction:
Steel
Length Overall:
189.99 m
Registered Length:
185.64 m
Gross Tonnage:
33044
Minimum Safe Manning:
16
Authorised Cargo:
Solid bulk
VOYAGE PARTICULARS
Port of Departure:
Tanjing, Indonesia
Port of Arrival:
Hazira, India
Type of Voyage:
International
Cargo Information:
Coal in bulk
Manning:
24
MARINE OCCURRENCE INFORMATION
Date and Time:
16 June 2014 at 0800
Classification of Occurrence:
Serious Marine Casualty
Location of Occurrence:
05° 37.8’N 097° 54.3’E
Place on Board
Boat deck
Injuries / Fatalities:
One serious injury
Damage / Environmental Impact:
None
Ship Operation:
In passage
Voyage Segment:
Transit
External & Internal Environment:
Clear weather with good visibility and a fresh
Westerly breeze. Air temperature was recorded at
28°C.
Persons on board:
24
MV Fantastic
5
201406/020