Weak safety culture blamed for injury-causing ladder mishap on containership at Port of Auckland

The New Zealand Transport Accident Investigation Commission (TAIC) has released its report on its investigation into an incident that resulted in a crewmember’s injury on a locally-registered vessel on December 10, 2021.

On the said date, the containership Moana Chief was preparing to leave the Port of Auckland, and the crew had started to retrieve the ship’s telescopic accommodation ladder for stowing.

A crewmember’s leg was seriously injured when it had become trapped between the fixed upper ladder and the moving lower ladder.

A crewmember was standing in an area that had previously been identified and designated as a danger area.

The accommodation ladder slipped off the port platform on which it was resting. The slack side chains allowed the ladder to drop and the ladder’s weight transferred to the fall wire, which caused the lower ladder to slide upwards, trapping and seriously injuring the crewmember’s leg.

Safety issues and recommendations

The TAIC said it is very likely that the accident could have been prevented by other crew members nearby if they had told the ladder winch operator that a crewmember was in the danger area.

The commission also identified two key safety issues and makes two recommendations:

• Weak safety culture at Moana Chief‘s operator: The operator did not identify the possibility of the accommodation ladder falling off the platform as a hazard and it took no measures to control the risk. TAIC Recommendation 006/23 is that Swire Shipping review its safety management system to ensure that safety leadership is developed at all levels within the organisation.
• Lack of safety guidance for telescopic accommodation ladders: Non-conformance to operating procedures and a diffusion of responsibility with respect to oversight and supervision are symptomatic of more systemic issues regarding the safety culture onboard. TAIC Recommendation 007/23 is that Maritime New Zealand develop and disseminate clear guidance to highlight the inherent risks associated with telescopic accommodation ladders.

Learning points

The crew retrieving the accommodation ladder did not take appropriate safety measures, as specified in the vessel’s Safety Management System.

• Deploying and retrieving accommodation ladders can be dangerous and often involves ships’ crews working over the side of the vessel. Telescopic accommodation ladders have moving parts that further increase risk of injury. All users should understand how to operate the equipment safely in accordance with the manufacturer’s instructions.
• Have a safety system and keep doing it. Risk assessment and management of a hazard is about more than just implementing risk controls. Safety management systems should also require ongoing monitoring and review of  the effectiveness of the risk controls.