Fatal injury to a crew member at Tallinn Shipyard
Summary:
On 19 May 2015, an able seaman on board the Maltese registered cargo vessel Kadri was found fatally injured on the quay. The vessel was alongside a lay by berth undergoing repairs at a shipyard in Tallinn, Estonia.
At the time of the accident the able seaman was reportedly standing on the cargo hatch cover, checking the hatch cleats prior to repairs by the shipyard. He was alone and no one witnessed the events leading to his fall. However, it was not excluded that he may have stumbled, lost his footing and fell over.
A shipyard employee found him on the quay, unresponsive and bleeding from the head. He was administered first aid and transported to the local hospital for further treatment. However, he died the following morning as a result of his injuries and hypovolemic shock.
On the basis of the safety actions communicated to the MSIU, no recommendations were issued to the Company.
Cause of Death:
The autopsy report revealed that the injured seaman had arrived at the hospital unconscious. He had multiple and very severe injuries including skull and skeletal fractures. All these fractures were consistent with a fall from a height onto a hard surface. The autopsy report concluded that death had resulted from Cerebral Oedema, cerebral contusion with haemorrhages under membranes and hypovolemic shock.
Conclusions:
- The serious injuries suffered by the able seaman were comparable with that of a fall from a height.
- The safety investigation did not exclude the possibility of the able seaman standing on the ship’s rails in order to reach for the cleats.
- It was considered probable that the able seaman’s movements, whether standing near the edge of the hatch cover or on the ship’s rails, faltered, lost his footing and fell down on the hard surface of the quay.
- The able seaman was not wearing a safety harness with a fall arrestor device attached to the safety line.
- The risk of falling overboard had been accepted by the crew member.
- It was not excluded that the risk perception of the crew member may have biased the intrinsic risk within the system, affecting the accuracy of his risk appraisal.
- The crew member may have either underestimated the actual risk and / or overestimated his personal capacity.
- There was no evidence of an applied ‘risk management culture’, which focussed on system safety with the application of various engineering techniques to identify hazards and, if possible, objectively quantifies risks.
Actions taken during the Course of Safety Investigation:
In the wake of the accident, the Company took the following safety actions:
- A Company Circular on the risk of crew member injuries was issued and circulated to all vessels, requesting a discussion among crew members. An extraordinary briefing / training on safety at work was also requested, focusing mainly on the Code of Safe Working Practice for Merchant Seamen and the Company’s SMS procedures. It was also required that special attention had to be paid to crew members working at a height, workplace arrangements and personal protective equipment;
- The safety investigation report, together with supporting documents was discussed internally during the Company’s management reviews. The SMS procedures related to safety at work were evaluated and amended as necessary. Moreover, safety audits carried out by the Company’s superintendents are now mandatory during each visit on board;
- The Ship’s Plan of Internal Audit in the SMS was revised and updated with items related to the safety audit. The Company’s Safety Manager is now required to conduct an additional safety audit, including a risk assessment of the ship’s routine work and checking of the crew’s personal protective equipment.
Source & Image credit: Transport Malta Published on 12 October 2016
