Cargo handling fatality report and recommendation issued by JTSB

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The Japan Transport Safety Board (JTSB) has published its investigation report concerning the fatality of two workers onboard the cargo vessel ‘BBC ASIA’. The incident happened in October 2016 at Hanshin Port. The report provides a description of what happened and provides important safety issues to prevent similar accidents in the future.

The incident
The accident occurred at around 11:31 on October 30, 2016, on the cargo ship BBC ASIA when, during work to load pipes with a crane at Shinko East Quay T Wharf, Kobe Section, Hanshin Port, three workers who were working in a cargo hold were caught between pipes being hoisted by the crane and a side wall. Two of the workers were killed and one was seriously injured.

Probable Causes
It is probable that the accident occurred when, as Vessel A was being loaded with cargo starboard-side alongside at the Wharf, the Pipes, which had been hoisted and then stopped by the No. 1 crane, swung to the starboard side, and as a result Stevedore A, Stevedore B, and Lashing Worker A, who had been standing by and doing other activities on top of the Two Bundles, were caught between the Pipes and starboard wall.

It is probable that the Pipes, which had been hoisted and then stopped by the No. 1 crane, swung to the starboard side because—under conditions whereby, at the time of the accident, the underside of the Hull Fender on Vessel A’s starboard midship hull was caught on the tops of the Wharf’s fenders and Vessel A’s starboard inclination was arrested because, among other reasons, the height of tide had fallen compared to that at the time of docking and the Vessel A’s draft had increased—the underside of the Hull Fender came off the tops of the wharf’s fenders when the Pipes were hoisted by the No. 1 crane and then stopped at the Stop Position, which caused Vessel A’s hull to roll and she inclined to the starboard side.

It is probable that workers were standing by and doing other activities on top of the Two Bundles at the time of the accident because, in addition to not being prohibited from standing on top of the Two Bundles for reasons that included over the Two Bundles not being in the handling area of the Pipes, they could not predict that the Pipes would swing over the Two Bundles from the Stop Position, as theretofore Hoisted Cargo had not swing greatly when the crane operation was stopped.

As a result from the incident, JTSB advises operators to implement the following measures:
When conducting cargo-handling using a deck crane on a vessel with fenders installed on the hull sides, appropriately monitor catching between the vessel’s fenders and wharf fenders and build a system that allows workers inside the cargo holds to ascertain whether catching has occurred. At such times, pay attention not only to catching of the underside of the hull fender with the tops of wharf fenders but also catching of the tops of the hull fender with the underside of wharf fenders.

Demand that crew members of vessels with fenders installed on the hull sides cooperate in preventing hull rolling caused by the catching of hull fenders and wharf fenders by, for example, holding meetings prior to the start of cargo-handling and adjusting draft to the tide so that catching does not occur.

Depending on the vessel structure, type of cargo, etc., study work procedures that include refuge places and methods that anticipate hull-rolling-caused swinging of hoisted cargo and having workers enter a planned stowage position, only after temporarily placing hoisted cargo on the floor and securing workers’ safety, and make those procedures known to workers.

Based on the possibility that hoisted cargo may swing greatly as a result of hull rolling, etc., provide guidance to workers to ensure that they can execute their work in a manner that makes emergency responses possible; for example, by ascertaining continually changing cargo-handling conditions through constant monitoring of hoisted cargo and maintaining a posture that allows movement to previously studied refuge areas.

Periodically provide worker education that incorporates lessons learned from this accident.

Read the report in full: JTSB-cargo-ship-BBC-Asia

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