Marine Safety Investigation Unit

MARINE SAFETY INVESTIGATION REPORT

Safety investigation into the fatality of a crew member

on board the Maltese registered general cargo

FLORIANA
at Tocopilla Anchorage, Chile
on 01 December 2014

201412/002
MARINE SAFETY INVESTIGATION REPORT NO. 31/2015
FINAL

Investigations into marine casualties are conducted under the provisions of the Merchant
Shipping (Accident and Incident Safety Investigation) Regulations, 2011 and therefore in
accordance with Regulation XI-I/6 of the International Convention for the Safety of Life at
Sea (SOLAS), and Directive 2009/18/EC of the European Parliament and of the Council of 23
April 2009, establishing the fundamental principles governing the investigation of accidents
in the maritime transport sector and amending Council Directive 1999/35/EC and Directive
2002/59/EC of the European Parliament and of the Council.
This safety investigation report is not written, in terms of content and style, with litigation in
mind and pursuant to Regulation 13(7) of the Merchant Shipping (Accident and Incident
Safety Investigation) Regulations, 2011, shall be inadmissible in any judicial proceedings
whose purpose or one of whose purposes is to attribute or apportion liability or blame, unless,
under prescribed conditions, a Court determines otherwise.
The objective of this safety investigation report is precautionary and seeks to avoid a repeat
occurrence through an understanding of the events of 01 December 2014. Its sole purpose is
confined to the promulgation of safety lessons and therefore may be misleading if used for
other purposes.
The findings of the safety investigation are not binding on any party and the conclusions
reached and recommendations made shall in no case create a presumption of liability
(criminal and/or civil) or blame. It should be therefore noted that the content of this safety
investigation report does not constitute legal advice in any way and should not be construed
as such.

Copyright TM, 2015.

This document/publication (excluding the logos) may be re-used free of charge in any format
or medium for education purposes. It may be only re-used accurately and not in a misleading
context. The material must be acknowledged as TM copyright.
The document/publication shall be cited and properly referenced. Where the MSIU would
have identified any third party copyright, permission must be obtained from the copyright
holders concerned.

MARINE SAFETY INVESTIGATION UNIT

Malta Transport Centre
Marsa MRS 1917
Malta

ii

CONTENTS
LIST OF REFERENCES AND SOURCES OF INFORMATION .......................................... iv
GLOSSARY OF TERMS AND ABBREVATIONS .................................................................v
SUMMARY ............................................................................................................................. vi
1

FACTUAL INFORMATION .............................................................................................1

1.1
Vessel, Voyage and Marine Casualty Particulars .......................................................1
1.2
Description of Vessel .................................................................................................2
1.3
Vessels Lifeboat ........................................................................................................2
1.4
The Bosun...................................................................................................................3
1.5
Environment ...............................................................................................................4
1.6
Narrative .....................................................................................................................4

ANALYSIS .........................................................................................................................7
2.1
Purpose .......................................................................................................................7
2.2
Potential Safety Issues Involved .................................................................................7
2.2.1 Bosuns fall from the freefall lifeboat ....................................................................7
2.2.2 Precautions which had been taken prior to the accident .........................................8
2.2.3 Precautions which had been taken to avoid the injury ...........................................8
2.2.4 Adequacy of the precautions taken .......................................................................10

CONCLUSIONS ...............................................................................................................12
3.1
Immediate Safety Factor...........................................................................................12
3.2
Latent Conditions and other Safety Factors .............................................................12
3.3
Other Findings ..........................................................................................................13

ACTIONS TAKEN ...........................................................................................................14

4.1
Safety Actions Taken During the Course of the Safety Investigation ......................14

LIST OF ANNEXES ................................................................................................................15

iii

LIST OF REFERENCES AND SOURCES OF INFORMATION

Master and crew MV Floriana
Managers MV Floriana

iv

GLOSSARY OF TERMS AND ABBREVIATIONS

AB

Able Seaman

cm

Centimetres

ISM

International Safety Management

kW

Kilowatt

LT

Local Time

Metres

MSIU

Marine Safety Investigation Unit

SUMMARY
On 01 December 2014, while Floriana was anchored at Tocopilla Bay, Chile, three
crew members were engaged in the cleaning of the freefall lifeboat davits. The crew
members were instructed to clean the davits in preparation for painting. Amongst the
three crew members was the bosun. Prior to the commencement of the cleaning
operations, the safety procedures were completed and the bosun was supplied with a
safety harness fitted with a lifeline and a hook.
About 20 minutes into the job, the bosun fell down from the davits structure to the
poop deck, hitting his head on the coaming around the deck winch. First aid was
administered by the crew members and immediate arrangements were made to
disembark the bosun, which was effectuated one hour later. Later that morning, the
master was informed by the agent that the bosun had succumbed to his injuries in
hospital at 1019.
The safety investigation identified that the immediate cause of the accident was the
failure of the lifeboat lifebelt to which the bosuns lifeline was attached after (in all
probability), he slipped before falling to the poop deck.
Taking into consideration the safety actions adopted by the Company, no
recommendations were made to the ISM managers of the vessel.

vi

FACTUAL INFORMATION

1.1

Vessel, Voyage and Marine Casualty Particulars

Name

Floriana

Flag

Malta

Classification Society

American Bureau of Shipping

IMO Number

9486477

Type

Bulk carrier

Registered Owner

MB Floriana Shipping Ltd

Managers

Transship Bulk, Ukraine

Construction

Steel (Double bottom)

Length overall

181.1 m

Registered Length

173.29 m

Gross Tonnage

23322

Minimum Safe Manning

16

Authorised Cargo

Solid Bulk

Port of Departure

Callao, Peru

Port of Arrival

Tocopilla, Chile

Type of Voyage

International

Cargo Information

In ballast

Manning

20

Date and Time

01 December 2014 at about 0900 (LT)

Type of Marine Casualty

Very Serious Marine Casualty

Place on Board

Ship Boat Deck

Injuries/Fatalities

One fatality

Damage/Environmental Impact

None

Ship Operation

Normal Service On anchor

Voyage Segment

Arrival

External & Internal Environment

Gentle Southwesterly breeze, force 3. Air

temperature recorded at 18C.

Persons on Board

20

1.2

Description of Vessel

Floriana, is 5-cargo hold, geared Maltese registered bulk carrier, owned by MB

Floriana Shipping Limited and managed by Transship Bulk, Ukraine. The vessel is
classed with American Bureau of Shipping. The vessel was built by 21st Century
Shipbuilding Co. Ltd., Republic of Korea in 2012.
Floriana has a length overall of 181.10 m, a moulded breadth of 30.0 m and a
moulded depth of 14.80 m. She has a summer draught of 9.93 m and a summer
deadweight of 33862 tonnes.
Propulsive power is provided by a 6-cylinder MAN-B&W 6S42MC, slow speed,
single acting, direct drive diesel engine producing 6480 kW at 136 rpm. This drives a
single, fixed pitch propeller, giving a service speed of about 14.50 knots.

1.3

Vessels Lifeboat

Floriana is equipped with a freefall lifeboat fitted aft of the funnel (Figure 1).

Figure 1: Freefall lifeboat on board Floriana

The lifeboat is housed in an A-frame davits (including a winch) fitted on launching

rails inclined at an angle of 45, and which can be accessed via a boarding platform,
one deck below the wheelhouse. In case of an emergency, the lifeboat could be
quickly released from its on-load release located at the stern of the lifeboat (Figure 2).
The davits launching rails are designed to guide the lifeboat during its initial freefall
motion. The winch fitted to the davits is used to recover the lifeboat back on board,
after it has been released into the water.

Quick
release

Davit
Lifeboat
lifeline

Guide rollers

Aft poop deck

Figure 2: Freefall lifeboat on the davits

1.4

The Bosun

The bosun, who was a Ukrainian national, was 43 years old at the time of the
accident. He signed on the vessel at Callao, Peru, on 11 November 2014. On the
same day, he carried out the basic familiarisation procedure in accordance with the
Companys safety management system (SMS). The initial familiarisation was
followed by an advanced familiarisation procedure, which took place on 24
November 2014.

The latest medical fitness certificate indicated that the bosun was fit for duty.
A drug / alcohol test report was included as well and certified that the test did not
indicate any presence of drugs or alcohol.

1.5

Environment

The weather was dry and sunny with ambient air temperatures ranging between 15C
and 22C. The wind was from a Southwesterly direction, force 3. Swell was around
0.5 m high. The vessel was neither moving nor rolling in an appreciable manner.

1.6

Narrative1

The vessel had been on anchor in Tocopilla Bay loading a cargo of fertilizer in bulk
from barges alongside the vessel.
On 01 December 2014, just before 0855, three crew members (two ABs and the
bosun) were tasked to clean the davits of the freefall lifeboat in preparation for
painting.
The cleaning work on the davits, which was done with fresh water, had started at
approximately 0830. At one point in time, while work was still in progress, the bosun
went from the lifeboats boarding platform and worked himself between the lifeboat,
the rail work and the davit structure to walk down the starboard side launching rail.
He attached the hook of his safety harness to the lifeboats lifeline. The bosuns
intention was to rinse the davits with fresh water.
Witnesses recalled that while the bosun was standing on the starboard side launching
rail, he lost his balance and fell down. The lifeboat lifeline (to which the safety hook
was attached) broke loose under the weight of the bosun. An attempt was made by
the bosun to stop the fall by catching the broken lifeboat line but, at that moment, the
other end broke off as well (Figure 3).

Unless otherwise stated, all times are local.

Figure 3: A sequential representation of the bosuns fall from the davits to the poop deck

The bosun fell a vertical drop of about six metres and landed heavily on the deck,
hitting his head on a 10 cm coaming structure in way of the deck winch (Figure 4).
One of the ABs was on the poop deck at the time of the accident. Witnessing the
accident, he rushed to the wheelhouse and informed the master, who, together with
the chief and third mates proceeded to the accident site. It was immediately evident
that the bosun had a serious injury to his head. They administered first aid and called
the agent to arrange for shore emergency assistance.

Figure 4: Coaming structure where the bosun hit is head

At about 0920, the agent and two port officers boarded the vessel, followed 30
minutes later by other five port officers. At 0955, the bosun was disembarked on a
stretcher, using a special evacuation equipment. A boat took the bosun ashore from
where he was transferred to a hospital by ambulance.
At 1040, the master was informed that at 1019, the bosun had succumbed to his
injuries in hospital.

ANALYSIS

2.1

Purpose

The purpose of a marine safety investigation is to determine the circumstances and

safety factors of the accident as a basis for making recommendations, to prevent
further marine casualties or incidents from occurring in the future.

2.2

Potential Safety Issues Involved

The MSIU took into consideration the following potential failure mechanisms:

The reason behind the bosuns fall from the freefall lifeboat davits;

The precautions which had been taken to prevent the accident;

The precautions which had been taken to avoid the injury; and

Whether these precautions were adequate.

2.2.1

Bosuns fall from the freefall lifeboat

During the interviews carried out by the MSIU, none of the witnesses could explain
why the bosun went onto the strongly inclined launching rail. On that part of the
frame, there were neither any steps, safety rails, nor suitable strong parts to attach a
lifeline. Moreover, there was a significant hazard of falling down should a person
have slip (as it actually happened).
It was not excluded that the painted steel surface was very slippery as a result of the
water used for cleaning and the likely presence of soot, which is usually found in the
areas surrounding the vessels funnel.
Given that the bosun did not discuss his intention with the rest of the crew members, it
can only be hypothesised that he tried to reach and clean those areas which would
have otherwise been difficult to access.
The fact that bosun wore a safety harness was suggestive that there were intentions to
climb on the lifeboat davits, i.e. there was an understanding and acknowledgment that
a fall hazard was realistic.

2.2.2

Precautions which had been taken prior to the accident

Approximately 25 minutes prior to the cleaning operations, the bosun received his
instructions from the master during a meeting on the bridge. The chief mate (who
was also the safety officer on board) inspected the work place, the preparations made,
the available tools and the personal protection equipment (fall preventers). At 0830,
an Aloft Working Permit was issued and signed by the bosun and chief mate, in
accordance with SMS Form 112 SAF/AOP. It appeared that the other two crew
members who witnessed the accident did not participate in this safety meeting.
The fact that a fall prevention device was provided and worn by the bosun, was
indicative that there had been a clear intention to access areas where the risk of a fall
was possible. Whatever the reason for the bosun to expose himself to the risk of
falling, necessitated him to step onto the (inclined) launching rail where there was no
suitable strong line to attach the hook of the safety harness.
2.2.3

Precautions which had been taken to avoid the injury

Section 7 of the Companys SMS, addresses working aloft and over the side. The
section stipulated that people working aloft should wear safety harness with lifeline
or other fall arresting device at all times. A safety net should be rigged where
necessary and appropriate.
The MSIU had access to the personal safety equipment which the bosun was wearing
at the time of the accident (Figure 5).

Figure 5: The bosuns safety belt and the hook

The safety belt was of a standard design and suitable for its purpose. The safety
investigation did not find any weakness in the safety belt, which could have

contributed to the accident. It was also noticed that the safety belt was fitted with a
fall arrestor which is designed to dampen a fall from a height (Figure 9 (encircled)).
Although not relevant in this particular case, it would have been very probable that the
arrestor would have reduced the risk of serious injuries to the crew members back
had he fallen and the lifeboat lifebelt did not part.
The strength of the lifeboat lifeline was not enough to take the dynamic impact of a
falling person (Figure 6). The lifeboat lifeline was attached to the lifeboat with
screws. Further, it was not excluded that the strength of the lifeboat lifeline may have
weakened due to the exposure to the environment.

Figure 6: Failed lifeboat lifebelt

It did not transpire that any of the crew members had either remarked about the
bosuns decision to walk on the davits launching rail or the attachment of the lifeline
to the lifeboats lifebelt. Neither was there evidence of any considerations to rig a
safety net underneath the lifeboat as an additional precaution against the consequences
of a fall from a height.

2.2.4

Adequacy of the precautions taken

The Aloft Work Permit [Annex A] made reference to a risk assessment [Annex B].
Risk assessments help determine control measures which are necessary to ensure safe
operation, accounting for different skill levels, knowledge and, where applicable,
language. The general aim of a risk assessment is to provide a basis for deciding
whether a system is acceptable as it is, or whether changes are necessary. A further
purpose is to distinguish between important risks and less important ones.
A review of the Risk Assessment Form showed that the work was commenced with
several medium rated risks and one high risk with a maximum score of 25. The
MSIU was unable to determine the reason behind the Code 5 entered in the Risk
Assessment Form, given that the sea / weather conditions were not adverse and the
vessel did not (significantly) roll at the time concerned.
An assessment to establish the risk of a fall hazard does not seem to have been
thoroughly considered on the Form as there was no reference to this hazard and/or
mitigating actions, which could have been put in place to prevent the fall. This has to
be seen in the light that the bosun had prepared a safety harness, indicating the
intention to work aloft. In this respect, the risk assessment did not identify this risk,
which, consequently was neither analysed nor mitigated.
The risk assessment document included an estimation of the magnitude of risk and an
evaluation of the significance of risk, i.e. whether the risk was acceptable or not. The
risk assessment did not consider the risk the bosun was exposed to because not all the
tasks were considered. Although several risks were considered, an accurate picture
had not been established.
Hazards associated with working aloft were present as a result of any or a
combination of height, the task, organisation and the physical aspects of the lifeboat
davits. It was important that all these different elements were addressed to ensure that
the hazard identification process was thorough. What was missing on the Risk
Assessment Form were not only the intrinsic hazards but also the possible
ways/mechanisms by which the hazards could be realised.

10

THE FOLLOWING CONCLUSIONS, SAFETY

ACTIONS AND RECOMMENDATIONS SHALL IN NO
CASE CREATE A PRESUMPTION OF BLAME OR
LIABILITY. NEITHER ARE THEY BINDING NOR
LISTED IN ANY ORDER OF PRIORITY.

11

CONCLUSIONS

Findings and safety factors are not listed in any order of priority.
3.1
.1

Immediate Safety Factor

The safety investigation identified that the immediate cause of the accident
was the failure of the lifeboats lifebelt under the dynamic weight of the bosun.

3.2
.1

Latent Conditions and other Safety Factors

The lifeboat davits frame did not have steps, safety rails, or suitable strong
parts to attach the fall preventer.

.2

Whatever the reason for the bosun to expose himself to the risk of falling, the
task necessitated him to step onto the inclining davit structure where there was
no suitably strong line to attach the hook of the safety harness.

.3

The strength of the lifeboat lifeline was not enough to take the dynamic impact
of a falling person.

.4

It was not excluded that the strength of the lifeboat lifeline may have been
weakened due to the exposure to the environment.

.5

It did not transpire that any of the crew members had either remarked about
the bosuns decision to walk on the davits launching rail or about the
attachment of the fall preventer to the lifeboats lifebelt.

.6

An assessment to establish the risk of a fall hazard did not seem to have been
thoroughly considered on the Form as there was no mentioning of this hazard
and/or mitigation actions, which could have been put in place to prevent the
fall.

.7

What seemed to be missing in the Risk Assessment Form was not only the
intrinsic hazards but also the possible ways/mechanisms by which the
hazards could be realised.

12

3.3
.1

Other Findings
The fact that bosun wore a safety harness is suggestive that there were
intentions to climb on the lifeboat davits, i.e. there was an understanding and
acknowledgment that a fall hazard was realistic.

.2

An Aloft Working Permit was issued and signed by the bosun and chief
mate, in accordance with SMS Form 112 SAF/AOP.

.3

The fact that a safety harness was provided and worn by the bosun, was
indicative that there had been a clear intention to access areas where the risk of
a fall was possible.

.4

The safety belt was found to be of a standard design and suitable for its
purpose. No weakness in the safety belt were identified.

13

ACTIONS TAKEN

4.1

Safety Actions Taken During the Course of the Safety Investigation

Over a period of several months, the Company took a number of actions with the aim
of preventing similar accidents on board its ships, including:

A procedure to evaluate the attachment point for working aloft was developed
and circulated on all ships in the fleet as a Fleet Circular;

Pre-joining shore based training on safe working practices at a height was

included in the mandatory training requirements for deck ratings. The training
is being offered at no costs to the seafarers;

SMS procedures on working aloft and over the side in the Fleet Operations
Manual were revised;

Unsafe access areas on the freefall lifeboat were identified and preventive
measures to address this hazard were circulated on all ships in the fleet;

The Companys SMS Form Aloft/Overside Work Permit was revised to

enhance the checkpoints intended to address fall hazards;

The fleets risk assessment document for working aloft / overside was revised
to better address the matter.

14

LIST OF ANNEXES
Annex A Aloft/overside Work Permit
Annex B Risk Assessment Form

15

Annex A Aloft/overside Work Permit

16

Annex B Risk Assessment

17