MAIB Accident Report 10/2020 - Crew fatality on the Stern Ramp during Ro-Ro Cargo Discharge

Published: Thursday, June 11, 2020 - 11:47

As part of PSS and Industry Chief Executive priorities for the sector, “Early Information Sharing” is aimed at proactively preventing incidents among members. These are good opportunities for PSS members to proactively review/modify safety control measures and is a leading indicator of a positive safety culture.

The following Accident Report has been Posted by the Marine Accident Investigation Branch(MAIB)  to raise awareness of and wider stakeholder engagement about mobile phone distraction and the importance of providing a safe means of segregating vehicles and pedestrians during a Ro-Ro Cargo Operation, the full details attached.

Ro-Ro fatality

On 15 May 2019, semi-trailers were being discharged from a ro-ro freight ferry,  in Brocklebank Dock, Liverpool, UK. The ferry’s stern ramp was the only means of access for vehicles and pedestrians. The vessel’s third officer, who was overseeing the cargo operations, was struck and fatally injured by a semi-trailer that was being pushed down the vessel’s stern ramp to the quayside (Figure 1). The driver of the tractor unit pushing the semi-trailer stopped immediately but the third officer was trapped between the trailer’s rear wheels and was pronounced life extinct by attending paramedics.

The third officer was talking on his mobile telephone and was facing down the ramp, away from the direction of the semi-trailer’s approach, when he was struck. He probably did not hear the trailer approaching amongst the noise from cargo operations on other decks, and he was standing away from a pedestrian walkway that was painted along the starboard edge of the ramp.

The tug driver was unable to see the third officer due to the semi-trailer blocking his view ahead (Figure 2) and he was not expecting any pedestrians to be on the stern ramp.

Figure 1
                                                                                       Figure 1​​​
Figure 2
                                                            Figure 2

 

Safety lessons

  • ‘Smartphone zombie’ and ‘smombie’ are used in popular culture to describe pedestrians who walk slowly and without attention to their surroundings because they are focused on their smartphones. Seafarers are not immune from such effects and, although mobile telephones provide a ready means of contact with friends and family, their use on working decks and other workspaces onboard ships is a distraction and is potentially hazardous.

  • When the stern ramp is the only means of access for pedestrians and vehicles, it is clear in the applicable codes of practice that either a protected walkway or other means of segregating vehicles and pedestrians is provided. Procedures based on a policy of ‘see and be seen’ are fraught with danger.

  • Painted walkways on vehicle ramps and decks that are not protected are liable to be encroached upon by vehicles and are not safe unless other measures to control pedestrian access and vehicular traffic are also implemented. They are even less safe if they are not used.

 

no mobile

 

This tragic accident has highlighted two significant safety issues.

  • The first, is the hazard of using a mobile phone when on duty or in a working environment. Users can too easily become distracted from the tasks they are doing and lose awareness of what is happening around them. This accident occurred on the loading ramp of a ro-ro ferry, however, the use of mobile phones in other hazardous workspaces and on the bridge of ships is becoming a serious concern.
  • Secondly, this accident again highlights the importance of separating moving vehicles and pedestrians on the ramps and vehicle decks of ro-ro ferries. Moving vehicles are a constant hazard during loading and discharge, and if physical separation cannot be achieved then robust procedural controls must be put in place to prevent people from being injured or killed.
  • Recommendations have been made to reinforce the importance of maintaining the safety of pedestrians when loading and discharging ro-ro cargo, and the UK and Island of Man marine administrations have been recommended to provide guidance on the danger.

Chief Inspector, Marine Accidents Investigation Branch

 

Suggested Use

Suggested use

Personnel: Please forward this alert on to colleagues in your port environment including management, supervisory, staff and the wider stakeholders including tenants/suppliers on the port estate.

Distribution: These can then be downloaded, printed and posted at various strategic locations such as workshops, notice boards, staff canteens, smoking areas etc to raise awareness about causes and preventive actions.

Discussions: This safety alert can be further utilised to facilitate safety discussions and stimulate employee safety leadership through toolbox talks, leadership 'Walk the talks' and hazard hunts, just to name a few.

More information on the incident, lesson learned and any actions that were taken can be found below

Attachments

Safety Flyer Ro-Ro Cargo Operation to Maritime Industry PDF (459.13 KB) Download (459.13 KB)
MAIB 10-2020 Report - SeatruckProgress PDF (3.92 MB) Download (3.92 MB)