Transport Malta Investigation: Fatal injuries to a crew member in the steering gear room

Transport Malta has published an investigation report regarding an incident that took place on 18 July 2022, whilst Sunny Isles was en route from Al Jubail, Saudi Arabia, to Durban, South Africa, in a loaded condition, the second engineer was organizing and inspecting chain blocks in the engine-room, along with two other crew members.

The incident 

While looking for additional material required for the task, the other crew members found the second engineer trapped and unresponsive between a
collapsed stack of spare steel plates and a guard rail, in the steering gear room. The second engineer suffered serious injuries and was evacuated to a
shore hospital, by helicopter. However, he was pronounced dead on arrival. The safety investigation considered it likely that the stack of steel plates collapsed onto the second engineer, after a turnbuckle securing pin and its split pin slipped out, while he was either removing or inspecting a chain block in the
plates’ securing arrangements. In view of the safety actions taken by the Company, no recommendations have been issued by the MSIU. 

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.

Cause of fatal injuries

In the absence of medical and autopsy reports, the safety investigation believes that the second engineer suffered fatal injuries, shortly after the stack of spare steel plates tipped over and fell onto him.

Probable cause of the tipping over of the steel plates

The data available to the safety investigation suggested that the securing arrangement for the stack of steel plates had been released. Since there were no witnesses to this occurrence, the safety investigation was unable to determine whether this was done intentionally and therefore, four hypothetical scenarios were considered in which the second engineer may have:

1. intentionally released the turnbuckle securing pin and slackened the chain block;
2. intentionally released the turnbuckle securing pin to access the chain block, following which, the chain block hook may have slipped;
3. intentionally slackened the chain block, during which, the split pin followed by the turnbuckle securing pin may have accidentally fallen out; or
4. accidentally released the chain block hook and the split pin, which resulted in the release of the turnbuckle securing pin.

It must be stated that the stack of steel plates was secured by wire slings and a turnbuckle, with the chain block meant to act as an additional means of securing. Bearing in mind the task that the second engineer was carrying out, the safety investigation considered it likely that his intentions were to release the chain block for inspection. Considering that the wire slings and turnbuckle were in place, he may have believed that the release of the chain block would not pose any hazard.

It is also possible that the second engineer may have viewed the use of the chain block in the securing arrangement as redundant and therefore, he intended to remove it altogether and store it on the newly installed hangers in the engine-room store. As the turnbuckle and chain block were securing the stack of spare steel plates, the safety investigation considered it highly unlikely that the second engineer would have intentionally released both arrangements (i.e., scenario ‘a’). Rather, it is more likely that he may have intentionally released only one of them.

In the case of scenario ‘b’, the intentional release of the turnbuckle may have been carried out to gain access to the chain block for a visual or physical inspection. This would have been a highly likely scenario, if the chain block, or any part of it was tightly wedged between the turnbuckle and the steel
plates. For an unknown reason, the hook(s) of the chain block may have slipped out during this inspection once the turnbuckle was released.

If any part of the chain block was not wedged between the turnbuckle and the steel plates, and the chain block was easily accessible, it is likely that the second engineer may have intentionally released the chain block to inspect and / or transfer it to the store, during which the split pin and the turnbuckle pin slipped out (scenario ‘c’). It could not be excluded that the second engineer may have attempted to inspect the chain block without releasing it, and that the release of its hook may have been accidental. If this was the case, it is possible that the split pin and turnbuckle securing pin may have slipped out while he was inspecting the chain block (scenario ‘d’).

For scenarios ‘c’ and ‘d’, it is also likely that the split pin may have slipped out much earlier before the occurrence and may have gone unnoticed. 

Conclusions

1. The second engineer was found trapped between a stack of spare steel plates and guard rails in the steering gear room, with fatal injuries.
2. The crew members found that the securing arrangement’s turnbuckle securing pin and its split pin were not in place.
3. The turnbuckle securing pin and its split pin may have either been removed or slipped out at one point, resulting in the collapse of the stack of spare steel
   plates.
4. It is likely that the second engineer was either inspecting or removing the chain block, which was meant to serve as an additional means of securing the stack of spare teel plates, when the stack collapsed onto him.
5. No damages were observed to any of the gear in the securing arrangement.
6. No formal risk assessment was carried out and recorded.
7. It is highly likely that a dynamic risk assessment by the second engineer would not have enabled him to identify all associated hazards, thus reducing
   the effectiveness of his risk assessment.

Safety actions taken during the course of the safety investigation 

Following the accident, the Company took the following safety actions:

1. Company’s representatives attended the vessel, and conducted various training sessions and safety briefings with the crew members;
2. a safety bulletin with details of the accident, was circulated across the Company’s fleet;
3. new storage racks were fabricated for the spare steel plates, pipes, and other heavy material on board Sunny Isles, followed by all other vessels in the
   Company’s fleet;
4. the status of the storage / racking and safe handling of heavy material on board all vessels in the Company’s fleet, was reviewed / verified by
   superintendents in the fourth quarter of 2022;
5. unnecessary heavy material, was landed ashore at convenient ports, from all vessels in the Company’s fleet;6. the Company added various computerbased training programmes to their competency management system, for shipboard and shore staff;
6. the Company’s safety management system was revised, and a new control of work process (emphasizing toolbox talks, risk assessments, use of permits
   and checklists, reporting procedures, etc.) was introduced as part of the permit to work system; and
7. risk assessments were prepared and / or revised for the preparation of storage racks and for the safe handling of heavy material on board all vessels
   in the fleet.

Recommendations

Taking into consideration the Actions taken by the Company, no recommendations have been made.