UK MAIB investigation: Fatal crush linked to intoxication and safety issues


The incident

On 21 May 2019, the general cargo vessel Karina C arrived in Seville, Spain and berthed port side alongside the Muelle del V Centenario.

The vessel visited the port to load a cargo of cement, which commenced during the morning of 23 May.

As explained, during the cargo operations, the second officer had been working at the aft end of the main deck and was attempting to pass between the hatch covers and the stationary crane.

As the second officer climbed onto the hatch coaming, the vessel’s chief officer drove the crane aft, trapping and crushing the second officer against the hatch covers.

Unseen by the crane operator, he was crushed when the crane moved, closing the gap.

In light of the situation, the chief officer immediately reversed the crane and the second officer fell onto the deck, where he received frst-aid and cardiopulmonary resuscitation from the deck crew and shore paramedics.

Following there, an emergency services doctor, who was informed of the incident, told the crew that the second officer probably died after having a heart attack.

Probable cause of the fall

As UK Maib noted, the accident occurred on the second officer’s birthday and his postmortem toxicology
report showed that he had a signifcant quantity of alcohol in his bloodstream.

The accident on Karina C is a further case where excess alcohol consumption almost certainly contributed to the death of a seafarer

…as Chief Inspector of Marine Accidents, stated.

Safety issues

  • The second offcer did not know the chief officer was about to move the crane and the chief officer did not know where the second officer was or what he intended to do.
  • Deck operations were not being properly controlled or supervised and the deck officers did not communicate with each other.
  • The second officer’s judgment and perception of risk were probably adversely affected by alcohol.
  • Tiredness might also have adversely infuenced the second officer’s actions.
  • The company’s drug and alcohol policy was not being enforced.

Ship’s decks are dangerous places and this accident could have been avoided if personnel operating Karina C’s deck that day, had adhered to established safe working practices. The limited space available and ambient noise on deck mean that travelling gantry cranes, common on many operators’ vessels, can be particularly hazardous.

…. Chief Inspector of Marine Accidents, added.

Recommendations

Following investigation, UK MAIB recommended the vessel’s company:

  • to improve the safety culture on its ships and the level of crew compliance with established safe systems of work.
  • to investigate alterations to crane movement warning systems.

UK Maib report

 



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