The Japan Transport Safety Board (JTSB) has published its report into the death of a boatswain while the cargo vessel FIRST AI was mooring off Kyoto in September 2019 when his head was trapped in a hatch cover panel while performing hatch cover closing duty.
A master, Officer A, a chief engineer, a boatswain, and six other crew members boarded the Vessel. While the ship was mooring at Maizuru Port in Kyoto, at around 10:45 on September 9, 2019, Officer A and the boatswain began closing the hatch covers in preparation for departure after finishing the unloading tasks.
While visually checking the condition of the hatch cover on the port upper deck during the closing of the hatch cover, Officer A noticed that the rubber packing 2 for sealing the hatch cover near the Arm that had been temporarily repaired during the previous navigation had flaked. Hence, he instructed the boatswain, who was operating the closure at the hatch cover handling stand on the starboard side of the upper deck, to stop the operation.
Officer A was checking the condition of the rubber packing after the hatch cover stopped moving. Then, the Arm Pin fell off and hit his right hip, so he turned to where the Arm Pin was inserted. At where the arm pin had fallen off, he noticed that the boatswain’s head was caught between panel No. 11 (about 2.5 tons), which had fallen, and panel No. 7 which is already stored in the drum. He called out loudly for other crew members to come, and asked the stevedore who came to the scene to call an ambulance.
The helmsman was in his room when he heard Officer A shouting and rushed to the scene of the accident. He confirmed that the head of the boatswain was caught between two hatch cover panels, reported the accident to the second officer in the chart room, and called the chief cook and the ordinary seaman. The second officer reported that the boatswain was injured to the master and immediately went to the scene of the accident. The helmsman and the chief cook transported the boatswain to the nearby corridor of the living quarter.
As the boatswain was in cardiac arrest, he received chest compressions and artificial respiration from the rescue squad that arrived near the scene at around 11:02. At around 11:08, the rescue squad called for a medical helicopter to be dispatched. The boatswain was transported to hospital at around 12:24 by a medical helicopter that arrived near the scene of the accident at around 11:31.
JTSB believes it is likely that as the boatswain received instructions from Officer A, he stopped winding up the drum for the closing of the hatch cover after the vessel had unloaded the cargo. Afterward, the boatswain passed through the space, and the Hinge Plate bent outward horizontally, the Key Plate flaked off and the Arm Pin, which was no longer restrained, fell off, causing panel No. 11 of the hatch cover to fall. As a result, his head was caught between panel No. 11 and panel No. 7, which was already stored in the drum.
The reason why the boatswain passed through the space, although he had been warned not to do so before the accident, could not be clarified.
– The company should make the crew aware of the danger of being caught in the hatch cover, and instruct them not to pass through space except for the situations of absolutely necessary repairs and inspections. Also, if working from under the panel is unavoidable, the crew should be instructed to take measures to prevent falling before starting their work.
– If the hatch cover is damaged, the company should carry out appropriate repairs before opening and closing it.
In view of the results of this accident investigation, the JTSB recommends that the management company of FIRST AI takes the following measures to prevent reoccurrence of a similar accident:
– Make the crew of ships under their management aware of the danger of being caught in the hatch cover and instruct them not to pass through the space between the winding drum and the hatch coaming unless it is absolutely necessary. Furthermore, when it is unavoidable to work under the panel, the crew should be instructed to take measures to prevent falling before starting the work.
– If the hatch covers of vessels managed by the company are damaged, the company should carry out appropriate repairing measures before opening and closing them.
Download the report about the hatch cover panel incident: JTSB - FIRST AI investigation report
Read another JTSB related article: Report published on cargo ship sinking in heavy weather that led to eight fatalities