Fatal Fall was the result of unsafe equipment and actions

The death of a man on bulk carrier New Legend Pearl (IMO 9414773) in November 2016 was the result of both equipment and safety practice failings, according to a just-published report from the New Zealand Transport Accident Investigation Commission.

On the morning of November 3rd 2016 New Legend Pearl was east of Coromandel Peninsula on a passage between the New Zealand ports of Bluff and Marsden Point. The crew were attempting to change a hoisting wire on one of its cargo cranes. Partway through the task the hoisting wire snagged on the crane jib that was resting in its cradle, about 8 metres above the hatch cover.

One of the crew donned a safety harness and climbed up onto the crane jib, secured the lanyard of his harness around a luffing wire and walked along the jib to unsnag the wire. However, the lanyard prevented him reaching the snag, and he was in the process of transferring the lanyard to a different securing point when he lost his balance or slipped and fell 8 metres to the deck below. He died from his injuries.

The Transport Accident Investigation Commission found that it was about as likely as not (assigned probability of between 33.3% and 66.6%) that the locking mechanism for the safety harness hook was not engaged, which allowed the lanyard to roll or burst out of the hook when the crew member fell, and that the safety harness was not suitable for the intended task.

The Commission also found that:

  • the risk assessment conducted prior to the crew starting the wire replacement on crane number 2 did not fulfil the requirements of the operator’s safety management system, because it did not adequately identify and manage the risks associated with the task:
  • the repeated failures of the crew to comply with safe working practices when working at height and the acceptance of using a substandard wire on a working crane were indications of a poor safety culture on board the New Legend Pearl.

The key lessons arising from the inquiry were:

  • working at height was a risky activity and all crew should use suitable safety harnesses that were fit for the intended tasks
  • working at height was an activity that should be managed using a formal risk assessment methodology
  • attaching a safety harness by passing it through or around the securing point and back onto the lanyard was a dangerous practice that could result in inadvertent release unless the lanyard and hook were designed for that purpose.

The Commission found that the repeated failures of the crew to comply with safe working practices when working at height and the acceptance of using a substandard wire on a working crane were indications of a poor safety culture on board the New Legend Pearl. It recommended that the general director of the Panama Maritime Authority seek improvements in the operator’s implementation of its safety management system on board its vessels, including the underlying safety culture.

2010-built, Panama-flagged, 20,809 gt New Legend Pearl is owned by Tianjin Zhongyuda Logistic Co Ltd, care of manager Tianjin Xinhai International Ship Management Co Ltd (New Legend Group) of Tianjin, China. ISM manager is Hong Kong Fortune Intl Shipping Co of Hong Kong. It is entered with American Club on behalf of Tianjin Zhongyuda Logistic Co Ltd.

http://www.taic.org.nz/sites/default/files/inquiry/documents/16-205%20Final.pdf (36 pages)