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MV Kiran Turkiye 201411/018 1

Marine Safety Investigation Unit

SAFETY INVESTIGATION REPORT

201411/018 REPORT NO.: 27/2015 November 2015

MV Kiran Turkiye

Man overboard from

the accommodation ladder at the

Eastern Bunkering C, off Singapore

13 November 2014

SUMMARY

On the 13 November 2014,

Kiran Turkiye was on anchor

at Eastern Bunkering C, off

Singapore to receive bunkers

on her port side, and

lubricating oil on her starboard

side. At about 2245 (LT), one

of the ABs fell overboard and

lost his life. At the time, he

was preparing for the heaving

up of the port side

accommodation ladder clear

from the bunker barge.

The safety investigation

concluded that the work on the

accommodation ladder was

also being carried out aloft and

over the ship‟s side.

Moreover, the hazards and risks

arising from working aloft and

over the ship‟s side were either

unforeseen, or the intended

measures to control them were

not implemented.

The Marine Safety Investigation

Unit has made three safety

recommendations to the managers

of the vessel, mainly focusing on

safety management system

procedures and risk assessment

related to rigging and unrigging

of accommodation ladders and

working aloft.

The Merchant Shipping (Accident and Incident Safety Investigation) Regulations, 2011 prescribe that the sole objective of marine safety investigations carried out in accordance with the regulations, including analysis, conclusions, and recommendations, which either result from them or are part of the process thereof, shall be the prevention of future marine accidents and incidents through the ascertainment of causes, contributing factors and circumstances.

Moreover, it is not the purpose of marine safety investigations carried out in accordance with these regulations to apportion blame or determine civil and criminal liabilities. NOTE

This report is not written with litigation in mind and pursuant to Regulation 13(7) of the Merchant Shipping (Accident and Incident Safety Investigation) Regulations, 2011, shall be inadmissible in any judicial proceedings whose purpose or one of whose purposes is to attribute or apportion liability or blame, unless, under prescribed conditions, a Court determines otherwise.

The report may therefore be misleading if used for purposes other than the promulgation of safety lessons.

© Copyright TM, 2015.

This document/publication (excluding the logos) may be re-used free of charge in any format or medium for education purposes. It may be only re-used accurately and not in a misleading context. The material must be acknowledged as TM copyright. The document/publication shall be cited and properly referenced. Where the MSIU would have identified any third party copyright, permission must be obtained from the copyright holders concerned.

This safety investigation has been conducted with the assistance and

cooperation of the Maritime and Port

Authority of Singapore

Kiran Turkiye


FACTUAL INFORMATION

Vessel

Kiran Turkiye, a 92050 gt bulk carrier was

built in 2011 and is registered in Malta.

She is owned by Silk Road Shipping Ltd,

managed by Pasifik Gemi Isletmeciligi,

Istanbul and classed with Bureau Veritas.

The vessel‟s length overall is 291.80 m and

her loaded draught is 18.25 m.

Propulsive power is provided by a

6-cylinder B&W 6S70MC, Mark VI, slow

speed direct drive diesel engine producing

14331 kW at 86.2 rpm. This drives a single

fixed pitch propeller, giving a service speed

of 14.91 knots.

Description of the telescopic ladder

The telescopic ladder (Figure 1) had about

60 steps and a maximum inclination angle

of 55° to the horizontal.

Figure 1: Location of the accommodation ladder

The lower ladder section (towards the

forward end of the ship) laid on top of the

upper ladder section. The upper ladder was

connected to the upper platform‟s turntable.

The lower ladder section was fitted with a

roller at the bottom, which supported the

weight of the telescopic ladder when it

rested on the quay. The lower platform,

which provided access to the accommodation

ladder, was adjustable.

The ladder was raised and lowered by a hoist

winch fitted at the upper deck level. The fall

wire was led from the winch down to a sheave

at the bottom end of the lower ladder section,

and along the lower ladder section to an

anchor point on the upper ladder section. A

stopper chain bridle prevented the angle of

inclination from exceeding 55° (Figure 2).

This arrangement allowed the accommodation

ladder to be lowered to its maximum

inclination by paying out the fall wire and then

extended by continued paying out of the fall

wire.

Figure 2: Telescopic accommodation ladder

arrangement, showing (A) fall wire being led round

to (B) anchor point on upper ladder section, and (C)

stopper chain bridle

For retrieving the extended ladder, hoisting the

fall wire would first retract the lower ladder

section by sliding it fully on top of the upper

ladder section. Continued hoisting of the fall


wire would then lift the ladder back to the

horizontal position.

Collapsible handrails were fitted to the

upper and lower ladder sections. Portable

stanchions with polypropylene man ropes

were fitted around the upper and lower

platforms. The collapsible handrails

enabled the ladder to be stowed on its side

on the upper deck.

Onboard instructions

Accommodation ladder instructions were

available on board the vessel. Drawings of

the accommodation ladder arrangement

were also available on board.

The fatally injured crew member

The AB was 49 years old, Turkish, and had

been employed by the managers for eight

years, since he first went to sea. He had

been serving on board as an AB for two

years. The AB had embarked in the port of

Istanbul on 21 June 2014. He was normally

assigned the 0800-1200 / 2000-0000

watches when the vessel was at sea and in

port.

Environmental conditions

At the time of the accident, it was dark

although the artificial lighting provided was

sufficient. Visibility was good. The sea

state was calm, with a Northwesterly force

3 wind. The sea temperature was about

28 °C.

Narrative

On 13 November 2014, at 1730(LT),

Kiran Turkiye arrived in ballast condition at

the Eastern Bunkering C anchorage, off

Singapore. She was scheduled to receive

bunkers, lubricating oil, and affect crew

changes, including a new master.

At 1930, a bunker barge was made fast on the

port side, beneath the accommodation block.

A barge supplying lubricating oil was made

fast on the starboard side at 2045.

The fourth engineer and the bunker surveyor

used the ship‟s port side telescopic

accommodation ladder to board the bunker

barge to conduct the opening bunker survey.

The accommodation ladder was lowered to the

main deck of the bunker barge (Figure 3), the

collapsible railing lifted and secured. The

safety net was not rigged.

After completing the bunker survey, the fourth

engineer and the bunker surveyor returned to

the ship. There being no need of further

personnel transfer between the ship and the

barge until completion of the bunkering

operation and, in order to avoid risks of

damage, the barge requested the ship to heave

up the accommodation ladder.

The duty AB was instructed by the fourth

engineer to proceed down the accommodation

ladder to unsecure the side ropes. While the

AB made his way down the accommodation

ladder, the fourth engineer stood by on the

upper deck at the wired remote control station

of the accommodation ladder (Figure 4) ready

to heave up the ladder.


Figure 3: Accommodation ladder rigged from

ship to barge showing (A) upper end of lower

ladder, being also probable position of AB at the

time of accident, (B) stopper chain bridle and (C)

davit arm

Figure 4: Control box for accommodation ladder

with remote control inside

The fourth engineer commenced heaving up

the accommodation ladder when signalled to

do so by the AB. The fourth engineer was

standing in a position which did not allow a

direct line of sight. It was reported that at this

time it was raining lightly, and that the AB

was bent down loosening the side ropes.

That was the last time that the AB was seen on

the accommodation ladder. Moments later, he

was observed motionless and facing down in

the water.

On seeing this, the fourth engineer started

shouting “man overboard,” and informed the

second and third engineers, who were on the

starboard side overseeing the lubricating oil

transfer. He then called the bridge from the

ship‟s office.

The third officer, on anchor watch on the

bridge, received the call from the fourth

engineer. He raised the alarm by making an

announcement on the PA system. In the

meantime, the master informed the agents,

who in turn immediately notified the Maritime

and Port Authority (MPA) of Singapore.

Two boats were dispatched by the MPA,

Singapore to conduct a search and rescue

operation. In the meantime, a search and


rescue team made up of the chief mate, the

bosun, the third engineer and the AB was

mustered on board. The vessel‟s rescue

team were unable to use the rescue boat

because the bunker barge was still

alongside right below it. In view of this,

the master authorised the launching of the

free fall lifeboat.

Eventually, the AB‟s body was localised an

hour later, at about 2350, by one of the

MPA, Singapore patrol boats. The body

was then recovered by a Police Coast

Guard‟s boat at 0025.

Cause of death

The autopsy determined the cause of death

to be drowning. The AB, however, had

suffered blunt force injuries to his head.

Although these injuries were not considered

to be fatal, it was not excluded that they

could have knocked him unconscious.

ANALYSIS

Aim

The purpose of a marine safety

investigation is to determine the

circumstances and safety factors of the

accident as a basis for making

recommendations, and to prevent further

marine casualties or incidents from

occurring in the future.

Cooperation

During the course of this safety

investigation, MSIU received all the

necessary assistance and cooperation from

the Maritime and Port Authority of

Singapore.

Fatigue

The hours of work and rest of the deceased

AB showed that prior to the accident he had

been on duty for four hours. These were

preceded by a rest period of seven hours.

Records of hours of work and rest for the

month of November indicated that the AB

worked for eight hours every day, except on

06 November 2014, since he had one hour of

overtime registered in his records.

Moreover, the safety investigation did not

identify anything in the behaviour of the crew

member, which would have indicated that

fatigue contributed to this fatality. To this

effect, fatigue was not considered to be a

contributing factor to this accident.

Preparation of the accommodation ladder

A significant body of literature is available in

the industry regarding accommodation ladders

and their safe use, such as, for instance, the

safe rigging of the safety net. The safety

management system on board Kiran Turkiye

also addressed the potential hazards associated

with the boarding and disembarking from the

ship.

It has to be specified, however, that whereas

the safety net is secured with the

railings/stanchions in place, the preparation of

the railings may necessitate personnel to be on

the ladder when the railings are not yet in

place. This is an intrinsic risk within the

system.

The preparation of an accommodation ladder,

and also the rigging and unrigging of the

safety net necessitated crew members to work

aloft and over the ship‟s side. Thus, the

possible consequence of a crew member losing

balance or staggering backwards was a fall

overboard.

Even more, crew members working at a height

may find themselves in a position where they

need to focus on the task in hand and

simultaneously guard themselves against a

potential fall overboard. It is very probable

that such situation would lay the ground for an

accident to happen, with potentially serious

consequences.


Academic literature indicates that a

fundamental property of selective attention

is the ability to process one source of

information (e.g. the task in hand), while

suppressing or paying less attention to

another source of information within the

prevailing context (e.g. the close proximity

to the edge of the accommodation ladder).

Risk assessment, work permit and the

use of LSA

The safety investigation was provided with

a number of Risk Assessment forms for the

rigging/lowering of the pilot/passenger

gangway. The forms were completed on

different occasions between the end of June

2014 and the end of October 2014. No Risk

Assessment Form for the day of the

accident was provided to the safety

investigation.

However, since all the risk assessment

forms provided were completed in an

identical manner, there was no reason to

believe that this would have been different

for the day of the accident. The completed

risk assessments stated that the number of

crew involved in the rigging / lowering of

the pilot / passenger gangway was three

persons.

When rigging the gangway, a man

overboard occurrence was one of the

hazards identified and the wearing of safety

belt and safety harness1was noted as an

existing risk control measure. A toolbox

meeting was considered to be an additional

control measure. It was also noted that crew

members were not required to wear a

lifejacket when rigging the accommodation

ladder, in all probability because of the

requirement to wear a safety belt / safety

harness.

1 The Risk Assessment Form does not make any

reference to the difference between safety belt

and safety harness. The Form requires that

“[w]hen hand rail fixed on gangway safety belt

must be used and safety harness to be weared.”

(sic).

Falling down while using the gangway was

another identified hazard, which had to be

controlled either by the rigging of a safety net

or by the use of a lifejacket. Supervision from

a person on deck other than the operator was

not identified as a risk control measure.

The consideration of „working at a height‟ (or

aloft) as a specific hazard was very important

because although the accommodation ladder

system could have been un-stowed and

lowered (to the bunker barge) without any

persons having to stand on it while the ladder

was suspended by its fall wire, the stanchions

and hand rails had to be erected manually.

The reverse procedure applied when the

accommodation ladder had to be re-stowed

before departure. Thus, in order to work the

stanchions and the hand rails, there was no

other option for the crew members but to step

on the accommodation ladder and expose

themselves to the risk of falling.

The fact that a work permit was neither

required nor issued for the crew member to

work aloft may be due to a task which may

have been seen as trivial, if not routine in

nature. This was indicative that the risks

arising from working aloft and over the ship‟s

side were unforeseen by the two crew

members involved and any measures to control

them were not implemented. The MSIU is

aware that a safety harness was not being used

by the crew member at the time of the

accident. It also transpired that there was no

safety net fitted.

The safety net would have not prevented this

fatality as it would have been already unrigged

prior to collapsing the side railings.

Nevertheless, the safety net was not rigged

when the accommodation ladder was being

used as a means of access between the ship

and the bunker barge. Under these

circumstances, the crew members were

required to use a lifejacket. However, the

evidence collected by the MSIU did not

indicate that lifejackets had been donned.


Considering that this accident was a first

experience for the crew members on board

Kiran Turkiye, a prima facia, it may be

proposed that risk behaviour includes the

extent to which the crew members ignored

safety regulations in order to get the job

done. However, risk perception and risk

behaviour are more complex than this.

What is definite, however, is that risk

perception is crucial to safety because it

may influence the crew members‟

behaviour and that behaviour may also have

an influence on the probability of accidents.

It did seem evident that the crew members

had a different perception of risk from that

described and assessed in the onboard

assessment made between June and October

2014.

Taking into consideration the above, it is

concluded that the AB fell into the water

from the accommodation ladder because he

was not wearing fall arrest equipment. His

drowning was a consequence of remaining

face down in the water.

Heaving up the accommodation ladder

The bunker barge crew members requested

that the accommodation ladder is heaved up

to prevent damages during bunkering, when

the transfer of personnel was not necessary.

It was not clear why this should have

required a person on the accommodation

ladder, as normal adjusting of the angle of

the accommodation ladder may be achieved

without the necessity of having persons

stepping on the accommodation ladder.

It is definite, however, that at the instant of

the fall, the lower half of the side hand rails

of the accommodation ladder were in the

collapsed position (Figure 5) while the

handrails of the upper half were left

standing. This indicated that the intention

was to retract the lower half of the

accommodation ladder rather than to hoist it

fully.

The operation was being conducted by two

crew members; one operating the controls,

whilst the other was on the accommodation

ladder.

Figure 5: View of the accommodation ladder after

the accident, showing (A) the lower section of the

handrails collapsed and (B) the stopper chain bridle

It is the MSIU‟s concern that this may have

led to inadequate supervision; to the extent

that the fall of the AB was not witnessed by

anyone on Kiran Turkiye. In fact, the safety

investigation was unable to determine from the

interviews whether the crew member fell

inboard or outboard of the accommodation

ladder.

It was stated to the MSIU that at the instant of

the fall, the AB was bent down undoing the

handrail ropes and that he may have slipped on

the steps of the accommodation ladder, given

that these were wet as a result of the light rain.

CCTV evidence obtained from the bunker

barge with the assistance of MPA, Singapore

showed the AB collapsing the outboard

handrails and then the inboard handrails of the

lower half of the accommodation ladder. He


then moved out of view as he climbed up

the upper half of the accommodation

ladder. The lower half of the

accommodation ladder was seen being

retracted, for only a few seconds, following

which, both the inboard and the outboard

hand rails moved up again, the inboard to a

larger extent than the outboard. This

movement appeared to be caused by the

collapsed lower handrails becoming fouled

against an obstruction while the lower half

of the accommodation ladder was being

retracted.

Almost instantly, retraction of the lower

half of the accommodation ladder stopped,

and the whole accommodation ladder was

seen to start being hoisted; the stopper

chains became slack during the process. At

that point in time, the tensile force of the

fall wire was transferred to the obstruction

blocking the lower half from retracting.

The hoisting of the fall wire continued,

causing the premature lift of the ladder

(Figure 6).

This indicated that the crew member operating

the controls was unable to observe and / or to

attribute the premature lifting of the

accommodation ladder to a fault in the

retracting system. It also suggested an

ineffective communication system between the

AB on the accommodation ladder and the

operator at the controls on the deck.

At the instant that the obstruction was

removed or gave way, the accommodation

ladder was in free fall, hinged at the upper end

only. As it fell to its original angle of

inclination (but on a shorter length of fall

wire), the lower half of the ladder retracted

(Figure 7).

Figure 6: View of the accommodation ladder partially retracted but also lifted as indicated by the slack

stopper chain


Figure 7: Sketch showing movements of the accommodation ladder leading to the fatal accident

The ladder came to rest when its weight was

taken violently by the stopper chains and the

fall wire (Figure 8).

Figure 8: View of the accommodation ladder after free-falling to its original angle of inclination but more

retracted than when it commenced lifting as indicated by the shorter length of lower ladder


It is possible that the AB was hit unconscious

by the retracting lower half of the ladder or

its handrails when the obstruction cleared

itself.

He was captured on CCTV falling off on the

inboard side of the ladder when the latter

jerked and rolled as it came to rest. The AB

fell in a horizontal position, legs towards the

bow, left side downwards and bent forward.

He entered the water face down, in the same

position that his body was recovered.

While it was clearly evident that the deceased

AB was not wearing a safety harness, the

safety investigation received conflicting

reports on whether or not he was donning a

lifejacket2. It was confirmed, however, that

the body of the deceased AB was found face

down in the water.

A lifejacket which is in compliance with the

LSA Code is designed as such to turn a body

of an unconscious person in the water from

any position to one where the mouth is clear

of the water in a defined period of time.

Moreover, an LSA Code compliant inflatable

lifejacket is designed to inflate automatically

and also with a device to permit inflation by

a single manual motion.

According to the Record of Equipment for

the Cargo Ship Safety Equipment Certificate

(Form E), the vessel was equipped with 42

lifejackets. Thus, in view of the conflicting

evidence, the MSIU was unable to determine:

whether or not the AB had been

wearing a lifejacket;

had been either wearing a lifejacket

that was not LSA Code compliant; or

had been wearing a SOLAS approved

lifejacket which was not secured

2 The photos provided to the MSIU did not provide

a definite answer to this, even because they were

taken in the dark. The photos, however, did not

show evidence of retro-reflective material, which

is normally fitted on the lifejacket. However,

managers stated that the crew member was

wearing a lifejacket when he fell overboard.

properly, thereby compromising its

ability to turn the victim‟s face clear of

the water, after he was knocked

unconscious.

The injuries sustained by the AB were not

considered to be fatal but serious enough to

potentially make him lose consciousness.

CONCLUSIONS

1. The cause of death was drowning after

the AB fell down from the

accommodation ladder;

2. The preparation of the railings required

(out of necessity) personnel to be on the

ladder when the railings were not yet in

place. This is an intrinsic risk within the

system;

3. The preparation of an accommodation

ladder, and also the rigging and

unrigging of the safety net necessitated

crew members to work aloft and over the

ship‟s side;

4. It was not excluded that the AB may

have found himself in a situation of

selective attention. Working at a height,

he may have had to focus on the task in

one hand and simultaneously guard

himself against a potential fall

overboard;

5. The risks arising from working aloft and

over the ship‟s side were unforeseen by

the two crew members involved and any

measures to control them were not

implemented;

6. A safety harness was not being used by

the crew member at the time of the

accident;

7. The crew members had a different

perception of risk from that described

and assessed in the assessment made

between June and October 2014;


8. The operation was being conducted by

two crew members; one operating the

controls, whilst the AB was on the

accommodation ladder. This has led to

inadequate supervision;

9. The crew member operating the controls

was unable to observe and / or attribute

the premature lifting of the

accommodation ladder to a fault in the

retracting system;

10. Communication between the AB and the

operator at the controls was ineffective.

RECOMMENDATIONS3

Pasifik Gemi Isletmeciligi Ve Ticaret A.S. is

recommended to:

27/2015_R1 review the present practices of

rigging and unrigging accommodation

ladders to identify relevant hazards and

minimise their risk.

27/2015_R2 review the Company‟s safety

management system to address the

rigging and unrigging of accommodation

ladders, as a separate operation from its

use, taking into consideration:

i. the practice of personnel on the

accommodation ladder when its

length and / or angle are being

adjusted;

ii. supervision and communication; and

iii. use of suitable personal protective

equipment as possible risk control

measures including but not limited to

the use of appropriate fall arresting

equipment and fit-for-task flotation

devices.

27/2015_R3 review the Company‟s safety

management system and the risk

assessment for working aloft and over

the ship side, in order to ensure that there

is adequate awareness of the exposure of

personnel to hazards related to falls from

heights.

3 Recommendations should not create a

presumption of blame and/or liability.


SHIP PARTICULARS

Vessel Name: Kiran Turkiye

Flag: Malta

Classification Society: Bureau Veritas

IMO Number: 9473353

Type: Bulk Carrier

Registered Owner: Silk Road Shipping Ltd

Managers: Pasifik Gemi Isletmeciligi Ve Ticaret A.S.

Construction: Steel

Length Overall: 291.80 m

Registered Length: 282.12 m

Gross Tonnage: 92050

Minimum Safe Manning: 17

Authorised Cargo: Solid Bulk

VOYAGE PARTICULARS

Port of Departure: Taicang, China

Port of Arrival: Singapore Bunkering Area, Singapore

Type of Voyage: International

Cargo Information: In Ballast

Manning: 20

MARINE OCCURRENCE INFORMATION

Date and Time: 13 November 2014 at about 2245

Classification of Occurrence: Very Serious Marine Casualty

Location of Occurrence: 01° 16.1‟N 103° 57.2‟E

Place on Board Ship / Overside

Injuries / Fatalities: One fatality

Damage/ Environmental Impact: None reported

Ship Operation: Anchored / Bunkering

Voyage Segment: Arrival

External & Internal Environment: Dark and good visibility. The sea state was

calm, with a Northwesterly force 3 wind. The

sea temperature was about 28 °C

Persons on board: 20

safety investigation report - mtip.gov.mt repository/msiu... · mv kiran turkiye 2 201411/018...

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