SMN Explorer Fatality MAIB Report

Published: Thursday, January 17, 2019 - 16:11

SMN Explorer Fatality MAIB Report

MAIB’s report on the uncontrolled closure of a hatch cover on the general cargo vessel SMN Explorer with loss of 1 life earlier this year, was recently published. This accident occurred when the crewman climbed up the inside of the open hatch cover after its locking pins had been removed. The report contains details of what happened and the subsequent action taken.

maib

Summary

A crewman from the Liberian registered general cargo vessel, SMN Explorer, died when he was crushed by a falling hatch cover. The crewman was part of a working party stowing cargo slings used for the discharge of the ship’s cargo. The accident occurred when the crewman climbed up the inside of the open hatch cover after its locking pins had been removed.

unsafe act

Safety issues

  • the crewman walked under and climbed up an unsecured hatch cover
  • the accident occurred because the routine deck operation was not adequately planned or supervised
  • the vessel’s safety management system was immature; some routine deck operations had not been risks assessed and safe systems of work had not been developed
  • the vessel’s lifting appliances had not been properly maintained
  • weak safety culture was evident on board SMN Explorer

Recommendation

Recommendations

Recommendations (2018/134, 2018/135 and 2018/136) have been made to the vessel’s managers to improve the system of work for closing SMN Explorer’s foredeck hatch; and, across its managed fleet, take steps both to improve the safety culture on board and, specifically, improve the maintenance management of lifting appliances.

It is vital that in any organisation, a suitable and sufficient risk assessment is conducted to ensure that all risks are identified. Once these risks are identified the hierarchy of risk control should be implemented to ensure that all risks are sufficiently controlled. The measures at the top of the hierarchy including elimination, substitution, engineering controls and then administrative controls are preferred over controls lower in the hierarchy. It is only when risks are suitably managed in this sequence and there is low to no possibility of harm that a strong culture of safety can develop.

Attachments

MAIBInvReport21_2018 PDF (1.05 MB) Download