An investigation report regarding an incident that took place, during the early hours of 07 October 2022. Port Gdynia was moored alongside in the port of Bata, Equatorial Guinea. Cargo operations had been stopped due to heavy rain and stevedores had left the vessel.
The incident
Upon resuming cargo operations, crew members noticed that one stevedore had fallen into cargo hold no. 1 and had suffered fatal injuries.
No person witnessed the accident, but the safety investigation believes that a gap between distal and proximal cues may have been the main
contributory cause of the accident. The MSIU has issued one recommendation to the Company to disseminate the findings of the safety
investigation to its fleet.
Aim
The purpose of a marine safety investigation is to determine the circumstances and safety factors of the accident as a basis for making recommendations, and to prevent further marine casualties or incidents from occurring in the future.
Cooperation
During this safety investigation, MSIU received assistance and cooperation from the Registro de Buques y Empresas Marítimas, Ministerio de Transporte, Correos y Telecomunicaciones of Equatorial Guinea. Immediate cause of the accident the stevedore’s external injuries suggested that they had been caused by a fall from a height. However, no autopsy report was provided to the MSIU to corroborate this. The safety investigation was also informed that prior to the accident, the stevedore was working inside crane no. 1. In the absence of any direct witnesses, and given that the stevedore was assigned to work in the area, it
was considered highly likely that the stevedore had fallen from a height of at least 16 metres.
Location of the fall
As mentioned elsewhere in this safety investigation report, the fatally injured stevedore was found about 5.5.m from the nearest vertical ladder. Since his final
position was deemed too far off from the ladder, it was considered highly unlikely that he had slipped while ascending / descending that ladder.
Credit: Transport Malta Investigation
The centre hatch of bay 06 had been opened and placed on the port side hatch cover of the same bay. The removal of the centre hatch provided access to rows 01, 00 and 02 of the cargo hold for loading. It was not excluded that before the stevedore fell into the cargo hold, he was either standing on the starboard
side hatch cover, or on the cross bay between bay 06 and bay 10, near the vessel’s crane structure.
Crane’s maintenance access hatch
Given the position of the body, the safety investigation also assessed the possibility of a fall through the crane’s maintenance access hatch. It was noticed that the access hatch was almost directly above the location where the stevedore had been found. That all depended on the position of the cabin (i.e., the angle of rotation) vis-à-vis the position from where the stevedore was found. The MSIU was unable to obtain specific and precise information on the crane’s last known
position.
Time of the fall
The MSIU was unable to establish the exact time when the stevedore fell into the cargo hold. The safety investigation was informed by the crew members that the centre hatch cover for bay 06 had been opened at about 0700. However, it was also reported that there were no crew members in attendance when the hatch cover was opened by the stevedores. Taking into consideration the level of water that was observed at the bottom of bay 06, the MSIU believes that the
centre hatch cover for the bay had been opened prior to the start of the heavy rain i.e.
Information provided by the terminal indicated that stevedores had organised a search party for the stevedore as soon as it was noticed that he did not report back to work and that he was missing (which was sometime around 0715). It is believed that if the stevedore had just started his shift, he would have boarded Port Gdynia with his colleagues who had all been assigned tasks / stations. Therefore, there would not have been a need to organise a search to locate
him, as they would have been aware of his whereabouts.
Additionally, the extent of bleeding observed on the tank top indicated that the stevedore may have been inside the cargo hold for quite some time. It was considered highly likely by the safety investigation that his fall had occurred at the time the cargo operations had been stopped because of the heavy rain.
Conclusions
- The stevedore’s external injuries suggested that they were caused by a fall from a height.
- Before the stevedore fell into the cargo hold, he was either standing on the starboard side hatch cover, or on the cross bay between bay 06 and bay 10
near the vessel’s crane structure. - It was not excluded that the reduced visibility may have contributed to the stevedore unknowingly stepping inside
the perimeter of the open cargo hold. - Artificial lighting in the area, coupled with the heavy rain, may have cast shadows around bay 06 and the vessel’s crane no. 1 structure during the
night. - Walking out of crane no. 1, the stevedore may have taken a wrong turn and fell into the open cargo hold.
- Considering that the deck was wet with rainwater, the stevedore may have slipped and fell into the cargo hold.
- Sudden vessel movements / motions were not considered to be contributory to the fatally injured stevedore’s loss of balance, footing and / or holding.
- Physical barrier systems had not been installed around the perimeter of the opened hatch cover at the time of the occurrence because crew members had
not been notified that the stevedores had opened the centre hatch cover of bay 06. - An ad hoc risk assessment exercise by the stevedore would have been subjective at best and incomplete at worst, not least because of the unknown variables which would need to be considered at the time.
- A gap existed between distal cues and proximal cues.
https://safety4sea.com/wp-content/uploads/2024/01/MSIU-Fatal-Fall-of-Stevedore-2024_01.pdf