BSafe Case Study 23 — Obscured for the Final 20 Seconds

A Routine Hatch Cover Move

Discharging fine coke cargo, the chief officer operated the ship's gantry crane to stack hatch covers per the discharge plan, moving them one at a time from position 7 toward position 11. Before each move he checked both walkways and coamings were clear, climbed to the control position, and proceeded — a process that had already worked cleanly for hatch cover 11.

Meanwhile the stevedore coordinator, directing the shoreside crane by radio, climbed the ship's fixed ladders and leaned over a 2-metre hatch coaming to check on his team's progress inside the hold — checking in periodically as work continued in different parts of the hold.

A Line of Sight That Closed Without Anyone Noticing

As the chief officer began moving hatch cover 9 aft, he had a clear line of sight to the area where the coordinator was working. As the crane approached hatch cover position 10, the suspended hatch cover itself began blocking that same sightline. The full move from position 7 to 11 took about 45 seconds — the crush site was obscured from the crane's control position for the final 20 seconds of that travel. When the crane abruptly stopped, the chief officer didn't yet know why. A stevedore foreman, boarding the ship, spotted the coordinator's head above hatch cover 11 and realised something had happened. They found him trapped between the gantry crane's aft leg and the hatch cover, a gap of roughly 130mm. He was pronounced dead at the scene.

What MAIB's Investigation Found

• The crane's emergency stops, warning bell, and flashing light were all confirmed working correctly post-incident — this wasn't an equipment failure in the conventional sense.
• The warning bell was loud enough, and the flashing light visible enough, that ambient noise likely wasn't the reason they didn't prevent the incident — but the suspended hatch cover itself could have blocked the flashing light from the coordinator's specific position as the crane approached.
• A genuinely clear sightline existed at the start of the relevant move — the visibility gap only developed partway through, as the crane's own suspended load came between the operator and the crush site.
• The coordinator's exact position, checking on his team from above the coaming, placed him somewhere the crane operator had no way to see once the load itself became the obstruction.

Recommended Actions

Grounded directly in MAIB's findings:

1. A crane operation where a suspended load can progressively obscure the operator's own sightline needs an alternative method of confirming the area stays clear throughout the entire move, not just at its start.
2. Personnel supervising cargo operations from an elevated, exposed position near a crane's working path need a clear, understood way to signal their presence and position to the equipment operator throughout, not just before the move begins.
3. Functioning warning systems (bell, light) are necessary but not sufficient if the geometry of a specific operation can block them from being seen or heard by the one person they're meant to warn.

Human Element Analysis

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Related Reading

• BSafe Case Study 7 – another fatal gantry crane crush, a different underlying cause, the same equipment