Intoxication, safety issues and poor communication led to fatal accident on board Karina C, says MAIB

The death of the second officer of UK-registered general cargo vessel Karina C (IMO 9558000) in 2019 was caused by several direct and indirect factors, the Marine Accident Investigation Branch (MAIB) has said in its just-published accident report.

MAIB said that the second officer was crushed because he attempted to walk between the vessel’s gantry crane and a stack of cargo hold hatch covers, unaware that the crane operator was about to drive the crane towards him.

The crane operator did not know the second officer was under the crane or what his intentions were because he was not monitoring the walkways and had not established effective communications with the crew working on deck.

MAIB said that the safety culture on board Karina C was weak, in that established safe systems of work were not followed, personnel were working close to moving equipment and unprotected edges, and personnel were not wearing adequate levels of PPE.

The risk assessment and procedure that the owner Carisbrooke had in place for operating the gantry crane was not as clear as it could have been, said MAIB. That said, if the safety controls that were stipulated had been implemented, the accident would have been avoided.

The second officer’s judgment was probably impaired by alcohol, MAIB said.

Carisbrooke’s drug and alcohol policy was not being effectively enforced on Karina C. The second officer’s and crane operator’s actions might also have been influenced by tiredness or fatigue.

Incident:

During the mid-morning of May 24th 2019 the second officer of the Karina C was fatally injured when he was crushed between the vessel’s gantry crane and a stack of cargo hold hatch covers during post-cargo loading operations in Seville, Spain. The second officer had been working at the aft end of the main deck and was attempting to pass between the hatch covers and the stationary crane. As the second officer climbed onto the hatch coaming, the vessel’s chief officer drove the crane aft, trapping and crushing the second officer against the hatch covers.

The chief officer immediately reversed the crane and the second officer fell onto the deck, where he received first-aid and cardiopulmonary resuscitation from the deck crew and shore paramedics

An emergency services doctor told the crew that the second officer probably died after having a heart attack. Based on the doctor’s initial assumption and the evidence provided by the vessel’s crew, the accident was not reported to the MAIB.

Following receipt of the second officer’s post-mortem report and close examination of Karina C’s closed-circuit television recordings, the vessel’s managers, Carisbrooke Shipping Ltd, reported the accident.

Investigation by MAIB:

The investigation concluded that the second officer did not know the chief officer was about to move the crane and the chief officer did not know where the second officer was or what he intended to do because the deck operations were not being properly controlled or supervised and the deck officers did not communicate with each other.

The MAIB said that the master did not adequately investigate or report the accident.

Carisbrooke Shipping said that it welcomed the MAIB report on the accident aboard the Karina C and the tragic loss of its second officer. “We acknowledge the MAIB’s findings and accept the report’s recommendations,” the shipping company said, adding that “since the accident, Carisbrooke has implemented tighter procedures surrounding deck protocols and the operation of gantry cranes.”

Carisbrooke Shipping Ltd has updated its incident reporting policy, fitted additional emergency stops to all its gantry cranes, improved the profile of its employee confidential reporting system, and reviewed and amended its alcohol policy to include frequent random testing of all crew and sanctions on masters in the event of policy breaches.

Recommendations were made by MAIB in the report that Carisbrooke Shipping Ltd  improve the safety culture on its ships and the level of crew compliance with established safe systems of work and to investigate alterations to crane movement warning systems.

Other safety issues not directly contributing to the accident noted in the MAIB were that the shoreside doctor and paramedics were not told the full circumstances of the second officer’s injuries. However, it was unlikely that this had any impact on his chances of survival.

The crane emergency stops were not easily accessible and were not within reach of the second officer when he was trapped.

Meanwhile, on November 24th, two days before the report was released, the Karina C suffered a exhaust gas compensator fault when 6.7 miles from Whitby, while en route from Tees to Amsterdam with nine crew members on board,. The vessel was carrying 6.155 tonnes of fertilizer. The ship was temporarily NUC in Southerly winds of 5 Beaufort. The crew carried out repairs, and once they were completed it resumed its voyage to Amsterdam.

2010-built, UK-flagged, 4,151 gt Karina C is owned by Carisbrooke Shipping 6250 BV care of manager Vertom Shipping & Trading BV of Rhoon, Netherlands. ISM manager is Carisbrooke Shipping Ltd of Cowes, UK. It is entered with British Marine on behalf of Carisbrooke Shipping Ltd.

https://www.gov.uk/maib-reports/crush-incident-on-general-cargo-vessel-karina-c-with-loss-of-1-life