TAIC notes that lack of “adverse events” can lead to risk desensitization

An investigation into two separate workplace deaths at New Zealand ports by the Transport Accident Investigation Commission (TAIC) has noted that people who work in high-risk industries who are not exposed to regular adverse events tend to become desensitized to the risk involved.

The report as a result of inquiries into the deaths of Atiroa Tuaiti and Don Grant was published on October 20th. The TAIC also said that safety regulations were not up to the required level. It cited insufficient regulatory oversight, a lack of industry-wide safety standards, and a lack of the formal safety management oversight and monitoring that was both required and the norm in other industries.

Atiroa Tuaiti died on April 19th 2022 when he was crushed by a 40ft container at the Port of Auckland, where he was working as a stevedore. Less than a week later Don Grant died at Lyttelton Port after coal spilled as it was being loaded onto ETG Aquarius (IMO 9928384).

Tuaiti was employed by independent stevedoring company Wallace Investments Ltd (WIL) at the Port of Auckland, while Grant was employed by the Lyttelton Port Company (LPC).

Tuaiti, a hold operator, was one of several staff tasked with loading 47 containers onto a vessel berthed at the port. Tuaiti was positioned on a tier of containers below, from which he hand-signalled to the crane operator. When the container was suspended about 1.5 metres above the first tier, another crew member on the main deck saw Tuaiti bend down and move underneath the suspended container, reaching with his arm toward the aft port side of the container. Almost immediately after observing this, the crew member saw the container lower, leaving Tuaiti pinned beneath it. The container was raised a little, and Tuaiti fell onto the main deck. Emergency assistance arrived within 10 minutes, but he died at the scene.

The TAIC report said it was likely that Tuaiti had moved underneath the container to rectify an issue with the aft port-side twist lock.

The other hold operator on the scene was unaware of Tuaiti’s position when they signalled to the crane operator to lower the container, and it was unlikely that the crane operator would have been able to see him moving underneath the container.

A few days later at Lyttelton Port, Grant, working as a coal signalman, was positioned onboard bulk carrier ETG Aquarius at a raised section of deck around the cargo hatch. His job was to observe the coal loading into the holds and provide instructions via radio to the ship-loader operator.

Throughout the loading process, coal flowed continuously from a jet slinger machine. The flow of coal would only normally be stopped by the ship-loader operator when it was necessary to move the ship-loader between cargo holds.

While the coal was being loaded the foreman, who was not onboard the vessel, used a hand-held radio to check in with the ship-loader operator to determine how much coal was still to be loaded.

At some point during this process, coal began to spill over the raised section at the approximate location where Grant was standing. About this time, Grant almost certainly fell off the platform he was standing on and as he fell, his helmet came off, and he hit his head on the deck.

After 23 seconds of radio silence, the ship-loader operator asked Grant if he was all right but received no reply. After someone radioed for assistance, three stevedores and some of the vessel’s crew began searching the coal and found Grant unresponsive near the base of the platform he had been standing on. He was pronounced dead at the scene.

The TAIC noted that both Wallace Investments and Lyttelton Port Co were in the process of improving their safety systems at the time, but there were deficiencies common to both organizations.

The commission found the risks associated with work activity were primarily managed with administrative risk controls, but there were no robust processes to ensure that these controls remained effective.

The commission said a “lack of cohesiveness” within the stevedoring industry meant the companies had little ability to benchmark comprehensively with others in the industry. There were no best-practice guidelines, no minimum training requirements and few safety-related information-sharing platforms.

2022-built, Liberia-flagged, 44,140 gt ETG Aquarius is owned by Lucretia Shipping SA care of Santoku Senpaku KK of Osaka, Japan. It is entered with Britannia on behalf of Lucretia Shipping SA. As Of October 20th it was at Rio Grande Anchorage, Brazil.