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

The incident

 On 21 May 2019, a general cargo vessel arrived in Seville, Spain and berthed port side alongside Muelle del V Centenario. Vessel visited port to load a cargo of cement, which commenced during morning of 23 May. As explained, during cargo operations, second officer had been working at the aft end of main deck and was attempting to pass between hatch covers and stationary crane. As second officer climbed onto hatch coaming, vessel’s chief officer drove crane aft, trapping and crushing second officer against the hatch covers. Unseen by crane operator, he was crushed when crane moved, closing the gap. In light of situation, chief officer immediately reversed crane and second officer fell onto deck, where he received first-aid and cardiopulmonary resuscitation from deck crew and shore paramedics. Following there, an emergency services doctor, who was informed of incident, told crew that second officer probably died after having a heart attack.

 Probable cause of fall

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

 Safety issues

  • Second officer did not know chief officer was about to move crane and chief officer did not know where second officer was or what he intended to do.
  • Deck operations were not being properly controlled or supervised and deck officers did not communicate with each other.
  • Second officer’s judgment and perception of risk were probably adversely affected by alcohol.
  • Tiredness might also have adversely influenced second officer’s actions.
  • Company’s drug and alcohol policy was not being enforced.
  • Recommendations
  • Following investigation, UK MAIB recommended vessel's company:
  • to improve safety culture on its ships and level of crew compliance with established safe systems of work.
  • to investigate alterations to crane movement warning systems.

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.

Source: Safety4Sea