Cyprus MAIC investigation – Fatality on ELB TRADER Container ship Jan 2018

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(www.MaritimeCyprus.com) The Cyprus Marine Accident and Incident Investigation Committee (MAIC) examines and investigates all types of marine accidents to or on board Cyprus Flag vessels worldwide, and other vessels in Cyprus territorial waters. The objective of the MAIC in investigating an accident, is the prevention of future accidents by establishing their root causes and circumstances.

Summary:

A fatality was investigated in which a visitor from another ship fell into the sea between the vessel and the berth when he attempted to jump over the bulwark instead of using the vessel’s gangway. In conducting its investigation, the Marine Accident Investigation Committee (MAIC), visited the ship in the port of Dublin, where, interviewed the crew members involved in the accident, reviewed events surrounding the accident and documents provided by the ship’s management and performed analyses to determine the causal factors that contributed to the accident.

Accident Description:
The M/V “ELBTRADER” departed from the port of Rotterdam, Netherlands on the 10th of January 2018 at 05:30 Hours LT. Destination Dublin (Ireland). Berthing on arrival in the port of Dublin at Dublin Ferry Terminals (DFT) Berth No.50 North, by starboard side alongside, on the 11th of January 2018 at 23:54 Hours LT (all fast). The weather was mild, slight winds, no fog, good visibility. Port Security Level 1.

On the 12/01/2018 at 02:30 Hours LT, the vessel was visited by the Master and the Chief Engineer of the M/V “SAMSKIP EXPRESS”. At 05:42 Hours LT, when they were leaving the vessel, despite the vessel’s watchman suggestion to use the gangway, both men jumped over the bulwark. The Chief Engineer fell into the water, within the gap between the vessel’s starboard side hull and the quay. At 05:43 Hours LT, in the area where the Chief Engineer fell, crew members threw two Life-Rings into the water and ringed a “Monkey Ladder” and LifeLines on the vessel’s starboard bulwark. At 05:45 Hours LT, the General Alarm was sounded.

Rescue Operation commenced. The emergency telephone number “112” was called for immediate assistance. Cargo Operations were suspended. At 05:46 Hours LT, vessel’s Rescue Team on Stand-By. At 05:49 Hours LT, the VTS Dublin
was informed on VHF Channel 12 and was requested immediate assistance. At 06:00 Hours LT, Port / Coast Guard Rescue Team arrived on scene. Rescue Operation under control of Port / Coast Guard Rescue Team. At 06:20 Hours LT the Rescue Operation was completed. The Chief Engineer was transferred to Hospital ashore. Later, the Police informed the “SAMSKIP EXPRESS” command, that the Chief Engineer passed away. It was later confirmed by the Irish Coroner, (Hearing in the Coroner’s Court, Dublin on 23/08/2018), that the cause of death was by drowning.

Conclusions:
Direct Cause:
Inadequate Real‐Time Risk Assessment: The Master and C/E of the “SAMSKIP EXPRESS” failed to adequately evaluate the risk associated with the jump over the bulwark and this faulty evaluation led to inappropriate decision‐making and subsequent fall of the C/E in the gap between the ship and the quay.

Root Cause
Both ships leadership safety attitudes were the root cause of the accident.

Contributing Cause(s):
Due to the post mortem exam report was not available at the time of writing of the report, it could not be established, whether alcohol intoxication, could have been considered as a contributing factor to the accident.

The environmental conditions (Tide) in conjunction with cargo operations were a contributing factor to the accident.

A Work‐Around Violation by hoisting up 3-4m and under-controlling the gangway was a contributing factor to the accident.

Inadequate supervision was a contributing factor to the accident.

A routine violation, not using the appropriate equipment for ship access by the visitors, was a contributing factor to the accident.

Wrong choice of action through false sense of security, was a contributing factor to the accident.

Lack of assertiveness by the Gangway Watchman was a contributing factor to the accident.

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Source: Cyprus MAIC

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