REPUBLIC OF CYPRUS MARINE ACCIDENT AND INCIDENT

INVESTIGATION COMMITTEE

[Investigation Report No: 55E / 2014] Very Serious Marine Casualty Crew member fatality due to fall into Cargo Hold, on the Container Ship “FEDERAL”, at the port of Busan – South Korea, on the 24th of October, 2014

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Foreward The sole objective of the safety investigation under the Marine Accidents and Incidents Investigation Law N. 94 (I)/2012, in investigating an accident, is to determine its causes and circumstances, with the aim of improving the safety of life at sea and the avoidance of accidents in the future. It is not the purpose to apportion blame or liability. Under Section 17-(2) of the Law N. 94 (I)/2012 a person is required to provide witness to investigators truthfully. If the contents of this statement were subsequently submitted as evidence in court proceedings, then this would contradict the principle that a person cannot be required to give evidence against themselves. Therefore, the Marine Accidents and Incidents Investigation Committee, makes this report available to interested parties, on the strict understanding that, it will not be used in any court proceedings anywhere in the world.

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GLOSSARY OF ABBREVIATIONS AND ACRONYMS AB - Able Bodied Seaman, an experienced and qualified member of the deck crew APT – After Peak Tank BA - Breathing Apparatus CC - Cargo Compartment (Cargo Hold) Foreman - Supervisor/Shore C/O – Chief Officer CoC - Certificate of Competency CYCOSWP – Cyprus Code of Safe Working Practices for Merchant Seamen DPA - Designated Person Ashore ISM Code - International Management Code for the Safe Operation of Ships Knots – Speed in nautical miles per hour ETA - Estimated Time of Arrival HC - Hatch Cover IMO - International Maritime Organization ILO - International Labour Organization LT - Local Time m - metre MT - Metric Ton OOW - Officer of the Watch OS – Ordinary Seaman PTW - Permit to Work RA - Risk Assessment Second Officer (2/O) SMC - ISM - Safety Management Certificate SMS - Safety Management System SOLAS - The International Convention for the Safety of Life at Sea 1974 (as amended) STCW - The International Convention on the Standards of Training, Certification and Watchkeeping for Seafarers 1978 (as amended VHF – Very High Frequency Hand Held Radio (Walky Talky) UTC - Universal Time Co-ordinated ZT - Zone Time

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Contents Glossary of Abbreviations 3 List of Figures 4 List of Annexes 4 1. Summary 5 2. Factual Information 6 2.1. Ship particulars 6 2.2. Voyage particulars 6 2.3. Marine casualty or incident information 6 2.4. Shore authority involvement and emergency response 6 3. Narrative 7 4. Analysis 10 5. Conclusions 16 6. Recommendations 16 List of Figures Figure 1: Photo M/V “FEDERAL” Figure 2: Photo of accident site List of Annexes Annex 1: Busan New Port Chart Annex 2: Ship’s Particulars Annex 3: Work Aloft /Oversite Permit Annex 4: Table of Shipboard Working Arrangements Annex 5: Records of Hours of Work or Hours of Rest of AB Annex 6: Records of Hours of Work or Hours of Bosun Annex 7: Duties of Deck Officer Annex 8: Duties of Bosun Annex 9: Duties of AB Annex 10: Safe manning Document Annex 11: Crew List Annex 12: Log Book extract (4 pages)

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1. Summary A fatality was investigated in which a sailor fell into the Cargo Hold of a Containership, from a Lashing Bridge via the open hatch cover. In conducting its investigation, the Marine Accident Investigation Committee (MAIC) reviewed events surrounding the accident, interviewed on board the ship the Master, the Second Officer and the Bosun, conducted extensive interview of the Chief Officer at Company’s Headquarters at Piraeus-Greece, reviewed documents provided by the Master and the ship’s Management Company and performed analyses to determine the causal factors that contributed to the accident, including any management system deficiencies. Accident Description The accident occurred on 24/10/2014 at approximately 12:45 LT at Busan-South Korea. The Bosun was working at No6 cargo hold’s aft lashing bridge, painting cell guides using an Aluminum Telescopic Rod with Roller. Seconds before, had ordered the sailor to check the mooring ropes forward and aft. The Bosun continued his job and suddenly, heard a loud scream “aaaaaaa”, then looked into the hold and saw the sailor lying motionless on the tanktop. He rushed panicked to the cargo control room and reported the event to the Chief Officer. The Chief Officer reported the event to the Master on his VHF. The Second Officer on duty (12-6) overheard on his VHF. The three Officers rushed to the scene of the accident. Maritime Police and Medico services subsequently attended. The deceased sailor’s body was transferred ashore by shore crane. There were no witnesses to the accident. However, the available evidence (photo taken immediately after the accident showing the position on the tanktop where he fell), indicates that at the time of the accident the sailor was near the opening of the railing (the opening provides access from the Lashing Bridge onto the Hatch Cover when it is closed) which is fitted with two horizontal chains. At the time of the accident, the upper one of the two horizontal chains was released. The painting roller and the helmet of the victim were found on the tanktop, close to the dead body. Few days later, after container cargo was discharged from the hold, the Aluminum Telescopic Rod was found in the hold. 5. Conclusions The Direct Cause of the casualty (death) was Skull Fracture and Rupture. Causes that led to death: Multiple fracture of Ribs and Hematothorax. Other condition not leading to death: Left side Tibia Fracture and right side wrist fracture The Immediate Cause of the accident which led to the fall of the AB into the hold: There were no eyewitnesses to the accident and the exact nature of the ABs fall is not known. It is assumed to have lost his balance when he attempted to paint the one remaining un-painted cell guide which is located beneath the opening (which is fitted with two horizontal chains) of the 1.20m high railing. The Contributing Causes of the accident were: It is assumed that Circadian Rhythm Desynchrony was a contributing factor to the accident. It is assumed that Inattention was a contributing factor to the accident. Failure to use defenses (barriers) i.e. Safety Harness (Personal Protective Equipment). Although there is no evidence, a sudden and unexpected extreme vibration could have contributed to the accident. 6. Recommendations Management Company by way of a circular or other means, to educate its crews, on Risk Assessment and Work Permit System, with particular emphasis on crew responsibility for carrying out the work and taking safety measures as described on the Work Permit.

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2. Factual Information 2.1. Ship particulars IMO: 9065625 Name of ship: FEDERAL Call sign: C4KK2 MMSI number: 212 711 000 Flag State: CYPRUS Type of ship: Container Gross tonnage: 51841 Length overall: 275.00 m Classification society: DNV Registered ship owner: Federal Marine Inc., 80 Broad Street, Monrovia-Liberia Ship’s Company: Danaos Shipping Company Ltd., Akti Miaouli 14, Piraeus Greece Year of build: 1993 Deadweight: 61153 MT Hull material: Steel Hull construction: Single Hull Propulsion type: Inernal Combustion Engine, Hyundai-B&W 12K90MC-C Type of bunkers: HFO & MDO Number of crew on ship’s certificate: 14 2.2. Voyage particulars Port of departure: Osaka-Japan Port of Destination: Busan-Korea Type of voyage: International Cargo information: Containers Manning: 25 Draft: Fwd= 8.60m Aft=7.45m 2.3. Marine casualty or incident information Type of marine casualty/incident: Very Serious Marine Casualty Date and time: 24/10/2014 @ 12:45 LT Position: Lat.: 35 10’ N - Long.: 128 49’ E Location: Port of Busan, South Korea External and internal environment: Slight sea, Day, Vis. good Ship operation and voyage segment: In port-Discharging Place on board: Cargo Compartment Human factors: Yes/ Human Error /Decision Consequences Death: 1 2.4. Shore authority involvement and emergency response Maritime Police and Medico services subsequently attended. The sailor’s body was transferred ashore by shore crane.

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3. Narrative Sequence of Events:

1. The ship’s schedule starts from Singapore, then to 4 ports in Australia, 2 ports in Japan, 1 port in South Korea, 3 ports in China, 4 ports in Australia and again Singapore. The last leg before the accident was from Osaka, Japan to Busan, South Korea.

2. On 22/10/2014 the M/V “FEDERAL”, departs from Osaka-Japan. 3. Sea passage from 22/10/2014 until 24/10/2014 i.e. 2 days. 4. Cell guides upper side painting was scheduled to be done during ship’s port stay

at Asia’s ports Yokohama, Osaka, Busan, before return to Australia. It was requested by Stevedores in Australia, in order to be well visible by cargo cranes operators during loading and discharging containers. The job is feasible to be performed, only when the Hatch Covers (HC) of the Cargo Holds are open, when the ship is moored in a port, and only when they are (the cell guides) not covered by containers.

5. Before arrival at Yokohama, the first port to commence the job, a Tool-Box meeting was convened on board the ship. At the meeting were present the Master, Chief Officer, (C/O) Bosun, the ABs. The Chief Officer referred to the job to be performed and underlined that safety comes first. For this purpose although the ABs would be standing on the Lashing Bridges to paint the cell guides, they should wear safety belts, attached on the railings which are located in front of the Lashing Bridge, for protection from fall in a hold. Also, the Chief Officer instructed that paint rollers should be attached on extension rods. It was not expected to finish the job before arrival at Australia, but they wanted to show to the Stevedores, good will.

6. The C/O prepared a plan showing the holds and the cell guides to be painted at each port. The plan was being given to the Bosun at each port. On sailing, the Bosun was giving the plan to the C/O with the painted cell guides, highlighted. Then, the C/O was giving it to the Master who was forwarding it to the Management Company.

7. The Bosun before commencing the task during and at the end of each day, was reporting to the C/O regarding its progress and safety performance.

8. The plan was implemented at Yokohama and Osaka. It was to be continued at Pusan.

9. On 24/10/2014 at about 06:45 Hrs LT, vessel arrives at Pusan, South Korea. 10. Cargo operations (loading and discharging containers) were determined by

Charterers from 24/10/2014 08:00 Hrs LT until 25/10/2014 01:30 Hrs LT. 11. Cargo operations commenced at 07:50 Hrs LT with 5 shore cranes (loading and

discharging containers). HC remain open during cargo operations. 12. Weather conditions good. No rain. Daytime. Vis. Good. 13. The C/O met with the Bosun in the cargo control room, shortly after mooring. He

gave him the plan showing the holds and the cell guides to be painted at the port and instructions for the safe performance of the job.

14. The C/O remained in the cargo control room. He was performing cargo and ballast operation, IMDG segregation, reefers handling and stowage. He was in continuous contact on the VHF with the Officer on Duty, who was on deck supervising (from the ship’s side), cargo operations, as well as ship’s safety and security.

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15. The Bosun went on the deck and reported to the C/O when commenced painting of the cell guides.

16. At 12:00 hrs LT cargo operations in progress. The Bosun did not make brake from 12:00 to 13:00 and had no lunch. He continued working i.e. painting cell guides. As he deposited, at Pusan many HC were open and was possible to work on cell guides. He wanted to work to finish the job.

17. The AB had lunch before 12:00 (not including beer - according to the Bosun, he was not drinking beer or vodka, nor smoking). His watch was from 00:00 until 04:00, therefore he had rest from 04:00 until 05:30 then woke up for the stand-by on arrival at Pusan and then again rested from 08:00 until 11:30. At 12:00 took over from his fellow AB, painting cell guides at No7 Cargo Hold.

18. At about 12:00hrs LT, the Second Officer (2/O) on duty 12-6 as soon as he commenced his watch, goes on deck aft and sees the AB working (painting cell guides using Aluminium Telescopic Long Rod with Roller ) at No7 Cargo Hold-Aft. He had started painting from the stbd side, moving towards port side. The AB stopped working and had a chat with the 2/O. The 2/O asked him “how are you?” and he said “very well”. According to the 2/O, he looked fine.

19. Then, the 2/O made a round on the deck and at about 12:30 hrs LT returned at No7 Cargo Hold. At that time the AB had finished with No7 and was stepping down from the port side ladder of the Lashing Bridge, in order to proceed to No6.

20. The 2/O stepped up on the No7 Lashing Bridge to supervise the discharging of the few remaining containers.

21. No6 Cargo Hold port side was empty of containers. The AB was at No6 Cargo Hold’s Fwd. The Bosun was at No6 Cargo Hold’s Aft-at Bay 43. They were painting the upper side of cell guides using Aluminum Folded Long Rod with Roller.

22. Bosun saw (looked at) the AB and told him to check the mooring lines fwd & aft (because the vessel was discharging very quickly and was necessary to adjust the mooring lines). The AB answered to the Bosun “OK”.

23. Bosun continued painting cell guides. Few seconds later, he heard a loud scream “aaaaaa”. He looked and saw the AB in the Cargo Hold onto the Tanktop lying motionless.

24. At about 12:45 hrs LT, Bosun rushed panicked and shocked to the cargo control room to inform the C/O. He was shouting: “He is falling, he is falling, he is dead”. The C/O asked him “Tell me which Bay” and he replied “in front of the Accommodation at Bay 42”

25. C/O rushed to the deck. Simultaneously notified the Master on the VHF. The 2/O (Duty Officer) overheard. All, (C/O, Master, Duty Officer) arrived in seconds at the scene of the accident. The C/O first and seconds later the 2/O and the Master.

26. C/O stepped up on the Lashing Bridge at No6 Cargo Hold. Looked down and saw the AB lying on the Tanktop in a distance of about 2m from the fwd bulkhead, his head looking downwards towards forward. He was wearing uniform, safety shoes, gloves and his helmet was disengaged. Close to him were his helmet and the painting roller without the aluminum extension rod. He was not wearing safety belt. On the Lashing Bridge close to the point of the fall was the paint bin. Over the fall position, there is an opening of the railings which is fitted with two horizontal chains. The upper chain was found by the C/O (according to his statement) released. The C/O noticed that the upper chain was released, because he attempted to look over to see into the hold and feared of fall.

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27. C/O realizes that the loading gang had not stopped but still working normally. He shouted and made signs with his hands to the crane operator and to the stevedores to stop.

28. Shore Crane stopped. 29. C/O asked the Duty Officer to bring stretcher. 30. Bosun returns from the cargo control room. The C/O asks him what (how)

happened. The Bosun said that they were working together. The AB was at No41 Bay (fwd) and the Bosun at No43 Bay (aft). At some time the AB left and then returned. The Bosun told him, before you start working go to check the ropes. The Bosun continued painting cell guides, and few seconds later heard a scream “aaaaaaaa” and saw the AB lying motionless with face down in the hold.

31. C/O goes to cargo control room takes his camera, returns to the scene and takes photographs. Returns to cargo control room and sees the Bosun sitting in the alleyway outside of the cargo control room, holding his head. The C/O thought to ask him about what happened but considering his psychological situation, left it for later.

32. Maritime Police arrives with the ship’s Agent. Took photographs. 33. Medico services attended. Examined and then covered the dead body with a sheet.

The sailor’s body was transferred ashore by shore crane. 34. At about 16:00-17:00 hrs LT, the Bosun and C/O were taken by Maritime Police

ashore for giving depositions. Depositions were signed by fingerprint. The Master went with them, although he was not interviewed by Maritime Police.

35. The deceased ABs personal belongings were recorded on board and along with his documents, were delivered to the ship’s local Agent in order to be sent to his family.

36. According to the Death Certificate (post mortem as death certificate), issued on 24/10/2014 by the Director of the “Seo-won Convalescent Hospital”: Cause directly leading to death: Skull Fracture and Rupture / Immediately Conditions that lead to death: Multiple fracture of Ribs and Hematothorax. Other conditions not leading to death: Left side Tibia Fracture and right side wrist fracture. Kind of incident: Unintentional fall in ship’s cargo hold.

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4. Analysis (The purpose of the analysis is to determine the contributory causes and circumstances of the accident as a basis for making recommendations to prevent similar accidents occurring in the future). The following analysis draws on documents provided by the Master and the ship’s Management Company and written statements taken on board the ship from the Master, the Second Officer and the Bosun and an extensive interview of the Chief Officer at Company’s headquarters at Piraeus-Greece. 4.1 The Crew Crew Certification Containership “FEDERAL” was manned with crew licensed, qualified and medically fit in accordance with the requirements of the International Convention on Standards of Training Certification and Watchkeeping (STCW) Convention as amended. A lack of certification was not a contributory factor to the accident. Manning level At the time of the incident, she was manned well in excess of the vessel’s Minimum Safe Manning Document. She had a crew of 25, although her Minimum Safe Manning Document provides for 14. The Master, Chief Officer, Second Officer, Chief Engineer, Second Engineer and Apprentice Officer were Greeks, the Third Officer, Third Engineer, 2 Forth Engineers, Electrician, Bosun, 3 ABs, 1 OS, 3 Fitters, and 1 Cook were Ukrainians, 2 Wipers and 2 Mess-boys were Tanzanians, 1 Fitter Moldavians and the victim was the only one Russian AB. A lack of manpower was not a contributory factor to the accident. Alcohol Impairment According to the Bosun, the AB was not drinking beer or vodka, nor smoking. The AB had lunch between 11:30 to 12:00. The Bosun had no lunch at all. There was no evidence to suggest that alcohol or drugs were taken by any of the crew members involved in the accident. Fatigue The deceased AB’s watch was 12-4. Therefore he had rest from the previous day from 16:00 until 24:00 i.e. 8 hours. Then from 00:00 until 04:00 he was on watch. At 05:30 stand-by on arrival. If he woke up half an hour before, it means that he had one hour rest, which is not enough time to sleep. Then again rested from 07:00 until 11:30. This means that he may have slept about 4 hours. At 12:00 took over from his fellow AB. The Bosun started working from 04:00hrs before berthing, he was active during stand-by on arrival and berthing and continued working until 12:00hrs. After 8 hours of work, he did not want to have either lunch or rest from 12:00 until 13:00. As he deposited, he wanted to finish the job (i.e. the painting of the cell guides). Due to the fact that he had rest from the previous day 23/10 at 18:00 until 04:00 in the morning of the 24th (the day of the incident), means that he was in compliance with the requirement of the MLC,2006

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to have 10 hours rest in every 24 hour period, even if he continued working until 18:00 hrs. Fatigue was not considered a contributory factor, due to those on watch being rested prior to undertaking duty, more than 6 hours. Organization on board Shipboard Working Arrangements when in Port: While in port the scheduled daily work hours of the Chief Officer and the Bosun who perform non-watchkeeping duties are from 06:00 until 18:00 . Watchkeeping duties are performed by the Second Officer (00-06) - (12-18) and the 3/O (08-12) - (20-24). Three ABs (AB1, AB2, AB3) perform watchkeeping duties AB1 (08-12)-(20-24), AB2 (00-04)-(12-16) AB3 (4-8)-(16-20). Two OSs perform non-watchkeeping duties from 06:00 until 18:00. One Cadet performs non -watchkeeping duties from 08:00 until 17:00. Lunch is being offered between 12-13. There is no reference in the ship’s “Table of Shipboard Working Arrangements” regarding the usual one-hour brake for lunch between 12-13. The accident happened at about 12:45 hrs LT. The Bosun had not had lunch. The C/O was in the cargo control room controlling all operations. At the time of the accident i.e. at about 12:45, on watch were the Second Officer (00-06) - (12-18), and the AB2 (12-4)-(12-16). Rank Age On Board

Years Experience Total At Rank

Master (STCW II/2)

Greek 47 80 days 24 4

Chief Officer (STCW II/2)

Greek 34 22 days 8 1,5

Second Officer (STCW II/2)

Greek 30 70 days 6 2

Bosun (STCW II/4)

Ukrainians 47 35 days 25 4

A.B. (STCW II/4)

Russian 35 35 days 8 5

The 2/O was holder of STCW II/2-certificate of competency. He was being trained by the C/O, in order to undertake the duties of the C/O for first time in his career. The A.B.1 and the Bosun were holders of STCW II/4-Certificate “Deck Rating, Support Level” They were communicating in the Russian language. There was no language barrier between them. They were communicating in the English language with their Greek Officers. Their duties corresponded to their qualifications and experience. There was no evidence to suggest that, the organizational conditions on board were a contributory factor to the accident. Working and Living Conditions At the time of the incident, the ship had valid Maritime Labour Compliance Certificate (MLC) along with a Declaration of Maritime Labour Compliance (DMLC) issued by her flag state.

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There was no evidence to suggest, that, the working and living conditions was a contributory factor to the accident. Physiological, Psychological, Psychosocial Condition All crew members involved were holders of medical certificate for service at sea issued in compliance with the STCW and MLC, 2006 Conventions as amended. They were certificated as fit for sea duty without restrictions and not suffering from any medical condition likely to be aggravated by service at sea or to render the seafarer unfit for such service or to endanger the health of other persons on board. There was no evidence to suggest that their physical, physiological, psychological, or psychosocial condition was such that could have contributed to the accident. They were physically and mentally fit to perform their job. 4.2 The Ship M/V “FEDERAL” is a Cellular Containership, built at Hyundai Heavy Industries Co. Ltd Korea, Year of built 1994 with DWT (Summer) 61152, GT/NT 51841 / 22101. She has LOA 275m, Beam 37,1m, Depth Moulded 21,7m, Draft (Summer) 13,6m Container Capacity: Nominal 4651 TEU, Reefers 350 Units, Homogeneous 14MT/TEU 3626 TEU Stackweights: In holds 20ft: 200MT / 40 ft: 280MT-On deck 20ft:80MT / 40 ft: 100 MT Engine Particulars: Main Engine HYUNDAI B&W 12K90MC-C MCR 67080 BHP x 104.0 RPM Generators 2 Sets x 2187,5 KVA and 2 Sets x 1937,5 KVA Bow Thruster 1 x 2000 kW Speed / Consumption: at sea abt 25.1 knots on abt 180.4 M/T HFO (380cst) plus 6 MT HFO (380cst) for DG - excluding reefers In port abt 6 M/T HFO (DG) + 4 M/T HFO for boiler, if working, - excluding reefers She has Seven (7) Holds and / Sixteen (16) / Hatches Between holds i.e. between 1-2, 2-3, 4-5, 5-6 there are Lashing Bridges The Lashing Bridges are fitted with railing with height 1.20m for protection from fall The Lashing Bridge’s floor, consists of Anti-Slip Galvanized Gratings At the time of the accident, she was classed with the DNV and had valid certificates including an ISM certificate. The maintenance records indicated that she was maintained in accordance with existing regulations and approved procedures. There was no evidence of any defect or malfunction that could have contributed to the accident. 4.3 The Environment External environment The weather conditions were mild and the visibility was good. It was noisy because of the loading/unloading operation. Vibrations were caused by the lowering-sitting / raising-unsitting of containers. Although there is no evidence, a sudden and unexpected extreme vibration could have contributed to the accident.

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4.4 Safety Management The vessel’s Management Company has a comprehensive safety management System (SMS) which is well documented and analyses risk. Are the Lashing Bridges considered as “aloft” place? In principle, when working aloft, bosun chairs, stage boards or scaffolding is being used. Therefore working on a Lashing Bridge where the worker is standing on its floor (and not two metres heigh above its floor) is not considered as work aloft. A Tool-Box meeting was carried out, before arrival at Yokohama, the first port to commence the job. At the meeting were present the Master, Chief Officer, Bosun, and the ABs. The Chief Officer referred to the job to be performed and underlined that safety comes first. For this purpose the ABs who would be standing on the Lashing Bridges to paint the cell guides, despite the fact that the 1.20m height of the railing located in front of the Lashing Bridge is sufficient to protect against falling into the open hatch, they should wear safety belts, attached on the railing, for protection from fall in the hold. Also, the Chief Officer instructed that paint rollers should be attached on extension rods. It was not expected to finish the job before arrival at Australia, but they wanted to show, good will. Since the job for painting with rollers the cell guides concerns a simple task and the crew is familiar with the equipment used, a further Risk Assessment was not made and documented. A work permit “Working Aloft / Overside Premit” based on the existing Risk Assessment as described in the ship’s DSMS, was issued on the day of the accident, by the C/O commencing at 07:00 and ending at18:00. The work permit contained the equipment and Personal Protective Equipment (PPE) to be used and worn: Helmet, Safety shoes, Gloves, Overall, Lifeline, Walkie-talkie. The Supervisor was the C/O and the Team members the Bosun and the three ABs. It was signed by all. 4.5 Human Factors The Bosun The Bosun was 47 years old, and he had 25 years at sea, 4 of them as Bosun. According to the C/O, the Bosun was cooperative, and experienced, as far as he could evaluate him during his short period of time on board. Any work he was given was performed with professionalism. His point of view regarding professionalism was on informing the C/O, supervising the ABs and simultaneously working himself. The Bosun did not make a break from 12:00 to 13:00 and had no lunch. He continued working i.e. painting cell guides. As he deposited, at Pusan many HC were open and was possible to work on cell guides. According to him, he wanted to work to finish the job. On the contrary, according to the C/O they wanted to show good will to the Australian Stevedores and they were not in a hurry. He can be characterized as overzealous, (enthusiastic and eager) a classical Bosun. His subordinates would have known his attitude.

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The AB The deceased AB was the only one Russian in the crew. He was 35 years old. He was on board for only 35 days. His watch was 12-4. He was communicating with the Bosun in the Russian language. He was described as normal, easy going, down to earth personality, with no signs of personality disorder and no disputes with anyone on board the ship. The ship has Seven (7) Holds and / Sixteen (16) / Hatches. Between holds i.e. between 1-2, 2-3, 4-5, 5-6 there are Lashing Bridges. The Lashing Bridge’s floor consists of Anti-Slip Galvanized Gratings. The Lashing Bridges are fitted with railing with height 1.20m for protection from fall. The 1.20m high railing is sufficient to protect from fall into the hold when the hatch is open. There is an opening of the railing, fitted with two horizontal chains, providing access onto the hatch cover when it is closed. No one saw the AB falling from the Lashing Bridge into the No6 Cargo Hold. However, the Bosun who was working on the Lashing Bridge at the aft side of the Hold ordered him (when the AB returned on the Lashing Bridge of No5 Hold fwd), to not start painting cell guides and to go to check the mooring ropes. He also heard the screaming “aaaaaaa” and then saw him landed on the tanktop. The upper one of the two horizontal chains giving access to the hatch coaming was noticed that it was released by the C/O according to his statement. Due to the fact that there were no witnesses, and because the horizontal upper chain of the Lashing Bridge’s railing which is close to the remaining cell guide to be painted was found released, it is supposed that it was deliberately released by the AB, in order to make it easier to reach the last cell guide remaining un- painted. It is assumed that he attempted this action before going to check the ropes as directed by the Bosun. At about 12:40 – 12:45 hrs LT, the AB presumably lost his balance as he attempted to paint the last one cell guide using his Aluminium Telescopic Rod with Roller and fell from the opening into the hold at a height of 17 metres. On the cell guide some paint was noticed according to the C/O and 2/O statements and is visible in a photograph (Figure 2: Presumed his position / encircled cell guide) The AB was wearing his PPE helmet and safety shoes and a uniform. He was not wearing harness. Circadian Rhythm Desynchrony Circadian Rhythm Desynchrony is a factor when the individual’s normal, 24-hour rhythmic biological cycle (circadian rhythm) is disturbed and it degrades task performance. This is caused typically by night work or rapid movement (such as one time zone per hour) across several time zones. Referred to as “shift lag” and “jet lag.” The deceased AB’s watch was 00:00 until 04:00. Therefore he had rest from the previous day from 16:00 until 24:00 i.e. 8 hours. It doesn’t mean that he slept for eight hours. Then from 00:00 until 04:00 he was on watch. At 05:30 Stand-By on arrival. If he woke up half an hour before, it means that he had one hour rest, which is not enough time to sleep. Then again rested from 07:00 until 11:30. This means that he may have slept about 4 hours in the morning. At 12:00 took over from his fellow AB.

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Circadian Rhythm Desynchrony may have been caused due to his watch (12-4 ) and his sleep pattern. Such a sleep pattern is normal for ships approaching ports every 1-2 days. Therefore, his performance could have been degraded. In addition, noisy environment and vibrations during sitting and unsitting of containers may have contributed to degraded performance. It is assumed that Circadian Rhythm Desynchrony was a contributing factor to the accident. Inattention Inattention is a factor when the individual has a state of reduced conscious attention due to a sense of security, self-confidence, boredom or a perceived absence of threat from the environment which degrades crew performance. This may often be a result of highly repetitive tasks. Lack of a state of alertness or readiness to process immediately available information. Risk-to-effort ratio: When doing something the correct way involves a lot of effort, or a level of preciseness that is perceived unrealistic, and if the perception of danger is not acute, the AB is very likely to improvised and not taken the precautions necessary i.e. to use the harness to avoid exposure. Therefore it is assumed that Inattention was a contributing factor to the accident.

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5. Conclusions The Direct Cause of the casualty (death) was Skull Fracture and Rupture. Causes that lead to death: Multiple fracture of Ribs and Hematothorax. Other condition not leading to death: Left side Tibia Fracture and right side wrist fracture The immediate cause of the accident which led to the fall of the AB into the hold: There were no eyewitnesses to the accident and the exact nature of the ABs fall is not known. It is assumed to be losing his balance when he attempted to paint the one remaining un-painted cell guide which is located beneath the opening (which is fitted with two horizontal chains) of the 1.20m high railing. The Contributing Causes of the accident were: It is assumed that Circadian Rhythm Desynchrony was a contributing factor to the accident. It is assumed that Inattention was a contributing factor to the accident. Failure to use defenses (barriers) i.e. Safety Harness (Personal Protective Equipment) Although there is no evidence, a sudden and unexpected extreme vibration could have contributed to the accident. 6. Recommendations Management Company by way of a circular or other means, to educate its crews, on Risk Assessment and Work Permit System, with particular emphasis on crew responsibility for carrying out the work and taking safety measures as described on the Work Permit.

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Figure 1: M/V "FEDERAL"

Figure: 2 Accident Site

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ANNEX 12

ANNEX 12

ANNEX 12