Report of investigation into the fatal man-overboard accident onboard - PDF document

Report of investigation into the fatal man-overboard accident onboard a Chinese registered container ship Ming Fen at Yau Ma Tei Anchorage, Hong Kong, China on 31 July 2010 Purpose of Investigation This incident is investigated, and published in accordance with the IMO Resolution MSC 255(84), the Code of the International Standards and Recommended Practices for a Safety Investigation into a Marine Casualty or Marine Incident (Casualty Investigation Code). The purpose of this investigation conducted by the Marine Accident Investigation and Shipping Security Policy Branch (MAISSPB) of Marine Department is to determine the circumstances and the causes of the incident with the aim of improving the safety of life at sea and avoiding similar incident in future. The conclusions drawn in this report aim to identify the different factors contributing to the incident. They are not intended to apportion blame or liability towards any particular organization or individual except so far as necessary to achieve the said purpose. The MAISSPB has no involvement in any prosecution or disciplinary action that may be taken by the Marine Department resulting from this incident. Table of Contents Page 1 Summary 1 2 Description of the Vessel 2 3 Sources of Evidence 3 4 Outline of Events 4 5 Analysis of Evidence 6 6 Conclusions 9 7 Recommendations 10 8 Submission 11 1 1. Summary 1.1 At about 0720 on 31 July 2010, a crewmember on board the Chinese registered container vessel Ming Fen fell overboard and drowned at Yau Ma Tei Anchorage, Hong Kong. 1.2 During cargo operation on board Ming Fen, pontoon hatch covers of No.1 cargo hold were lifted, shifted and stacked on top of the pontoon hatch covers of No.2 cargo hold. A mechanic engaged in the operation lost balance and fell overboard on the port side when he leaned over the edge of the pontoon cover to detach a lifting hook from the lug. It was shower and there was swell at sea. 1.3 He went missing in the water. Search and rescue operation was carried out but was in vain. At about 0635 on 2 August 2010, his body was found floating in approximate position 22o17.968’N, 114o09.229’E. 1.4 The investigation revealed the main contributory factor to the accident was the surface of the pontoon hatch cover became slippery due to shower and there was swell at sea, the mechanic lost balance when leaning forward over the edge of the pontoon hatch cover to detach a lifting hook from the lug. 2 2. Description of the Vessel 2.1 Particulars of Ming Fen Port of Registry: Fu Zhou Registration No. : 080006000012 Type of Vessel : Container Year of Built : 2006 Built At : Linhai, China Owner : Huaming Shipping Co. Ltd. Length : 88.13 metres Breadth : 13.00 metres Depth: 5.5 metres Gross Tonnage: 1 916.00 Net Tonnage: 1 027.00 Engine Power: 735 kW No. of Crew: 14 Fig. 1 Container ship Ming Fen 3 3. Sources of Evidence a) The Master and a mechanic of the Ming Fen b) The Crane Operator the Cheung Kee No.28 c) Weather report provided by the Hong Kong Observatory d) Autopsy report provided by the Department of Health 4 4. Outline of Events 4.1 The Chinese registered container ship Ming Fen (the Vessel) departed the port of Xiamen, China and arrived at the Yau Ma Tei Anchorage, Hong Kong at about 0630 on 31 July 2010. 4.2 At about 0700, a locally licenced dumb steel lighters Cheung Kee No. 28 (DSL-A) and Hoi Fat No.3 (DSL-B) moored to the starboard and port side respectively of the Vessel (Fig 2). 4.3 The derrick of DSL-A was used to shift five pontoon hatch covers of No. 1 cargo hold and stack on top of No. 2 cargo hold of the Vessel. Mechanic A and Mechanic B assisted in handling the lifting hooks during operation. 4.4 There were five pieces of pontoon hatch covers for No.1 cargo hold and four for No.2 cargo hold. Four pieces were placed on top of the pontoon covers of No.2 cargo hold in two layers, leaving the fifth one stacked on the third layer as shown in Fig. 2. 4.5 At about 0720, when the fifth pontoon hatch cover was stacked, the two mechanics went on top of the pontoon cover to release the lifting hooks. 4.6 While Mechanic B was releasing the lifting hooks on the starboard side of the pontoon, he heard screaming of Mechanic A. But he saw nobody over the port side of the pontoon. He ran to the port side of the pontoon where he saw Mechanic A was drowning in the water between Vessel and DSL-B. He rushed to inform the Master of the Vessel immediately. 4.7 The Master reported the accident to Vessel Traffic Centre of Hong Kong Marine Department who then requested assistance from Marine Police and Fire Services Department. 4.8 At about 0724, the crew launched the starboard lifeboat for search and rescue of Mechanic A. Later on, they were joined by the launches of Marine Department, Marine Police and the Fire Services Department. But the SAR operation for Mechanic A was in vain. 4.9 At about 0635 on 2 August 2010, the master of a tugboat found a body floating in the water near the Western Harbour Tunnel and he reported it to the Marine Department. 4.10 At about 0640, two Marine Department launches arrived at the scene in position 22o17.968’N, 114o09.229’E. The body was lifted by a fireboat at 0725 and delivered for post-mortem examination. The identity of the dead body was confirmed to be Mechanic A by his father on 10.8.2010. 5 Fig .2 Sketch showing the accident


\n \r "!#%$  "!#&('*)%+,(-%.&#x=?0;푠/10325432657819;:#&#x=?0;푠/10325432657819;:#&#x=?0;:7"4@\rH4Ò7G46#JLKMNPORQSTVUIWJLKMNPORQSTVUIWJLKMNPORQSTVUIWJLKMNPORQSTVUIWYXLZ[\^]R_*[XLZ[\^]R_*[XLZ[\^]R_*[XLZ[\^]R_*[J\rUI`badcFQe\rSfORQSTVUIWJ\rUI`badcFQe\rSfORQSTVUIWJ\rUI`badcFQe\rSfORQSTVUIWJ\rUI`badcFQe\rSfORQSTVUIWYXLZ[\^]R_*[XLZ[\^]R_*[XLZ[\^]R_*[XLZ[\^]R_*[g8h\n i\r&#x?7"4;0&#xI19;;&#x*lI; =;&#x;�4=?j=55k#0&#xI19;;&#x*lI; =;&#x;�0&#xI19;;&#x*lF$;&#xG=;&#x;�4=?j=55k# 6 5. Analysis of Evidence Working experience & training 5.1 The Master of the Vessel held a certificate of competency issued by Fuzhou Maritime Safety Administration of the People’s Republic of China. As the certificate was issued in pursuant to STCW Convention, he was considered qualified and complied with local regulations to work as a works supervisor on board during cargo handling operation while within Hong Kong waters. 5.2 The Mechanic A and Mechanic B had attended training courses meeting the requirements of STCW convention. They were considered qualified and complied with local regulations to carry out cargo handling work on board while within Hong Kong waters. Fatigue at work
5.3 The Vessel arrived Hong Kong at about 0630 on 31 July 2010. Shifting of hatch covers started at 0700 and the accident happened at 0720. There was no evidence to show that the deceased have suffered from fatigue at work. Personal protective equipment 5.4 The deceased wore reflective vest while working on board. It cannot be traced whether he had used safety helmet and safety shoes at work. No lifejacket was used by him while working on deck. Weather and sea conditions 5.5 There was shower at the time of the accident and the Master of the Vessel reported that there was swell at sea. Possible cause of the accident 5.6 Two lugs each were welded on the port and starboard side of the pontoon hatch cover for lifting (Fig 3). When a person standing on the side of the pontoon cover to handle the lifting hooks, he would have to lean his body forward and partly over the side of the pontoon hatch cover (Fig 4). It was probable that during Mechanic A was releasing a lifting hook from the lug, he lost balance and fell over the shipside into the water from a height of stacked pontoon hatch covers. 5.7 There was shower at the time of the accident and the wet surface of hatch covers would have become slippery. Also there was swell as sea. The environmental condition could have contributed the accident. 7 Risk assessment 5.8 During cargo operation on this type of vessels, the pontoon hatch covers have to be lifted, shifted and stacked on top of another cargo holds so as to allow assess to the cargo holds. 5.9 The Vessel was designed with narrow passageway on the sides. When pontoon hatch covers were stacked up on top of another cargo hold to a certain height, the risk of crewmembers falling over the shipside while handling the lifting hooks on top of the pontoon hatch covers increased. 5.10 The design for lifting of this type of pontoon hatch covers requiring crewmembers to lean their body partly forward over the edge of the pontoon for handling the hooks poses potential hazards to the operators. The risk aggravates further when the operation has to be performed under adverse weather and rough sea conditions. 5.11 Had the Company and/or the Master of the Vessel conducted comprehensive risks assessment to cargo operation on board, the risks to personal safety during operation could have been identified earlier and the accident avoided. Fig 3 Hatch cover onboard Ming Fen Lugs for hanging hooks