mairne accident investigation - maritime cyprus · 2020-03-10 · smc ism safety management...

REPUBLIC OF CYPRUS MARINE ACCIDENT AND INCIDENT

INVESTIGATION COMMITTEE

Investigation Report No: 44E/2019

Very Serious Marine Casualty

Death of ABLE SEAMAN (A/B)

on M/V “ISLE OF INISHMORE”

on 21/03/2019

at Rosslare Harbour

i ©Marine Accident and Incident Investigation Committee

Foreword

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. This marine accident investigation was carried out by Cyprus MAIC as Lead Investigating State and Irish Marine Casualty Investigation Board as substantially Interested State. The accident investigation was conducted in cooperation with the Irish Marine Casualty Investigation Board, which provided essential information and data relevant to the accident. The investigation was conducted following the guidelines and policies of the Republic of Cyprus Law, the applicable IMO Code, IMO Circulars, EU Regulation and EU Directive.

ii ©Marine Accident and Incident Investigation Committee

Contents

FOREWORD .............................................................................................................................................. I

LIST OF ACRONYMS AND ABBREVIATIONS ............................................................................... III

1. SUMMARY ....................................................................................................................................... 1

2. FACTUAL INFORMATION ........................................................................................................... 5

2.1. MV “ISLE OF INISHMORE” ..................................................................................................................... 5 2.1.1. Ship Particulars ................................................................................................................. 5 2.1.2. Voyage Particulars ............................................................................................................ 6 2.1.3. Marine Casualty or Incident Information .......................................................................... 6 2.1.4. Shore authority involvement and emergency response ...................................................... 7

3. NARRATIVE .................................................................................................................................... 8

3.1. SEQUENCE OF EVENTS ................................................................................................................................. 8

4. ANALYSIS ...................................................................................................................................... 14

4.1 THE ABLE SEAMAN (A/B) – DECEASED CREWMEMBER ............................................................................. 14 4.1.1 Certification ..................................................................................................................... 14 4.1.2 Medical Fitness................................................................................................................ 14 4.1.3 Seafarer Employment Agreement .................................................................................... 15 4.1.4 Seaman’s Previous Experience ........................................................................................ 15 4.1.5 Working Language .......................................................................................................... 15 4.1.7 Familiarization training .................................................................................................. 16 4.1.8 Fatigue ............................................................................................................................. 16 4.1.9 Working and Living Conditions ....................................................................................... 17 4.1.10 Physiological, Psychological, Psychosocial Condition ................................................... 17 4.1.11 Post Mortem Examination ............................................................................................... 17

4.2 EXPERIENCE OF SENIOR MANAGEMENT ..................................................................................................... 19 4.3 EXPERIENCE OF SHIP MANAGEMENT COMPANY ........................................................................................ 19 4.4 ONBOARD MEDICAL ACTIONS ................................................................................................................... 20 4.5 THE SHIP .................................................................................................................................................... 21 4.6 THE ENVIRONMENT ................................................................................................................................... 23

4.6.1 External environment....................................................................................................... 23 4.6.2 Internal Environment ....................................................................................................... 23

4.7 SAFETY MANAGEMENT .............................................................................................................................. 27 4.8 "TUGMASTER" DRIVER .............................................................................................................................. 32 4.9 "TUGMASTER" INVOLVED IN THE ACCIDENT .............................................................................................. 33 4.10 PORT AUTHORITY ...................................................................................................................................... 35 4.11 SUMMARY OF EVENTS ................................................................................................................................ 37

5. CONCLUSIONS ............................................................................................................................. 41

6. RECOMMENDATIONS ................................................................................................................ 43

iii ©Marine Accident and Incident Investigation Committee

List of Acronyms and Abbreviations A/B Able Seaman BAC Blood Alcohol Content C/E Chief Engineer C/O Chief Officer CoC Certificate of Competency GA General Alarm CPR Cardio-Pulmonary-Resuscitation DPA Designated Person Ashore ISM Code International Management Code for the Safe Operation of Ships Knots Speed in nautical miles per hour Lat. Latitude Long. Longitude LT Local Time m Meter MC Management Company MT Metric Ton NM Nautical Mile PSN Position 2/O Second Officer 2/E Second Engineer SMC ISM Safety Management Certificate SMM Safety Management Manual SMS Safety Management System SOLAS Safety of Life At Sea Convention STCW95 International Convention on Standards of Training, Certification and Watch

keeping for Seafarers 1978, as amended UTC Universal Time Coordinated VHF Very High Frequency Radio ZT Zone Time

1 ©Marine Accident and Incident Investigation Committee

1. Summary In conducting its investigation, the Marine Accident Investigation Committee (MAIC), reviewed events surrounding the accident, documents, statements of witnesses, external examination report of the corpse, preliminary results of the Post Mortem report, Autopsy report, Toxicology Test report and performed analyses to determine the causal factors that contributed to the accident. The Irish Marine Accident Investigator embarked the vessel immediately after the accident whereas, the MAIC Marine Accident Investigator embarked the vessel for carrying out on-scene investigation on 04/05/2019, approximately one and a half months after the accident date, due to waiting for re-recruitment of crew witnesses, who, coincidentally, signed off after completing their scheduled employment contract after the accident. Accident Description On 21/03/2019 about 07:40 LT, during loading operations of un-accompanied drop trailers onboard MV “Isle of Inishmore”, flying Cyprus Flag with IMO No. 9142605, while the vessel was berthed port side to, on Berth No.1 at Rosslare Europort - Ireland, an Able Seaman (A/B) of Latvian nationality became trapped and was crushed between a reversing drop trailer towed by a tugmaster truck and one drop trailer which had already been parked, during the maneuvering of the said truck on the port side aft end of Deck 3. The tugmaster truck was driven by a port employee driver. The drop trailer towed by the tugmaster truck was being driven in reverse (backing-up) to the parking position (Lane 1-aft port side). There were no eye witnesses of the accident. The reasons for which the A/B was found between the two drop trailers during manoeuvring are unknown. The onboard medical emergency team (Alpha Team) attended the A/B immediately providing first aid to him (CPR - Cardiopulmonary resuscitation). The Port’s Authorities and the shore emergency services (Fire Brigade and Ambulance) attended the vessel soon after the accident providing first aid to the A/B who, despite their efforts, was declared dead on scene by the paramedics on 08:32 LT. The case is under investigation by An Garda Siochana and Health & Safety as per Irish Law and Legislation. As a result of being crushed between the two trailers, the cause of death of A/B was multiple severe crush injuries including cardiac and lung contusions, rib and sternal fractures, injury to pulmonary artery and haemothorax. Conclusions The deceased person received familiarization training as per the company's Safety Management System requirements. He had previous experience as ordinary seaman and able seaman onboard vessels other than the specific vessel type (RORO-PAX), since 2015. The accident occurred a few days after his assignment as able seaman and after serving onboard this vessel for approximately three weeks as Cleaner / Painter. There was inadequate implementation of the ship management company's safety management system and particularly the cargo operations on vehicle decks by the involved crew members. Specifically, the deceased person was working without effective supervision, the backing-up manoeuvring was


carried out by only one able seaman without eye contact with the driver, he attempted to cross behind the moving trailer without signalling for stopping the tugmaster etc. During the maneuvering, the driver and the deceased person lost eye contact and neither of the two took any measures to remedy this. Neither the driver nor the second able seaman, who was working on the starboard side, heard any whistle blown by the deceased person warning the driver to stop. The review of operations by the Port Authority had identified the risk of persons moving between trailers when moving on the vehicle decks for all vessels operating from the port. The implementation of the determined control measures, issued by the Port Authority, could not prevent the accident. Due to the lack of eye witnesses, no safe conclusions can be extracted as to the exact conditions of the accident. However, on the basis of the information and data presented to the investigator and the analysis carried out, the following causes were considered as the most appropriate: Root Cause(s) (If corrected, the same accident will not happen again) Root Cause: Safety Management System Inadequate Implementation The inadequate implementation of the safety management system and particularly the cargo operations on vehicle decks safety guidelines and procedures, resulted in non-realistic risk assessment, non-implementation of the safety precautions by the deceased and the involved crewmembers, lack of supervision of the operation of the specific tugmaster etc is considered as a root cause of the accident. If the safety management system documented procedures were being implemented correctly, the accident would have been avoided. Root Cause: Lack of Visual Contact The lack of visual contact between the tugmaster driver and the A/B, throughout any stage of the maneuvering operations, is considered as a root cause of the accident. If visual contact had been established during all stages of the maneuver, the driver would have stopped the trailer when he could not see the A/B or he would be informed to stop by the A/B. Direct Cause: Wrong Decision (Moving behind Reversing Trailer) (The immediate events or conditions that caused the accident) The deceased person for unknown reasons attempted to move behind the reversing trailer, against all written procedures and guidelines, a decision which caused the accident. This is an action which should not have been decided irrespective of any safety measures in place, such as eye contact with driver, placement of second assisting A/B, whistle signal / gesture / hand signal.


Contributing Cause(s): (An event or condition that collectively with other causes increases the likelihood of an accident but that individually did not cause the accident) Contributing Cause: Inadequate Experience of the Deceased The deceased's limited previous experience in the position of able seaman with duties involving vehicle operations, considering that the accident occurred a few days after his assignment as able seaman, may have led to his poor decision making and lack of hazard identification, which may have contributed to the accident. Contributing Cause: Poor Evaluation of self-readiness of the Deceased to undertake the assigned duties The deceased received familiarisation training as per the SMS requirements. The accident occurred three days after its completion and the deceased failed to follow written SMS procedures pertaining to cargo vehicle operations. The poor evaluation of the deceased person's self-readiness to undertake the assigned duties following his familiarization, may have caused failure to recognize his inability for implementing procedures to prevent unsafe acts, may have contributed to the accident. Contributing Cause: Impairment of Physical Condition Impairment of physical condition due to the abrasion over the right eyebrow of the deceased person, may have led to loss of judgment, poor decisions making, panic and loss of concentration, which may have contributed to the accident. Contributing Cause: : Ineffective Monitoring of Implementation of Control Measures by Port Authority The ineffective monitoring of implementation of control measures determined by the Port Authority (for mitigating the potential hazard for restricting crew walking behind trailers whilst being pushed into stowage position), may have led to failure of preventing the particular hazard, either by the involved ships' crew or by the port employees, may have contributed to the accident.


Recommendations 1. For the Management Company:

a. The Safety Management System to be revised in order to include provisions for new crewmembers with little experience to be supervised directly when working on vehicle decks for a specific period of time. (Within three months)

b. Onboard familiarisation training procedures to be reviewed by the company to ensure effective evaluation of the outcome. (Within three months)

c. Additional training to be provided to the crewmembers involved in cargo vehicle operations covering the safe zone for crew movement, the blind sectors of drivers for several types of vehicles, signalling, supervision, conditions for ceasing manoeuvring etc. (Within one month)

d. To consider carrying out unscheduled internal audits on board ships in order to verify effectiveness of the SMS implementation. (Within three months)

e. The risk assessment for cargo vehicles operations to be more detailed regarding the hazards and counter measures to mitigate the risk covering individual tasks. (Within three months)

f. The company to establish "visual contact policy" providing necessary instructions, training etc. In addition, the company to consider alternative means of driver / crew communication additional to the use of whistles for signalling (e.g. dedicated radios could be used to communicate between crew and tugmaster drivers). (Within one month)

2. For the Port Authority: a. To instruct vehicle drivers when they do not have visual contact with the assigned parking

guide, to stop their vehicles until achieving visual contact, especially in reverse manoeuvring. b. To increase monitoring / supervision of cargo deck operations in order to ensure that all

procedures, guidelines, control measures etc are properly and effectively implemented. c. Instructions to be given to the drivers in order to cease operation and report unsafe acts during

the operations.


2. Factual Information

2.1. MV “ISLE OF INISHMORE”

Figure 1: M/V “Isle of Inishmore”

The vessel is owned by Zatarga Limited and managed by “Matrix Ship Management Ltd” since 13/06/2017. The ship manager’s particulars are as follows:

▪ IMO Number: 5642516 ▪ Address: 80, Spyrou Kyprianou, Agathokleous House, Office 101

4043 Limassol Cyprus

The vessel is a Roll-on/Roll-off cargo and passenger vessel and is built with vehicle decks and a number of passenger cabins and passenger common areas. The vessel has the ability to carry out cargo operations on her Deck 3 and Deck 5 simultaneously. The vessel is constructed of steel and has bow and stern door ramps. The vessel operates between Rosslare Europort (Ireland) and Pembroke Dock (Wales-UK), making two round trips every day.

2.1.1. Ship Particulars

Name of ship: ISLE OF INISHMORE IMO number: 9142605 Call sign: C4HQ2 MMSI number: 209093000 Flag State: CYPRUS Type of ship: RO-RO PASSENGER Gross tonnage: 34031 Length overall: 182.50 meters LPP: 169.05 meters Breadth overall: 28.3 meters Depth (Deck 3): 9.4 meters Classification society: Lloyd’s Register of Shipping


Registered shipowner: ZATARGA LIMITED Shipmanagement company: MATRIX SHIP MANAGEMENT LTD Year of build: 1997 Deadweight: 5860 tonnes Hull material: Steel Hull construction: Single Hull with bow and stern doors Propulsion type: Diesel Engines (x4) Number of crew on ship’s certificate: Seventy (70)

2.1.2. Voyage Particulars

Port of departure: Rosslare Europort (Ireland) Port of call: Pembroke Dock (Wales-UK) Type of voyage: Short International Voyage (Passenger Ship Safety Certificate) Cargo information: Partially loaded condition (Passengers and vehicles) Manning: Arrived at Rosslare (Ireland) with total 94 persons

(crew and supernumeraries)

The vessel is engaged on a daily liner trade pattern (two round trips every day) between the ports of Rosslare Europort (Ireland) and Pembroke Dock (Wales). The cargo vehicles consist of trailers, drop trailers, trucks and vehicles of various sizes, un-accompanied or accompanied. The un-accompanied drop trailers are loaded / discharged at Rosslare Europort by Port Authority employed drivers utilizing Port Authority’s fleet of Temberg and Kalmar Tugmasters. According to the current schedule of the vessel, she approximetely arrives at Rosslare Europort at 06:45 LT and 18:45 LT and departs at 08:45 LT and 20:45 LT respectively, depending on the the circumstances.

2.1.3. Marine Casualty or Incident Information

Type of marine casualty/incident: Very Serious Marine Casualty Date/Time: 21/03/2019 @ 07:40 Hours LT Location / Position (Latitude/Longitude): Rosslare Europort, Berth No. 1, Ireland / (52°15.224 N / 006°20.244 W)

Figure 2: Layout of Rosslare Europort Ireland, showing accident location


External and Internal Environment: Sea State: Calm Wind: WSW 3, Day/Night: Daylight Sky: Overcast Visibility: Moderate Ship operation and Voyage segment: Normal operation alongside loading Human Factors: Yes Consequences: Death: 1 crewmember (Able Seaman)

The vessel on 21/03/2019 06:46 LT was berthed port side to, on Berth No.1 at Rosslare Europort (Ireland) and was loading vehicles for Pembroke Dock (Wales), following the discharge of all incoming vehicles. The vessel had Estimated Time of Departure (ETD) from Rosslare Europort at 08:45. The vessel had completed discharge and was being back loaded with un-accompanied drop trailers. During the loading operation of an un-accompanied drop trailer towed by a tugmaster truck driven by a Port employee driver (stevedore) at about 07:40 LT, the Able Seaman (A/B), who was assigned to assist the driver, became trapped and was crushed between the reversing drop trailer and one drop trailer which had already been parked, during the maneuvering of the said truck on the port side aft end of Deck 3, with fatal consequences. The drop trailer towed by the tugmaster truck was being driven in reverse (backing-up) to the parking position (Lane 1-aft port side). There were no eye witnesses of the accident. Despite the efforts of the onboard medical emergency team (Alpha Team) and the shore emergency services, the A/B was declared dead on scene by the paramedics. (Statements)

2.1.4. Shore authority involvement and emergency response

▪ The Bosun notified the Chief Officer who in turn assembled the onboard “Alpha Code”

team for emergency response. ▪ An A/B who was at Deck 3 aft starboard side and the Bosun who were nearby attended

immediately the scene and provided first aid to the injured A/B. ▪ The vessel’s “Alpha Code” team attended the injured A/B and continued rendering first

aid. ▪ Traffic Coordinator of the port was informed by the driver immediately after the accident. ▪ The Local Harbour Police and ambulance were informed at 07:47 LT. ▪ The Local Harbour Police officers arrived onboard at 07:48 LT. ▪ Paramedic arrived onboard at 08:08 LT. The attending paramedic assisted vessel’s Code

Alpha Team to resuscitate the injured A/B. ▪ The Emergency services (Fire brigade and ambulance) arrived onboard at 08:19 LT. The

attending medical personnel made efforts to resuscitate the injured A/B. ▪ Larger ambulance arrived on-scene at 08:25 LT. ▪ Garda Siochana and Health & Safety Department were notified and attended the vessel for

carrying out investigation as per Irish Law and Legislation. ▪ The ship management company (Deputy DPA) was informed soon after the accident. ▪ Vessel’s P&I Club was also notified and involved.

On the basis of the facts and statements, it can be concluded that the response period of the

shore authorities including the emergency response services was fast. The shore authorities and emergency services were contacted immediately after the accident. There is a Local Harbour Police Station ("Garda Station") and the duty Officers arrived on board almost immediately after the alarm was raised. The local Police Station at Rosslare ("Gardaí from Rosslare Garda Station") also attended the vessel.


3. Narrative

3.1. Sequence of Events 1 21/03/2019

06:00 LT The Tugmaster driver, employee of the Irish rail in Rosslare Port, started work at approximately 06:00 LT on 21/03/2019. He was instructed to drive a Tugmaster for the discharging and loading operation of unaccompanied trailers on MV “Isle of Inishmore”, which would arrive at about

06:45 LT. (Driver's statement) 2 21/03/2019

06:46 LT Vessel berthed at Rosslare Europort Berth No.1. (Statement)

3 21/03/2019 07:00 LT

Commencement of discharge operation of all Rosslare bound cargo. The discharging operation from vessel’s Deck 3 was

assigned to the vessel’s “A” Bosun (responsible) and three A/Bs assisting the Bosun, working all together. (Bosun statement) The Tugmaster driver commenced discharging operation of unaccompanied trailers, together with his colleagues. (Driver's statement)

4 21/03/2019 07:20 LT

Commencement of loading operation. (Statement) The tugmaster drivers started loading of unaccompanied trailers, following the completion of the discharging operation. (Driver's statement) The Bosun instructed two A/Bs to prepare the trestles for loading, starting from the aft part of Deck 3, whereas the Bosun and the third A/B started to prepare the trestles from the forward part of Deck 3. The two A/Bs, upon finishing the preparation in the aft part of the deck, went forward to assist the Bosun and the other A/B with the loading. Upon finishing the loading of trailers on the starboard side (remaining only one drop aft) and two-three drops were left for finishing the port side aft, the Bosun instructed A/B1 and A/B2 to complete the remaining drops in the aft part. (Bosun statement)

5 21/03/2019 About 07:30 LT

The two A/Bs were loading the aft of Deck 3. The third A/B, who was also assigned for the loading operation on Deck 3 went to the restroom, whereas the two A/Bs (A/B1 & A/B2) continued loading the remaining trailers, with A/B2 covering the starboard side drop and A/B1 the port side drops on Deck 3 aft. The Bosun went forward to start loading of new starboard lane. (Crew statements)

While loading the sixth consecutive trailer of unaccompanied trailers, the driver of tugmaster no. DT22 hooked up the trailer with number NT666F. This trailer was a flat bed trailer carrying three (3) pieces of agricultural equipment (animal feeders). When the driver hooked up the trailer in question, he realized that the wheels of the animal feeders were slightly overhanging on each side of the trailer, however it was common for this type of load. (Driver's statement)


Figure 3: Tugmaster DT22 and unaccompanied trailer NT666F

6

21/03/2019 About 07:40 LT

The driver received instructions, to drive the tugmaster with the unaccompanied trailer to Lane 1 of Deck 3 aft.

Figure 4: Layout of lanes on Deck 3 (looking aft)

Figure 5: Designated final parking position of the trailer NT666F on Deck 3

AFT

FWD

PORT TUNNEL

LANE

STBD TUNNEL

LANE

LANE 2

LANE1

LANE 3

LANE 4

LANE 5

Designated parking place of NT666F


7 21/03/2019 About 07:40 LT

While parking trailer NT666F which would have been the eighth trailer on the port side lane no.1 aft, a fan unit over-hanging was found to be obstructing the parking maneuvre for the particular parking space, due to the extra height of the load on the trailer. The tugmaster driver drove past the seventh trailer NT1135CX, which had already been parked, and stopped in order to drive in reverse (back-up) the trailer to the parking position aft of the stationary trailer.

Figure 6: Description of the designated parking space

While the tugmaster driver stopped and his seat was still looking forward towards the aft part of Deck 3 (the driver’s

seat of tugmaster can be rotated 180 degrees when backing-up), A/B1, who was responsible for assisting the drivers on the port side of Deck 3, was standing over to the right of the driver. The driver rotated his seat for backing-up. The assigned A/B1 was standing to the left hand side of the driver, on the step by the bulkhead, when the driver commenced pushing back the trailer. The driver stated that the assigned A/B1 gave him a wave and a wolf whistle to commence the maneuvre. The initial approach ended up with the trailer's wheels protruding over the lane lines due to the difficulty imposed by the over-hanging fan unit. A second approach was attempted by the driver, by pulling forward to straighten / align the trailer into the lane line and by pushing it back after the A/B1’s wave signal. A/B1 was standing against the bulkhead on the ledge at the head of the seventh stationary trailer. While reversing, the position of A/B1 was out of driver’s view. (Driver's statement)

Overhanging fan unit

AFT

FWD

Port side Bulkhead

Step on the edge the of longitudinal bulkhead


Figure 7: Description of operation on Deck 3

The second A/B (A/B2), who was assigned for the operation on the starboard side of Deck 3 aft, was standing approximately ten meters away from the aforementioned operation on the port side. (A/B2 statement)

8 21/03/2019 About 07:42 LT

While the tugmaster driver was backing-up the trailer and awaiting A/B1’s whistle signal to stop the trailer, on his second attempt to correct the final position of the trailer, the driver heard a whistle and he stopped. (Driver's statement) A/B2, who was positioning the trestle on the starboard side at the same time, saw A/B1 standing between the stationary and the moving trailers. From his angle of view, A/B2 could not estimate the space between the two trailers. He did not hear any whistle. He immediately blew his whistle (the whistle signal reported by the driver) and shouted to the tugmaster to stop, waving him to go forward. The tugmaster driver stopped and pulled ahead again. When the driver pulled ahead, A/B2 saw A/B1 collapsing on the deck. A/B2 called the Bosun who was on Deck 3 forward via his radio, informing him about the incident and ran straight over to A/B1. (Driver and A/B2 statements) Another tugmaster driver, who had been waiting to back-up on Lane 5 aft starboard side, ran over and told the driver of DT22 that the A/B assigned for his operation might have been hit. The driver of DT22 got down from his tug and when he saw that A/B1 had been injured, he ran directly off the ship and informed the Traffic Coordinator requesting also ambulance. (Driver's statement)

A/B1 was lying with the face down on the deck, in a pool of blood where his head was lying, between the two drop trailers (the stationery trailer and the second trailer which was attached to the tug). The Chief Officer (C/O) stated that

Course followed by tugmaster on Deck 3

NT1135CX

AFT

LANE1

LANE2

LANE3

LANE4

LANE5

NT666F

A/B 1

A/B 2

PORT SIDE

STBD SIDE


Position where A/B1 was lying

A/B1 had a cut over his eye. His helmet was found on deck underneath the front of the stationery trailer, whereas the deceased person was found with boiler suit, working jacket with reflecting straps, gloves, safety shoes and portable VHF radio. (Several statements)

Figure 8: View of the accident location

A/B2 and Bosun were the first to attend the deceased person and Second Engineer (2/E) arrived on-scene after a few seconds. The 2/E checked his pulse and he could not feel any. In the meantime, as the initial notification was made via the portable radio so that all holders of portable radios heard the notification and the communication between the Bosun and the Chief Officer (C/O), an announcement on the public address of a “Code Alpha” followed by the accident location was made by the off-duty Master who was together with the C/O on the bridge. (Crew statements) The harbour Traffic Coordinator notified the harbour Duty Controller who in turn informed the emergency services. (Traffic Coordinator statement)

The Code Alpha team attended the deceased person, immediately after the announcement, for providing first aid (applied pads and started CPR). There was no response and no indication of vital signs, however they continued applying CPR until the first paramedics arrived. (Crew statements)

9 21/03/2019 07:47 LT

The local harbour police officer received a call from a fellow police officer informing that a call had been received from ambulance control which notified that an accident had occurred onboard subject vessel. (Police statement)

11 21/03/2019 07:48 LT

Local Harbour Police Officers arrived onboard. (Police statement)

10 21/03/2019 07:55 LT

Local Harbour Police informed advanced paramedic, who lives close by the port. (Police statement)

11 21/03/2019 08:08 LT

Paramedic arrived onboard. The attending paramedic made efforts to resuscitate A/B1. (2/O statement)

12 21/03/2019 08:19 LT

Fire Brigade and a small ambulance arrived. The attending medical personnel made efforts to resuscitate A/B1. (2/O statement)

13 21/03/2019 08:25 LT

A second larger ambulance arrived. (2/O statement)

Moving trailer

Stationery trailer

Head Feet


14 21/03/2019 08:26 LT

Tugmaster driver of the tug with attached trailer NT666F was breathalysed by the Local Harbour Police Officers. The result of this test was “Pass”. (Police statement)

15 21/03/2019 08:32 LT

Ambulance service officer informed the Local Harbour Police Officer that they were stopping CPR and Defib, as there were no signs of life. A/B1 was declared dead. (Police statement)

16 21/03/2019 10:45 LT

The body of A/B1 was formally identified by a crewmember who knew the deceased person since he joined the vessel. (Police statement)

17 21/03/2019 10:50 LT

The body of the deceased person was removed from the vessel by undertaker. (Police statement)


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 is based on interviews, reports and documents provided.

4.1 The Able Seaman (A/B) – Deceased crewmember

4.1.1 Certification The following Seafarer’s Certificates of the deceased person (Able Seaman), issued by the Republic of Latvia, Latvia Registry of Seamen and Novikontas Maritime College were presented to the investigator: 1. Certificate of Proficiency for:

▪ Able Seafarer deck Valid until: 27/11/2022 ▪ Basic Safety Training Valid until: 29/05/2023 ▪ Seafarer with Designated Security Duties Valid until: Unlimited ▪ Training for Passenger ships Personnel Valid until: 30/08/2023 ▪ Proficiency in survival craft and rescue boat

other than fast rescue boat Valid until: 31/05/2021 The Cyprus Flag Seaman Book or application for issuance of Seaman Book was not presented to the Investigator. There was no evidence to suggest that the Certification of the deceased person, could have been considered a contributory factor to the accident.

4.1.2 Medical Fitness The Able Seaman’s “Seafarer Medical Certificate” was valid until 28/03/2020. the date of last health examination (including colour vision test) was 28/03/2018, approximately one year before the accident. The certificate was issued by medical practitioner of "SIA PARVENTA Polyclinic" in Latvia, in accordance with the STCW as amended, MLC 2006 and national legislation of the Republic of Latvia. The seafarer was declared medically fit for service in deck department with no limitation or restrictions on fitness. The “Alcohol and Drug Test” dated 29/01/2019 issued by

"SIA KRONOSS" indicated negative results to all tests. The list of personal belongings of the deceased person was not provided to the investigator. The A/B had valid medical examination report at the time of the accident. Although the A/B signed-on March 2019 and the latest medical examinations were carried out almost one year ago with expiration date 28/03/2020, there was no evidence to suggest that medical fitness of the deceased person could have been considered a contributory factor to the accident.


4.1.3 Seafarer Employment Agreement The A/B was officially registered on the vessel’s crew list dated 21/03/2019 under reference number 17 and designated as “Able Seaman (AB)”. He embarked the vessel on 13/02/2019 at Rosslare assigned with the "Cleaner" position, as per Ship’s Articles. When the Appointment Letter for the position of Able Seaman was signed, the vessel was towards the end of dry docking at Birkenhead, UK. Appointment Letter dated 06/03/2019, between the ship management company and the Able Seaman (A/B) for service on board MV “Isle of Inishmore” (2 months ± two (2) weeks), properly signed by both parties was presented to the investigator. The Appointment Letter was endorsed by the Master of the said vessel. The Appointment Letter directly referred to the "Terms and Conditions of Employment for Personnel on Sea Service" dated 25/01/2019. The ship management company has contracted and authorized "Matrix Crew Management Latvia" as its Crewing Agent, for and on behalf of ship owners, to recruit shipboard personnel for subject vessel. There was evidence of a seafarer employment agreement / appointment letter for the deceased person as "Cleaner" from the date of his embarkation 13/02/2019 until 06/03/2019 and as "A/B" from 06/03/2019 and afterwards. There was no evidence to suggest that the conditions of the “Seafarer Employment” of the deceased person could have been considered a contributory factor to the accident.

4.1.4 Seaman’s Previous Experience The National and International Seaman’s Book of the A/B was not presented to the investigator. The deceased had previous experience as ordinary seaman and able seaman onboard vessels other than RO-PAX, since 2015. The "Application for Sea Staff Employment (Pers 21)" indicating the sea previous experience was presented to the Investigator. The deceased was initially appointed as "Cleaner / Painter" onboard this vessel with a contract valid for three weeks. He then had contract agreement, for serving onboard MV "Isle of Inishmore" as an Able Seaman, dated 06/03/2019. On the basis of statements, the vessel had only re-entered service after the dry-docking on 16th March 2019, thus the A/B had five (5) days operational experience as A/B in the specific type of work. As stated by the Bosun, the A/B was very good in his job and very clever. There is evidence to suggest that the limited / inadequate “Experience” of the deceased person in vehicle operations could have been considered a contributory factor to the accident.

4.1.5 Working Language The vessel’s working language is English. There was no any evidence to suggest that the deceased person faced language communication problems with his colleagues. Furthermore, there was not any communication problem regarding the working language between the crew and the stevedores during the loading of the vessel, as all communication was done through gestures and whistle. Any other way of communication would have been choked out by the noise of tugmasters and trucks moving around on deck.


There was no evidence to suggest that ineffective communication due to Working language of the deceased person could have been considered a contributory factor to the accident.

4.1.6 Familiarization training Records properly signed by all required personnel for the deceased person’s familiarization training in accordance with company’s Safety Management System, Familiarization Training (Pers 13) were presented to the investigator, as follows: 1. Familiarization training programme for: Master, Chief Engineer, Deck & Engine Officers,

Hotel Staff and all Ratings, indicating training from 12/03/2019 until 15/03/2019 and date training completed 18/03/2019

2. Familiarization Matrix - Deck ratings 3. Familiarization for Deck Department 4. Quality Safety & Environment Management System Familiarization 5. Basic Safety Familiarization 6. Prior Sailing Familiarization 7. ISM Familiarization 8. Security Familiarization 9. Ship Energy Efficiency Management Plan (SEEMP) 10. Passenger Ship Emergency Familiarization 11. Familiarization for Bridge Crew 12. Certificate of Competence to Operate Ship's Lifting Equipment, dated 14/03/2019 13. Lashing Certificate, dated 15/03/2019 14. Steering Gear Certificate, dated 15/03/2019 15. Certificate of Competence to Operate Ship's Watertight Doors, dated 17/03/2019 16. Disability Awareness & Assistance Training Certificate, dated 12/03/2019 All aforementioned records indicated that the "Place of joining" was Birkenhead, UK when the vessel was in dry-dock and the "Date of Joining" was left blank. The aforementioned records referred to the deceased person assigned with the position of Able Seaman. There is no evidence to suggest inadequacy of the familiarization training of the deceased person could have been considered a contributory factor to the accident. However, taking into consideration that: ▪ the deceased received familiarization training as per the company's Safety Management

System requirements; ▪ the deceased had no documented previous experience in such position with vehicle

operations; ▪ the accident occurred few days after the assignment of deceased with duties as A/B; ▪ the vessel had recently commenced operation after dry docking, it may be considered that the poor evaluation of the deceased person's self-readiness to undertake the assigned duties following his familiarization could have been a contributory factor to the accident.

4.1.7 Fatigue The “Hours of Work and Rest”, form Pers 11 for February and March 2019 was presented to the Investigator properly completed and signed by the Head of Department, covering the working hours for March 2019 till 21/03/2019. The aforementioned form indicated that the A/B was


working continuously on a daily basis totally 10 hours except the last three days before the accident (18/03, 19/03 and 20/03) when he worked continuously 11, 12 and 12 hours respectively. The minimum rest periods were found in accordance with the requirements of MLC, 2006 Ratification Law of 2012 of the Cyprus Flag Administration issued in conformity with the ILO Maritime Labour Convention, 2006 and the relevant STCW regulation, for month March 2019. In addition, the record for March 2019 indicated that from 12/03/2019 till 18/03/2019 the deceased was under familiarization training for the position of A/B and the vessel left dry-dock on 14/03/2019. There was no extraordinary situation onboard vessel within the three days preceding the accident that could have created additional working hours over the normal schedule hours of the A/B. In addition, no complaint by the A/B regarding his resting hours was presented to the investigator. There was no evidence to suggest that Fatigue of the deceased person could have been considered a contributory factor to the accident.

4.1.8 Working and Living Conditions The vessel was furnished with valid MLC 2006 Certificate along with the Declaration of Maritime Labour Compliance.

On the basis of the interviews and the investigation onboard, there was no evidence to suggest that inadequate working and living conditions could have been considered a contributory factor to the accident.

4.1.10 Physiological, Psychological, Psychosocial Condition On the basis of the interviews during the investigation onboard, there was no evidence or indications to suggest that the A/B's physical, physiological, psychological, or psychosocial condition could have been considered a contributory factor to the accident.

It was stated by the Bosun that he was very good in his job and very clever. There was no evidence to suggest that complacency on behalf of the deceased could have been considered a contributory factor to the accident.

4.1.9 Post Mortem Examination According to the Post Mortem Examination which was carried out at the mortuary of University Hospital Waterford on 22/03/2019 and on the basis of the provisional post mortem report and the autopsy report, the conclusion of the examination about the cause of death was multiple severe crush injuries including cardiac and lung contusions, rib and sternal fractures, tear injury to the left main pulmonary artery and haemothorax. In addition, on the basis of the external examination of the corpse in place, among other findings: ▪ there was blood smearing on the face. There was an abrasion over the right eyebrow; ▪ an "L" shaped reddish purple bruise was present on the skin of the back; ▪ a dark reddish purple bruise measuring 100 mm was present on the chest.

The indications are that the casualty had his back to the moving trailer when he was pinned between the two trailers.


The abrasion over the right eyebrow of the deceased person could have been considered a contributory factor to the accident, considering that it could have been caused before the crushing of the deceased between the two trailers. According to the toxicology report dated 01/07/2019 and the relevant analysis, which was carried out by "The State Laboratory", ethanol (alcohol) and drugs were not detected in the post mortem blood and urine analyses, respectively. There was no evidence to suggest that influence of alcohol or drugs on the deceased could have been considered a contributory factor to the accident.


4.2 Experience of Senior Management On the basis of the presented IMO Crew List when the accident occurred and during the investigation onboard, the vessel is manned with duplicated crew for day and night duties (i.e. Master, C/O, 2/O, C/E) due to the vessel's pattern which requires navigational and port operations continuously day and night. Same applies for deck ratings (i.e. two Bosuns and nine A/Bs were signed-on during the accident). The duty Master and C/O were found qualified and competent for their position. The duty C/O was entitled to serve in the capacity of Master. There was no documented evidence of the involvement of the duty Master during or immediately after the accident. The A/B who was working at the time of the accident on the starboard side of Deck 3 aft and first saw the deceased person immediately after the accident, was not onboard during the investigator's attendance and thus was not interviewed by the investigator. Also, during the investigator's attendance, the rest of the crewmembers who were onboard at the time of the accident had either been coincidentally signed-off after completing their scheduled employment contract after the accident or they were not involved in the development of the accident. However, some of them had participated in the "Alpha Code" team. The duty C/O was available during the investigation. On the basis of the interviews which were carried out during the investigator's attendance onboard, as well as the immediate emergency response of the senior management and the rest involved crewmembers, it was indicated that the experience of the deck senior management is adequate.

4.3 Experience of Ship Management Company

The ship management company has experience in managing Roll-on/Roll-off cargo and passenger vessels. The company was founded in 2011. This vessel was delivered for management on 13/06/2017. The ship management company maintains a Document of Compliance in accordance with ISM Code. The company has published quality, safety and environmental protection policies. The company was involved in the actions taken after the accident. Messages between the company and other entities were presented to the investigator covering the period following the accident. There was no evidence to suggest that lack of experience of the ship management company for managing Ro-Pax vessels could have been considered a contributory factor to the accident.


4.4 Onboard Medical Actions

On the basis of the crew statements, crew members attended the scene immediately (such as the Bosun, C/O etc). The "Alpha Code" team members attended the deceased person immediately after the relevant announcement after the accident, providing first aid. They applied cardiopulmonary resuscitation (CPR) to the deceased person without reaction. When the first paramedic attended the deceased person, the "Alpha Code" team continued applying CPR under the instructions of the paramedic till the arrival of the emergency services which happened a few minutes later, as the vessel was in port. There was no evidence to suggest that inadequate and / or delayed provision of first aid or medical treatment could have been considered a contributory factor to the fatal consequence of the accident.


4.5 The Ship

The vessel’s crew was multinational. The official language onboard is the English language. The vessel arrived at Rosslare Port with totally 94 persons out of which 4 contractors and one temporary fitter, as indicated in the official IMO Crew List presented to the investigator. The rest of the persons were the crewmembers, including the deceased person. The vessel was manned well in excess of the Minimum Safe Manning Document requirements (70 crewmembers).

The vessel, at the time of the accident, had valid all statutory and class certificates including the SMC and DOC certificates (ISM Code). The vessel is classed by an IACS Classification Society, whereas the ISM related certificates are issued by the same IACS Classification Society. There was one Condition of Class with due date 06/05/2019, which however was irrelevant to the accident. (Survey Status dd 29/04/2019). The vessel's SOLAS Passenger Ship Safety Certificate was found "Conditional" due to malfunction of the VDR. (Certificate was presented to the investigator).

Flag Administration (Certificates presented to the investigator) Date issue Date expiry

Certificate of Registration 16/02/2018 --- Minimum Safe Manning Certificate 15/04/2015 --- Statutory ISM / MLC Certificates (IACS Class) (Certificates presented to the investigator) Date survey Date expiry

DOC (certificate was not presented to the investigator - information was gathered by PSC reports)

16/05/2017 29/05/2022

SMC 07/06/2017 13/06/2022

Maritime Labour Certificate 27/06/2018 16/07/2023

ISSP 07/06/2017 13/06/2022

Class and Statutory Certificates (IACS Class) (Obtained from Survey Status dated 29/04/2019, which was presented to the investigator) Date survey Date expiry

Class 14/02/2017 13/02/2022

Load Line 12/02/2017 13/02/2022

SOLAS Passenger Ship Safety Certificate (Conditional) 14/03/2019 31/05/2019

DoC Special requirements for Ships carrying Dangerous goods

14/03/2019 13/02/2020

MARPOL Annex I Oil Pollution Prevention 12/02/2017 13/02/2022

MARPOL Annex IV Sewage certificate 12/02/2017 13/02/2022

MARPOL Annex VI Prevention Air Pollution Certificate 12/02/2017 13/02/2022


Port State Control inspection was carried out by Maritime Safety Directorate-Department of Transport, Leeson Lane, Dublin 2 on 03/12/2018 at Rosslare Port, without any deficiency noted. (PSC report dd 03/12/2018 was presented to the investigator) No history record for PSC detention in the last three years, was found. (Equasis-Ship Info dd 04/05/2019)

A survey for the safe operation of regular Ro-Ro and high speed passenger craft services in accordance with the Council Directive 1999/35/EC was carried out on 03/12/2018 at Rosslare Port without any deficiency noted. (Report of Survey dd 03/12/2018 was presented to the investigator)

The vessel has an internal CCTV system, however there are no provisions for recording and at the time of the accident nobody was monitoring the monitors at the bridge and Engine Control Room, as stated by the crew members during investigator's attendance onboard.

There was no evidence to suggest that the ship’s general condition could have been considered a contributory factor to the accident.


4.6 The Environment

4.6.1 External environment The weather conditions at the time of the accident were:

▪ Sea State: Calm ▪ Wind: WSW 3, ▪ Day/Night: Daylight ▪ Sky: Overcast ▪ Visibility: Moderate

The vessel was berthed in port and there was no report of vessel's sudden movement, which could have caused the deceased person to slip or lose his balance. There was no evidence to suggest that physical external environmental factors (such as weather, climate, etc.) affecting the actions of the persons involved in the accident, could have been considered a contributory factor to the accident.

4.6.2 Internal Environment Two (2) decks of garage spaces are available onboard for loading trailers; Deck 3 and Deck 5, which include areas for dangerous cargoes. The vessel is fitted with one stern and one bow ramp, which are the loading / discharging accesses to / from the vessel. There is a tiltable (internal) ramp leading to Deck 5 from Deck 3. The vessel berths at Berth No. 1 at Rosslare Europort twice per day. The vessel berths head in (bow in) and cargo is loaded through the bow doors. The vessel has the ability to carry out cargo operations on Deck 3 and Deck 5 simultaneously, utilising the port's "Two-Tier ramp" on Berth 1.

Figure 9: Vessel’s forward layout

Fwd door leading to Deck 5

Bow door/ramp for Deck 3

Two-Tier ramp on Berth No.1


On Deck 3, which is also referred to as Main deck, there are totally seven (7) trailer lanes. There are two longitudinal partial bulkheads port and starboard dividing the deck with two (2) outer lanes (port tunnel lane and stbd tunnel lane) and five central lanes (Lane 1 to Lane 5 counting from the port side when looking forward).

Figure 10: Trailer decks cross section arrangement These partial port and starboard bulkheads have openings through which personnel can walk.

Figure 11: Deck 3 layout looking aft

Between the partial bulkhead and the adjacent parking lane there is alley of width 80 cm, protected by steel steps at the forward and aft ends of the bulkhead. Deck 3 is furnished with ventilation fan units hanging from the above deck, for ventilation of the space. The accident occurred within garage space on Deck 3 port side aft, Lane 1.

Port Tunnel Lane

Stbd Tunnel Lane

Lane 1

Lane 2

Lane 3

Lane 4

Lane 5

Deck 3

Deck 5

Stbd partial bulkhead Port partial bulkhead

Stbd partial bulkhead Port partial bulkhead

Opening on aft part of the port partial bhd


Figure 12: Description of accident location on Deck 3

The environment within the garage space at the time of the accident (07:42 LT) was as follows: ▪ the space was ventilated; ▪ the temperature was normal; ▪ the humidity was limited within the garage space; ▪ the lighting was satisfactory; ▪ the marking of the garage deck was clear, the lines defining lane borders being of yellow

colour and clearly visible. Minor leakages and vehicle oil stains on deck may appear (there was no evidence of such existence at the time of the accident). All leakages and oil stains are removed after every discharging operation (standard shipboard practice as stated by A/B during the investigation). There were no reported leakages / stains which could have caused the deceased person to slip or lose balance and thus fall at the rear side of the moving trailer. There was no indication that deck could be slippery, when wearing safety shoes. The fixed securing devices are of “flush lashing pot” type, without sharp edges and are located along the yellow lines separating the parking lanes. There was no evidence that any lashing pot could have caused the deceased person to trip and lose his balance.

There was no evidence that loose obstacles, securing chains or cables were found in the garage space at the time of the accident (during loading operation). There were no loose items which could have caused the deceased person to make a sudden move to collect them and get in way of the moving trailer. As stated by crewmembers during investigator's attendance, it was standard practice after every discharging operation and before commencement of the loading operation, that the garage space is tidied-up, storing lashing chains and electrical cables, arranging the trestles for use and removal of any leakage/stains.

Alley (width 80 cm)

Fan Unit

Steel step

Appr. 2.95 cm

Lashing pod


There was no evidence of mobile phone next to the body in order to suggest that the A/B was concentrated on something else and did not notice the movement of the trailer. There was no evidence to suggest that the internal environment could have been considered a contributory factor to the accident.


4.7 Safety Management

The company’s Safety Management System procedures and instructions for cargo operations together with the relevant risk assessment for "Loading and discharging drops" were presented to the investigator. The officers interviewed during investigator's attendance onboard stated that there was no incident or accident in the past involving drivers onboard the vessel, as far as they knew. The "Accident - Incident - Near Miss Observation Report Log (OPS 05)" - Crew Accident Log covering the period from 01/01/2019 till 04/05/2019 was presented to the investigator. This fatal accident was properly recorded. The remaining five cases (not identified as accidents) were found irrelevant with any cargo operations on vehicle decks. Same forms referring to Passenger Accident Log were also presented to the investigator without any identifiable accident relating to vehicle decks operation. The "Medical Log (Shipboard Treatment Only) (Pers 28)" forms covering February and March 2019 were presented to the investigator. The deceased person name does not appear in aforementioned forms requiring shipboard treatment. The first aid provided to the deceased person on 21/03/2019 was not recorded in the subject form. The Familiarization training (Pers 13) consists of several checklists and onboard certification which are applicable depending on the assigned rank (duties and responsibilities) of the crew members and should be carried out partially before departure and within seven (7) days. Signatures are presented only on the "Familiarization Training Programme for: Master, Chief Engineer, Deck & Engine Officers, Hotel Staff and All Ratings" and the applicable checklists are attached with relevant ticking of the applicable fields of training without signature. The checklists include, among other, the familiarization with cargo operations on vehicle decks, signalling used while directing on the car deck, shipboard safety operations of the Safety Management System etc. According to the company’s Safety Management System procedures and instructions, the following reference documents were developed describing the cargo operations and should be implemented and strictly followed by all crewmembers: ▪ CAR03: Cargo List, manifest & Pre-loading Plan / Rev.01 / Status Date: 20 October 2013 ▪ CAR 02: Safety on Vehicle Decks / Rev. 02 / Status Date 31 October 2018 ▪ Isle of Inishmore - Chief Officer Standing Order No.8 - Cargo Operations / Rev.14 / Status

Date 23 January 2019 ▪ Form Risk Assessment (Deck 24) / RA Number: 3-03 / Loading and Discharging drops /

Dated 20 October 2017 On the basis of the interviews, the following loading operation procedure is implemented onboard: ▪ The vessel’s loading/discharging operations are organized by the Loading Officer (Chief

Officer) who has the overall responsibility of the operations. The C/O is standing at the door on Deck 5 whereas the Second Officer (2/O) is standing on the bow ramp of Deck 3, both giving instructions to the drivers as to which position they should drive their vehicles and being responsible for monitoring the operations.

▪ The C/O prepares in advance a stowage plan which is given to the duty officers. The stowage plan for the loading at Rosslare Europort on 21/03/2019 was presented to the investigator. The loading is carried out as per the stowage plan which is further explained to the duty officers, prior commencement of the operation. This is also communicated to the


crewmembers responsible for receiving the vehicles on each deck, advising the designated parking place via portable radio.

▪ The duty Bosun, who is acting as the Foreman, is responsible to receive the cars at the designated deck and to inform the driver which his designated parking position is, following the instructions of the Chief Officer / Duty Officer. The “vehicle receiver” instructs the

assisting crewmember (normally there are three crewmembers available) accordingly, who is then responsible to guide, help and provide further instructions to the drivers to park. There is always an assigned crewmember (at least one and under certain circumstances two) for each vehicle for providing guidance to the drivers.

▪ The crewmembers should always guide the vehicles from a position where the drivers can see them and the drivers should be aware of the crewmember in the vicinity. The crewmembers should move to the “safe zone” of the vehicles giving them space for free movement, avoiding entrapment between fixed structures and the moving vehicles. The crewmembers communicate with the drivers with hand signals / gestures and with whistles. The crewmembers should wear overalls, reflective vest (hi-vis), safety shoes and helmet.

▪ They use the drive-in method when the vehicles are of low height and when the number of the loaded vehicles is small. The reversing method (backing up) is used when the number of vehicles to be loaded is high.

▪ When reversing method for trailers is used, two A/Bs are assigned for every trailer. The one A/B maintains eye contact with the driver and the other A/B whereas the second A/B controls the distances of the moving trailer. In the case of loading of Lane 1 with reversing method, which is the first lane inboard of the partial bulkhead on the port side of the lane, both A/Bs should be moving on the starboard side of the moving trailer (i.e. to the inboard side).

▪ The separation between the rear of a trailer and the front of the next inline is between 200 mm to 300 mm.

▪ The car deck is washed every month. On a daily basis, the crew members wash the entrance and exit area of the deck in order to remove the dust that the vehicles bring from outside during loading and discharging.

▪ The drivers are requested to follow generic safety instructions (not related to parking instructions) as per relevant notice which is posted at the entrance access of the deck, port and starboard. During the investigator's attendance, notices were found posted at the bow and stern entrances on Deck 3.

The SMS procedure "CAR 02: Safety on Vehicle Decks" requires among others, the following precautions: ▪ The vehicle decks of a Ro-Ro ship during cargo operations present certain hazards and it is

very important that only trained personnel are allowed to work on the deck unless provided with adequate supervision.

▪ all crew members when transiting cargo decks should be instructed to keep close to a bulkhead, ship’s side or vehicles that are already parked and not moving. They should be warned not to walk or stand in the middle of a vehicle deck where they may easily be hit from behind.

▪ For cargo operations, one officer or petty officer will be delegated responsibility for each vehicle deck. The Loading Officer will retain overall responsibility for all decks.

▪ Communications, usually by “walkie-talkie”, must be maintained at all times amongst and

between all persons involved in vehicle loading/ unloading and passenger embarkation/ disembarkation.

▪ In addition to full PPE (safety boots, hi-vis jacket, helmet) they shall also be equipped with a safety whistle on a lanyard and ear protection.

▪ Should work in pairs where practicable.


▪ When instructing a driver to reverse his vehicle, they should position themselves so as to always be able to “SEE” one of the vehicle's rear view mirrors. They should not stand between a stationary or parked vehicle and the vehicle that is reversing towards them.

▪ Never stand in the “Blind Zone” of a moving vehicle. ▪ Hand signals used by crew directing traffic should be positive and unmistakable. ▪ Wherever and whenever possible, crew should keep their back protected by a bulkhead, ship’s

side or vehicle that is already parked and not moving. ▪ Crew members must not be allowed to work on the vehicle decks without the safety whistle

on a lanyard. ▪ The whistle should only be blown to stop an operation. For example:

- Stopping a drop in its stowage position. - Stopping an Artic in its stowage position. - Stopping a vehicle from doing damage. - Stopping traffic to prevent an accident.

▪ Whistle signals should not be used for any other operation. This is to prevent confusion on the vehicle decks, a whistle signal means stop. Regular toolbox meetings, along with ship to shore meetings, should take place to emphasise this point.

▪ When assisting the parking of drop trailers (same meaning as an unaccompanied trailer) crew members must always remain in eye contact with the tugmaster driver manoeuvring the drop. A crew member must never stand directly behind a reversing drop trailer.

▪ If, due to the nature of the stowage position, the crew member directing it is unable to remain in eye contact with the driver of the tugmaster, then this becomes a two-man operation. The 2nd man must be in visual contact with all parties. However, no crew member is permitted to stand under, or in the way of a drop that is being manoeuvred into position.

The Chief Officer’s Standing Order no. 8 "Cargo Operations" requires among others, the following precautions: ▪ All crewmembers working on the vehicle decks during cargo operations must use whistle

signals and where possible visual signals when directing or parking vehicles and freight. This practice should be carried out even when the driver and crewmember are in clear and obvious visual contact. This is to avoid misunderstanding, particularly when the driver is ordered to stop.

▪ Extreme caution must be exercised at all times whilst on the vehicle decks. PPE is to be worn at all times and must include high-vis vest or jacket, safety shoes, hard-hat and signalling whistle.

▪ When loading drops on Deck 3 fans must be running on appropriate mode (Bow or Stern door opened).

▪ During reversing drop trailers for stowage position one A/B must monitor safe movement from behind and must have continuous visual contact with driver, via mirror or directly, until trailer is fully stopped in stowage position. However, deckhand must never stay right behind a moving drop trailer / other unit or stay in the corner where they can be trapped by moving vehicle. If the A/B must change sides to have better visual contact with the driver then the unit should be fully stopped until the A/B has changed sides and is standing clear. Only then can the unit be given the order to reverse again.

The Form Risk Assessment (Deck 24) / RA Number: 3-03 / Loading and Discharging drops, which was presented to the investigator, was found generic but non-realistic in order to represent the actual hazards and determine the corresponding control measures for mitigating the risks (i.e. hazards missing: lack of supervision, lack of communication, inadequate personnel / Control measures: implementation of SMS relevant procedures etc)


The casualty had undergone a safety induction / familiarization training when he was assigned with his new duties as able seaman, which was completed 18/03/2019 (five days before the accident). The casualty had limited experience of working on the vessel’s vehicle decks. He was

not directly supervised at the time of the accident, taking into account the inexperience and the requirements of the SMS-CAR 2. The loading operation had commenced a short time before the accident. The task was to load unaccompanied trailers through the bow door using “tugmasters” (generic name), parking the first ones along the outer lanes first (Lane 1 port side and Lane 5 starboard side) and then filling the central lanes (Lane 2 and Lane 4), in accordance with the stowage plan of that day. The deck ratings (three A/Bs) were deployed by the Chief Officer under the supervision of the Duty Officer and the Bosun, responsible for Deck 3 operations. One of the A/B left temporarily his task in order to pay a visit to the restroom. Thus, only two A/Bs were available for loading operation on Deck 3, one working on the port side and the other on starboard side. The instructions were to use the reversing (backing-up) method of parking, in which case the crew member assigned for this task should maintain eye contact with the driver of "tugmaster" or if this not practicable, the task should be carried out by two deck ratings. According to the statements, the deceased person lost his eye contact with the driver of the "tugmaster" (when he went to the rear part of the moving trailer to check the distance from the stationary trailer) and he did not request for a second A/B for assistance or ceased the operation till the return of the third A/B, or ceased operation until achieving eye contact with driver, as required by SMS CAR 02. In addition, the deceased person was found between a stationary trailer and the trailer that was reversing against it at the time of the accident and no whistle signal was heard by the driver or the other A/B who was working starboard side, which is against the safety precautions measures of the SMS CAR 02. The deceased was found bearing overall suit, safety shoes, helmet (which was found underneath the forward area of the stationary trailer), jacket with reflective straps, gloves. The PPE requirements when working on vehicle deck included a whistle which was to be used strictly as a signal for drivers to stop their vehicles. The common procedure for assisting the drivers to park was to communicate positions between driver and crewmember by the use of gestures, signals and, in case of stopping the "tugmaster", the use of whistle. There was no statement that the deceased was equipped with whistle on lanyard or not. The driver of the "tugmaster" stated that at the initial stage of the manoeuvring (starting, not stopping) and while the driver and the deceased were maintaining eye contact, the deceased gave him a wave and a wolf whistle as a signal to start. According to the aforementioned findings there was no evidence to suggest that the "Documentation of the Safety Management System" could be considered that may have been a contributing factor to the accident. With due consideration to the events that led to the accident and the aforementioned findings, there was evidence to suggest that the implementation of the safety management system and particularly the cargo operations on vehicle decks (e.g. non-realistic risk assessment, non-implementation of the safety precautions, lack of supervision, poor evaluation of familiarization training, etc) by the involved crewmembers could be considered that may have been contributing factor to the accident. "Lack of visual contact" between the driver of "tugmaster" and the crewmember is a contributing factor to the accident. Non-establishment of visual contact at all times of manoeuvring indicates a failure to strictly implement the safety guidelines and procedures.


The vessel’s official Log Book was checked and found that there were references to the Deck Log Book, instead of properly filling-in the official log book as per Cyprus Flag requirements. The accident was recorded in both log books dated 21/03/2019.

The vessel’s medical locker was verified to be in order during the attendance of the investigator.

However, due to the severity of the accident and as the vessel during the accident was at Rosslare port, first aid was provided initially by the crewmembers of the "Alpha Code" team and then by the ambulance personnel who attended the vessel immediately after the accident. The vessel's medical locker was found certificated in accordance with the "Merchant Shipping Medical Scale Regulations - UK MSN 1768 (M&F): Scale B (Restricted trade) (complies with current EC Directive 92/29 on minimum standards for ship's medical stores)", "UK MSN 1768 (M&F): Doctor Bag" and "IMO Poison Treatment Chest (IMDG 2000 Regulations - Scale B". The aforementioned certificate was presented to the investigator and was valid till 14/05/2019.

There was no evidence to suggest that “Lack of medical supplies” could have been considered a contributory factor to the accident. During the visit of the investigator, the crew was found bearing the appropriate Personal Protective Equipment, i.e. Overall suit, safety shoes, helmet, hi-vis vest, and whistle. The use of whistle was verified during the operations. During the visit, the "tugmaster" drivers were not driving fast or in an unsafe manner.


4.8 "Tugmaster" Driver

The "Tugmaster" drivers are employees of the Port Authority, which is owned by Irish Rail, part of Coras Iompair Eireann (C.I.E.). The following analysis refers to the driver who was driving the "tugmaster" of the moving trailer which was involved in the accident. As stated by the driver, he works with Irish Rail in Rosslare Europort for the last fourteen years. He stated that on a daily basis, when he works, he is driving the "tugmaster" on an average day discharging and loading up to thirty trailers. He is a qualified "tugmaster" driver for the last ten years. The "tugmaster" driver stated that on 21st March 2019 he was assigned to drive a "tugmaster" for loading and discharging unaccompanied trailers onboard MV "Isle of Inishimore". He stated that while he was reversing the trailer slowly, we waited for the A/B assigned to assist him to signal by whistle for stopping the manoeuvre. He also stated that it was not unusual for the A/B to go out of drivers' view while they were reversing the trailers. "Lack of visual contact" between the "tugmaster" driver and the assigned A/B is a contributing factor to the accident. There is no information about the driver's working and resting periods, thus fatigue cannot be commented upon at this time. Immediately after the accident, the "tugmaster" driver was submitted to an alcohol test (breathalyser) by the Local Harbour Police Officers. The result of this test was "Pass". The “tugmaster" driver' alcohol blood content was not a contributory factor to the accident. The drivers' employment selection criteria, employment terms and conditions, training requirements, medical fitness, previous historical records etc were not available. This accident is also under investigation by the Irish Authorities, other than the Irish Marine Casualty Investigation Board. On the basis of the available information, there are no grounds to suggest that the "tugmaster" driver's lack of training, medical condition, experience, employment terms and conditions, and fatigue could have been considered contributory factors to the accident.


4.9 "Tugmaster" involved in the accident

The "tugmaster" (generic name) involved in the accident was manufactured by KALMAR. The Kalmar "tugmaster" which was involved in the loading operation of trailer with number NT666F had the port designation of DT22. This "tugmaster" is a TR618i model.

Figure 13: "Tugmaster" KALMAR involved in the accident

On the basis of the "Preliminary Report into the fatal Accident on the main vehicle deck of the MV "Isle of Inishmore" at Rosslare Europort on 21/03/2019" issued by the Rosslare Europort, this "tugmaster" was bought new by the port in November 2008 and had c 7900 running hrs on it. The servicing for the "tugmaster" fleet is carried out by Iarnród Éireann’s sister company, Bus

Éireann who have maintained the fleet for many years at a nearby facility. DT22 had received its most recent service on 4th

March 2019 with a 500hr service. In addition to the service regime, an independent inspection is carried out annually by the Freight Transport Association (FTA). The "tugmaster" tyres of DT 22 are maintained under a contract with DUNLOP LTD. Thread depth had been checked in February and were well within tolerances.

When the "tugmaster" Kalmar is operated, the driver’s seat can be rotated through 180 degrees. When the seat is facing forward, the side mirrors provide rear view to the driver. All side mirrors of DT22 were found in satisfactory condition at the time of the accident.


Figure 14: "Tugmaster" DT22 rotated seat and side mirrors

The driver stated that while reversing the DT 22 attached to the trailer, his seat was facing backwards. The unaccompanied trailer (NT666F), which was attached to the DT22, was loaded with agricultural machinery which were protruding from both sides of the trailer. As stated by the aforementioned Rosslare Europort, "tugmasters" are designed to be very maneuverable and when being reversed the pivot point is in front of the "tugmaster" driver. When facing backwards, the vehicle’s side mirrors become useless and the driver becomes

unsighted. The "tugmaster" driver experiences significant blind spots when reversing. The "tugmaster" driver cannot control the rear of the attached trailer. When the driver of DT22 reversed, his line of sight with the A/B was momentarily obstructed by the protruding loads, which further reduced the driver's field of vision and possibly the side-to-side movement of the "tugmaster" when maneuvering backwards. The driver was reliant on the assigned A/B to guide him into position.

After detailed analysis of the photos presented to the investigator, it was evident that the final position of the truck was within safety (yellow) lines of Lane 1.

There was no evidence to suggest, that, the "tugmaster" condition could have been considered contributory factor to the accident.


4.10 Port Authority

The "tugmaster" drivers are employees of the Port Authority, which is owned by Irish Rail, part of Coras Iompair Eireann (C.I.E.). Rosslare Europort is a wholly owned and operated division of Iarnród Éireann. The Port Authority carries out all Ro-Ro stevedoring operations at the port with its own fleet of Terberg and Kalmar "Tugmasters".

In June 2017 there was a similar incident at Dublin Port. The revised work practices at Rosslare Europort followed a review of the publication of the Casualty Investigation report at the time. On the basis of several observations of the drivers and cases of vessels calling the port and involved in tugmaster operations, the Rosslare Port Authority carried out risk assessment in order to identify the potential risks of such operation and determine the required control measures, on 26/01/2017. The records of the risk assessment were presented to the investigator and the following hazards were noted which directly addressed the subject vessel: 1. Code 714: Roof damage caused by collision with ventilation in tunnel no.3 deck. The proposed control measure for mitigating the risk was "the driver awareness and keeping fifth wheel in travel position. No high nolan / perennial trailers". 2. Code 1721: Crew walking behind trailers prior to positioning on deck. The proposed control measure for mitigating the risk was "crew awareness through training procedures - especially new crew on joining. Driver to report incident to controller for onward communication with master". 3. Core 1729: Drivers to be aware of crew and other persons passing through access openings. The proposed control measure for mitigating the risk was "onboard procedures to keep safety barriers closed when loading / discharging. Slow speed and driver awareness". On 09/02/2017, an additional potential risk was identified addressed to all vessels: 1. Code 1731:Crew walking behind trailer whilst it is being pushed into stowage position. The control measure for mitigating the risk was "driver to stop vehicle immediately and warn crew not to repeat. Report immediately to controller who will arrange to contact master". According to the records, the control measures should be implemented by 13/02 and 15/02/2018. As declared in the "Draft Report of the Irish Marine Casualty Investigation Board" following acceptance of the concept, the Harbour Master’s office issued a Safety Notice on 10th March 2018 to all operational staff in the employment of port. The review of operations by the Port Authority had identified the risk of persons moving between trailers when moving on the vehicle decks for all vessels operating from the port. The determined control measures could not prevent the accident from occurring. With due consideration to the aforementioned information, there was evidence to suggest that the ineffective monitoring of implementation of control measures determined by the Port Authority for mitigating the potential hazard for restricting crew walking behind trailers whilst being pushed into stowage position, could be considered that may have been contributing factor to the accident. In May 2018, the Harbour Master of Rosslare Europort sought and obtained agreement from all vessels using the port, for a single system of using whistles. Relevant records were presented to the investigator. Both entities, Port Authority and the subject vessel, agreed that the only use of the whistle was to signal drivers to stop their vehicles immediately. Once all accepted the principle, Safety Notice was issued by the Port Authority. The vessel's ship management company revised the relevant procedure in order to comply with the aforementioned safety notice.


The Port Authority, as previously mentioned, carried out an investigation after the accident and the "Preliminary Report into the fatal Accident on the main vehicle deck of the MV "Isle of Inishmore" at Rosslare Europort on 21/03/2019" was presented to the investigator. The following findings are taken from the aforementioned preliminary report: QUOTE: 1. Observations

▪ The deceased appears to have been working alone. ▪ The deceased appears to have walked behind the reversing trailer as it closed on the one

behind it. ▪ There were reports from the Tugmaster drivers loading that morning that some of the

Deck crew were “wolf whistling” instead of using a signalling whistle. Furthermore the agreed standardised practice within the port of the whistle signal only being used to signal Stop was not being adhered to.

2. Initial Actions taken

▪ The HSA made some recommendations to the Port Authority following the accident which have all been actioned. These were: - Fitting of Electrical Suzi’s to Tugmasters. This is not an Industry norm and involved

approaching the manufacturers of both manufacturers of Tugmaster to have some modifications made to allow for a secondary Electrical Suzi connection to be fitted to each Tugmaster to allow for both Reversing and Side / Brake lights to operate on the trailer.

- Review of Tugmaster Operations Risk assessments. - Review of the Ports Local Safety Statement. - Review of the Ports Traffic Management Plan.

▪ Following Internal review, other areas of Tugmaster operations and Traffic Management were also reviewed to identify any other hazards.

▪ There has been a joint demonstration held between the Master, Officers and Crew of the Isle of Inishmore and Port staff on board the vessel to look at the additional procedures which the vessel has put in place since the accident. These include: - Change of work practice so that AB’s do not position themselves against bulkheads. - Prohibition of crew walking behind moving trailers. - AB’s working in pairs when positioning trailers on the Port side of the Main deck. - Positioning an AB in sight of the Tugmaster driver to guide the Trailers back into

position on the Port side. - The presence of a Deck Officer for the positioning of the final trailers Aft on the Port

side. - The positioning of an extra AB in Lane 7 when positioning Trailer No 9. - The introduction of the practice, where load size allows, of “driving in” trailers on the

Port side of the Main deck to reduce the amount of reversing required. The Port also demonstrated the new Electrical Suzi connections on its Tugmasters and trailer lighting. The vessel has also been asked to forward a copy of its revised Vehicle Deck Procedures.

▪ Periodic monitoring of the procedures have also been carried out.

UNQUOTE


4.11 Summary of events On the 21/03/2019 06:00 LT, the Tugmaster driver was instructed to drive a Tugmaster for the discharging and loading operation of unaccompanied trailers of MV “Isle of Inishmore. The vessel berthed at Rosslare Europort Berth No.1 at 06:46 LT and commencement of discharge operation of all Rosslare bound cargoes was at 07:00 LT. At 07:20 LT the vessel commenced the loading operation. The two A/Bs, upon finishing the preparation in the aft part of the deck, went forward to assist the Bosun and the other A/B with the loading. Upon finishing the loading of trailers on the starboard side (remaining only one drop aft) and two-three drops were left for finishing the port side aft, the Bosun instructed A/B1 and A/B2 to complete the remaining drops in the aft part. The stowage plan for Deck 3 indicated that the unaccompanied trailers should be stowed in Lane 1, 2, 4 and 5, parking the first ones loaded along the outer lanes first (Lane 1 port side and Lane 5 starboard side) and then filling the central lanes (Lane 2 and Lane 4).

Figure 15: Stowage plan of Deck 3 at 21/03/2019

The instructions were to use the reversing (backing-up) method of parking. The tugmaster driver started loading of unaccompanied trailers, following the completion of the discharging operation. The two A/Bs were loading the aft of Deck 3. The third A/B, who was also assigned for the loading operation on Deck 3 went to the restroom, whereas the two A/Bs (A/B1 & A/B2) continued loading the remaining trailers, with A/B2 covering the starboard side drop and A/B1 the port side drops on Deck 3 aft. The Bosun went forward to start loading of new starboard lane. While loading the sixth consecutive trailer of unaccompanied trailers, the driver of tugmaster no. DT22 hooked up the trailer with number NT666F. This trailer was a flat bed trailer carrying three (3) pieces of agricultural equipment (animal feeders). When the driver hooked up the trailer in question, he realized that the wheels of the animal feeders were slightly overhanging on each side of the trailer, however it was common for this type of load. At about 07:40 LT, the driver received instruction to drive the tugmaster with the unaccompanied trailer at Lane 1 aft of Deck 3. While parking trailer NT666F, which would have been the eighth trailer on the port side lane

LANE1

LANE2

LANE3

LANE4

LANE5


no.1 aft, a fan unit over-hanged at this parking space, which could be an obstacle for trailers with high loads.

Figure 16: Deck 3 arrangement plan

The tugmaster driver passed by the seventh trailer NT1135CX, which had already been parked, and stopped in order to drive in reverse (back-up) the trailer to the parking position aft of the stationary trailer in his effort to line up the trailer into position. While the tugmaster driver stopped and his seat was still looking forward towards the aft part of Deck 3, A/B1, who was responsible for assisting the drivers on the port side of Deck 3, was standing over to the driver's right hand side. The driver rotated his seat for backing-up. The assigned A/B1 was now standing to the left hand side of the driver, on the step by the bulkhead. The tugmaster driver, who was sitting on the left hand side of the Cab (when reversing) was in sight of A/B1 as he was reversing. The assigned A/B1 gave him a wave and a wolf whistle, to start manoeuvring. The drive and A/B1 maintained eye contact.

Figure 17: 1st and 2nd positions of A/B 1

The initial approach ended up with the trailer's wheels protruding over the lane lines due to the difficulty imposed by the over-hanging fan unit. The driver was aware of the overhanging fan unit and during his maneuvering he tried to avoid any contact. It is noted that at the edge of the bulkhead there was a step which should be also taken into consideration during maneuvering in this location. A second approach was attempted by the driver, by pulling forward to straighten / align the trailer into the lane line and by pushing it back after the A/B1’s wave signal. A/B1 was standing against the bulkhead on the ledge at the head of the seventh stationary trailer. The driver and the A/B1 at

Location of the overhang fan unit

Parking for NT666F NT1135CX

7th - NT1135CX

NT1135CX NT666F

A/B 1 1st position

A/B 1 2nd position


this moment maintained eye contact, due to the manoeuvring position of the tugmaster's cabin in relation to the trailer and the left position of the driver in the cab which provided him with adequate left hand field view.

Figure 17: 3rd position of A/B 1

Due to the type of reversing manoeuvre, the position of A/B1 would come at some point out of driver’s view. As the trailer was reversing the driver's line of sight with A/B1 was momentarily obstructed by the protruding parts of the Agricultural machinery which were loaded on the trailer and possibly by the rotational movement of the Tugmaster when maneuvering. During this maneuver the driver and A/B1 lost eye contact. A/B2, who was assigned to the operation on the starboard side of aft Deck 3, was standing approximately ten meters away from the aforementioned operation on the port side. While the tugmaster driver was backing-up the trailer and awaiting for A/B1’s signal to stop the trailer by

whistle, on his second effort to correct the final position of the trailer, he heard a whistle and he stopped. A/B2, who was positioning the trestle on the starboard side at that time, saw A/B1 standing between the stationary and the moving trailer. From his angle of view A/B2 could not estimate the space between the two trailers. He did not hear any whistle. He immediately blew his whistle and shouted to the tugmaster to stop waving him to go forward. The tugmaster driver stopped and pulled ahead again. A/B1 became trapped and was crushed between the reversing drop trailer towed by the tugmaster truck and the drop trailer which had already been parked. It is estimated that A/B1 was moving from port to starboard (left to right as per driver's view at the time) at the rear of the moving trailer when he was trapped between the two trailers. There was no eye contact with the tugmaster driver. Due to lack of eye witness of the accident, the reasons for A/B1 being behind the moving trailer cannot be reliably determined, taking into consideration that: 1. the last time the driver saw A/B1, he was standing against the bulkhead on the ledge at the

head of the seventh stationary trailer, where there is a bulkhead opening access leading to the port tunnel lane through which he could escape,

2. his last seen position was protected by the stationary trailer and the alley of approximately 80 cm width towards the longitudinal bulkhead.

There are two possibilities for A/B1 to decide to cross from left to right at the rear of the moving trailer ending being trapped between the two trailers:

NT1135CX NT666F

A/B 1 3rd position


1. Some accidental event which caused A/B1 to panic / loose his judgment (taking into consideration his limited experience in working on vehicle decks and the fact that the trailer was under reverse movement) and attempting to cross. Accidental event may but not be limited to: ▪ during moving in the area after his last position seen, he struck a sharp edge which caused

him an abrasion over the right eyebrow (causing blood smearing on his face, possible temporary loss of his right eye vision, temporary loss of direction). This abrasion was mentioned in the statement of the Chief Officer and verified during the post mortem examination. A/B1 was wearing a helmet, however this could not protect his eye.

▪ Slippage / loss of balance (e.g. tripping on stationary trailer). 2. Poor decision making such as:

▪ due to lack of experience or concentration, to urgently achieve eye contact with the driver in order to advise him to stop the tugmaster moving (the possibility of not carrying a whistle cannot be excluded).


5. Conclusions The deceased person received familiarization training as per the company's Safety Management System requirements. He had previous experience as ordinary seaman and able seaman onboard vessels other than the specific vessel type (RORO-PAX), since 2015. The accident occurred a few days after his assignment as able seaman and after serving onboard this vessel for approximately three weeks as Cleaner / Painter. There was inadequate implementation of the ship management company's safety management system and particularly the cargo operations on vehicle decks by the involved crew members. Specifically, the deceased person was working without effective supervision, the backing-up manoeuvring was carried out by only one able seaman without eye contact with the driver, he attempted to cross behind the moving trailer without signalling for stopping the tugmaster etc. During the maneuvering, the driver and the deceased person lost eye contact and neither of the two took any measures to remedy this. Neither the driver nor the second able seaman, who was working on the starboard side, heard any whistle blown by the deceased person warning the driver to stop. The review of operations by the Port Authority had identified the risk of persons moving between trailers when moving on the vehicle decks for all vessels operating from the port. The implementation of the determined control measures, issued by the Port Authority, could not prevent the accident. Due to the lack of eye witnesses, no safe conclusions can be extracted as to the exact conditions of the accident. However, on the basis of the information and data presented to the investigator and the analysis carried out, the following causes were considered as the most appropriate: Root Cause(s) (If corrected, the same accident will not happen again) Root Cause: Safety Management System Inadequate Implementation The inadequate implementation of the safety management system and particularly the cargo operations on vehicle decks safety guidelines and procedures, resulted in non-realistic risk assessment, non-implementation of the safety precautions by the deceased and the involved crewmembers, lack of supervision of the operation of the specific tugmaster etc is considered as a root cause of the accident. If the safety management system documented procedures were being implemented correctly, the accident would have been avoided. Root Cause: Lack of Visual Contact The lack of visual contact between the tugmaster driver and the A/B, throughout any stage of the maneuvering operations, is considered as a root cause of the accident. If visual contact had been established during all stages of the maneuver, the driver would have stopped the trailer when he could not see the A/B or he would be informed to stop by the A/B. Direct Cause: Wrong Decision (Moving behind Reversing Trailer) (The immediate events or conditions that caused the accident) The deceased person for unknown reasons attempted to move behind the reversing trailer, against all written procedures and guidelines, a decision which caused the accident. This is an action which


should not have been decided irrespective of any safety measures in place, such as eye contact with driver, placement of second assisting A/B, whistle signal / gesture / hand signal. Contributing Cause(s): (An event or condition that collectively with other causes increases the likelihood of an accident but that individually did not cause the accident) Contributing Cause: Inadequate Experience of the Deceased The deceased's limited previous experience in the position of able seaman with duties involving vehicle operations, considering that the accident occurred a few days after his assignment as able seaman, may have led to his poor decision making and lack of hazard identification, which may have contributed to the accident. Contributing Cause: Poor Evaluation of self-readiness of the Deceased to undertake the assigned duties The deceased received familiarisation training as per the SMS requirements. The accident occurred three days after its completion and the deceased failed to follow written SMS procedures pertaining to cargo vehicle operations. The poor evaluation of the deceased person's self-readiness to undertake the assigned duties following his familiarization, may have caused failure to recognize his inability for implementing procedures to prevent unsafe acts, may have contributed to the accident. Contributing Cause: Impairment of Physical Condition Impairment of physical condition due to the abrasion over the right eyebrow of the deceased person, may have led to loss of judgment, poor decisions making, panic and loss of concentration, which may have contributed to the accident. Contributing Cause: : Ineffective Monitoring of Implementation of Control Measures by Port Authority The ineffective monitoring of implementation of control measures determined by the Port Authority (for mitigating the potential hazard for restricting crew walking behind trailers whilst being pushed into stowage position), may have led to failure of preventing the particular hazard, either by the involved ships' crew or by the port employees, may have contributed to the accident.


6. Recommendations (With Time limit i.e., Within 3 months)

1. For the Management Company:

a. The Safety Management System to be revised in order to include provisions for new crewmembers with little experience to be supervised directly when working on vehicle decks for a specific period of time. (Within three months)

b. Onboard familiarisation training procedures to be reviewed by the company to ensure effective evaluation of the outcome. (Within three months)

c. Additional training to be provided to the crewmembers involved in cargo vehicle operations covering the safe zone for crew movement, the blind sectors of drivers for several types of vehicles, signalling, supervision, conditions for ceasing manoeuvring etc. (Within one month)

d. To consider carrying out unscheduled internal audits on board ships in order to verify effectiveness of the SMS implementation. (Within three months)

e. The risk assessment for cargo vehicles operations to be more detailed regarding the hazards and counter measures to mitigate the risk covering individual tasks. (Within three months)

f. The company to establish "visual contact policy" providing necessary instructions, training etc. In addition, the company to consider alternative means of driver / crew communication additional to the use of whistles for signalling (e.g. dedicated radios could be used to communicate between crew and tugmaster drivers). (Within one month)

2. For the Port Authority: a. To instruct vehicle drivers when they do not have visual contact with the assigned parking

guide, to stop their vehicles until achieving visual contact, especially in reverse manoeuvring. b. To increase monitoring / supervision of cargo deck operations in order to ensure that all

procedures, guidelines, control measures etc are properly and effectively implemented. a. Instructions to be given to the drivers in order to cease operation and report unsafe acts during

the operations.

mairne accident investigation - maritime cyprus · 2020-03-10 · smc ism safety management...

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