BSafe Case Study 6 — The Morning Did It Right. The Afternoon Didn't.

The Morning: Done Correctly

Painting cargo hold upper structures needed a portable scaffold tower, 6 to 9 metres up. In the morning, the chief officer briefed the team and personally supervised from the tank top. Every time the tower needed repositioning, the two crew members painting from it climbed all the way down, safety lines and harnesses removed, before the tower was moved and resecured — then climbed back up and resecured before resuming. Slow, deliberate, and it worked: hold No. 1 finished by 1130 without incident.

The Afternoon: The Same Job, a Different Process

After lunch, the same crew (minus one AB now on bridge duty, replaced by another) moved to hold No. 4. The chief officer was resting. This time, when the tower needed repositioning, the bosun and an AB stayed on it while two others pushed it from below — and neither wore a safety harness or safety line, unlike that same morning.

The tower was repositioned five times this way without incident. On the sixth, the bosun decided to reach a hopper tank edge and had the tower pushed forward one more time with both men still aboard, about 8m and 6m up. It moved half a metre and toppled forward onto the deck, throwing both men into the wreckage of the scaffolding.

What ATSB's Investigation Found

• Remaining on an unsecured, moving tower made it top-heavy and unstable — directly contributing to the topple.
• The absence of formal supervision in the afternoon, combined with a desire to get the job done, likely drove the shortcut from the morning's own established, safer method.
• The scaffold had no manufacturer identification plate and showed wear, damage, and repairs — condition wasn't checked as part of the process either.
• Onboard guidance existed stating scaffolding should not be moved with people on it — followed all morning, not followed in the afternoon.
• Safety harnesses and lines, used correctly that same morning, would have prevented the fall that afternoon.
• A functioning Stop Work Authority programme should have let any of the attending crew challenge the change in practice — none did.

Recommended Actions

Grounded directly in ATSB's findings:

1. Scaffolding must never be repositioned with personnel still aboard — a standing rule, not situationally applied depending on who's supervising that hour.
2. Supervision shouldn't be treated as optional once a safe method has been established — the method needs to hold regardless of whether the original supervisor is present.
3. Safety harness and line use should be a fixed requirement for the task, not a practice that quietly lapses across a single working day.
4. Equipment condition — identification, wear, damage — should be checked as a standing part of the job, not assumed adequate because it was used successfully that same morning.

Human Element Analysis

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Related Reading

• BSafe Case Study 2 – another working-at-height incident where an intervention attempt didn't hold