MAIB releases report on 2019 fatal crush incident on cargo ship

The UK Marine Accident Investigation Branch (MAIB) has released its report on the investigation of an incident wherein one person was killed on a UK-flagged cargo vessel at the Spanish port of Seville on May 24, 2019.

At 09:45 local time on the said date, the second officer of the general cargo vessel Karina C was fatally injured when he was trapped between a stack of cargo hold hatch covers and a gantry crane used to move hatch covers.

The ship was completing cargo operations and preparing to sail when the second officer, who was working on deck, climbed into a small gap between hatch covers and the stopped crane, probably to cross the vessel.

Unseen by the chief officer, who was operating the crane at the time, the second officer was crushed when the crane moved, closing the gap. The chief officer then immediately reversed the crane and the second officer fell onto the deck, where he received first aid and CPR from the deck crew and shore paramedics.

The MAIB identified the following safety issues:

• An emergency services doctor, who was informed that the second officer had fallen from the hatch coaming onto the deck, told the crew that the second officer died after having a heart attack.
• Based on the doctor's initial assumption and the evidence provided by the vessel's crew, the accident was not reported to the MAIB.
• Following receipt of the second officer's postmortem report and close examination of Karina C's CCTV recordings, the vessel's manager's Carisbrooke Shipping, reported the accident.
• The MAIB said that the accident occurred on the second officer's birthday and his postmortem toxicology report showed that he had a significant quantity of alcohol in his bloodstream.

The investigation concluded that:

• The second officer 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. This is because the 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 influenced the second officer's actions.
• The master did not adequately investigate or report the accident.
• The safety culture on board Karina C was weak; company procedures were not followed, and several unsafe working practices were observed.
• Carisbrooke Shipping's drug and alcohol policy was not being enforced.

Carisbrooke Shipping has: updated its gantry crane operating procedures and safety measures; updated its incident reporting policy; fitted additional emergency stops to all its gantry cranes; improved the profile of its employee confidential reporting system; and, reviewed and amended its alcohol policy to include frequent random testing of all crew and sanctions on masters in the event of policy breaches.

Recommendations have also been made to Carisbrooke Shipping to improve the safety culture on its ships and the level of crew compliance with established safe systems of work and to investigate alterations to crane movement warning systems.