UK MAIB Investigation: Able seaman fatally crushed onboard RoRo

UK MAIB has issued an investigation report into an incident where an able seaman was fatally crushed between a reversing trailer and the vessel’s structure during vehicle deck loading operations on a Malta-registered roll-on/roll-off cargo vessel alongside at Purfleet, England.

The incident

At about 1711 on 13 July 2024, an able seaman was fatally injured on board a Malta registered roll-on/roll-off cargo vessel when he was crushed between the rear of a moving trailer and the vessel’s structure. The vessel was alongside at Purfleet, England, loading and discharging trailers using the terminal’s tugs under the direction of the ship’s crew.

One of the two able seamen who were working on the vehicle deck passed behind a trailer while it was being loaded, likely assuming that the tug driver had completed manoeuvring the trailer. Unaware of the able seamen’s position, the tug driver reversed the trailer again to realign it. The able seaman was crushed between the trailer and the vessel’s structure, causing fatal injuries.

The investigation found that the vessel management company’s new vehicle deck cargo operations safety procedure was not well understood by the vehicle deck crew and that they routinely entered the defined danger zone around manoeuvring vehicles and trailers.

The lack of understanding highlighted weaknesses in the training and implementation of the new procedure, and that the tug driver’s knowledge of danger zones and the requirement to stop when a crew member was out of sight did not align with their actual working practices.

The investigation also established that there was ineffective supervision on the vehicle deck. Although the terminal carried out audits of vehicle deck operations, the vessel’s management company had not provided effective assurance to confirm that the new safety procedure had been understood or fully implemented on board.

Since the accident, the terminal operator and the ship management company have taken several steps to improve vehicle deck safety, including the issuing of safety bulletins; trialling the use of blind spot cameras on tugs; reviewing the positioning of on board closed-circuit television cameras; developing training videos; and introducing new audit procedures.

Safety issues directly contributing to the accident that have been addressed or resulted in recommendations

1. The able seaman was fatally injured when he passed behind a reversing trailer and was trapped and crushed against the vessel’s structure.
2. The interaction between AB1 and the tug driver was based on assumptions instead of positive feedback, with the result that neither had a clear understanding of what the other was doing. This placed AB1 at risk from the manoeuvring trailer.
3. The new cargo operations safety procedure provided a weak safeguard that did not articulate key safety messages and was not followed. Consequently, ABs regularly entered the danger zone behind moving trailers, placing them at risk.
4. The safe execution of a trailer’s manoeuvre relied on AB1’s positioning because the tug driver moved the trailer after AB1 had moved out of sight. The terminal’s cargo handling manual did not explain the new vessel procedure or define the danger zone, which meant that the tug driver was potentially unable to recognise when AB1 was at risk.
5. The two ABs on the garage deck were working independently of each other. Consequently, they were not monitoring each other’s safety and were unable to cross-check or stop trailer movements when unsafe actions occurred.

Other safety issues not directly contributing to the accident that have been addressed or resulted in recommendations

1. Industry guidance that tug drivers should stop when they lost sight of the crew member did not reflect the operational reality that it was not always possible to keep the marshalling crew member visible. This probably contributed to the procedure not being followed, placing vehicle deck crew at risk.
2. The new vessel procedure’s training programme was ineffective and failed to ensure the ABs understood the procedures. This meant that the crew were unsure what to do, placing them at risk.
3. The use of a whistle as a stop signal is ineffective when more than one trailer is manoeuvring on the same deck. There is a risk of miscommunication when crew members are marshalling more than one trailer simultaneously.
4. The ineffective supervision and control of vehicle deck operations on the garage deck resulted in a lost opportunity to reinforce the new vessel procedure’s safety elements or identify and prevent unsafe practices.
5. The ship management company did not provide effective assurance to confirm the latest procedures were effective or had been safely implemented on board, which meant a missed opportunity to review and enhance operational safety on the vehicle decks.
6. Industry guidance on ro-ro vehicle deck operations relied heavily on the misconception that drivers depend on marshallers to safely position their trailers and will stop their vehicle if they lose sight of their marshaller. Further, in the absence of positive feedback mechanisms, safety is contingent on crew making assumptions about when a trailer has stopped moving and is safe to approach. Consequently, operators continue to develop ineffective procedures and the risk to personnel working on vehicle decks persists.

Actions taken by the Marine Accident Investigation Branch

The Marine Accident Investigation Branch, in its Clipper Pennant investigation report, made a recommendation to the UK Chamber of Shipping and Port Skills and Safety Limited to:

2024/148 Develop a jointly agreed and consolidated industry Code of Practice for vehicle deck safety on roll-on/roll-off vessels by consulting with the Maritime and Coastguard Agency, Health and Safety Executive, Interferry, and ro-ro ferry operators, considering existing best practice guidance and the lessons learned from this accident and other previous similar accidents. The guidelines should cover, inter alia:

• The role, responsibilities and positioning of banksman while marshalling on vehicle decks in or near the path of a moving vehicle
• The dynamic nature of vehicle deck loading operation that reflects the moving danger zone around a semi-trailer
• Identification and risk mitigation of vehicle stowage spaces with limited or obstructed areas for escape
• Suitable control measures to reduce the risk to people working in close proximity to moving vehicles, including the development of cargo handling procedures and safe systems of work
• Safe access arrangements for crew during and after cargo operations
• An agreed industry standard for signalling and communication on vehicle decks
• The use of technology to improve safety on deck

Actions taken by other organisations

The terminal operator has:

• Following a successful blind spot camera trial, fitted all tugmasters in use at its UK terminals with blind spot cameras
• Maintained ongoing audits of the positioning of the marshalling crew during vehicle deck manoeuvres
• Issued a fleet information bulletin about crew positioning
• Provided crew with the opportunity to see the view from a tug to understand the limitations of visibility

The ship management company has:

• Issued a fleetwide safety bulletin and completed a focus area campaign on the implementation of cargo operation safety procedures
• Developed and distributed training videos about personnel safety on ro-ro vessel cargo decks
• Updated job descriptions to emphasise the responsibility of the master and officers in ensuring compliance with cargo operation safety procedures
• Reviewed the RCOM Section 4.7 – Safety during (un)loading operations
• Started a programme of unannounced cargo safety audits
• Introduced the requirement for vessel masters to perform an unannounced cargo safety audit when instructed by the office
• Issued translated copies of some of its procedures, including Filipino, Russian, and Ukrainian versions of the RCOM Section 4.7
• Started a review of the near miss reporting system
• Started a review of on board CCTV installations in conjunction with the terminal operator

Recommendations

The Marine Accident Investigation Branch’s previously issued recommendation 2024/148 is superseded, and the following amended recommendation is issued in its place:

The UK Chamber of Shipping and Port Skills and Safety Limited are recommended to:

2026/130 Develop an industry Code of Practice for vehicle deck safety on roll-on/roll-off vessels by consulting with the Maritime and Coastguard Agency, Health and Safety Executive, Interferry, and roll-on/roll-off ferry operators. The guidelines should cover, among others:

• effective separation of personnel and moving vehicles
• the role, responsibilities, positioning and supervision of crew members and shoreside personnel working on vehicle decks
• the dynamic nature of vehicle deck operations that reflects the moving danger zone around vehicles
• the need for positive feedback to assure crew that a trailer is stopped and is safe to approach
• identification and risk mitigation of vehicle stowage spaces with limited or obstructed areas for escape
• harmonisation of ship and shoreside cargo handling procedures, including signalling and communication on vehicle decks
• effective training of harmonised ship and shoreside cargo handling procedures
• the use of technology to improve safety on deck
• source : safety4sea