Twenty Minutes Before Anyone Knew: Working the Fore Deck at Anchor in a Gale

What Happened

A Hong Kong-registered chemical tanker was at anchor in the open sea east of Ningbo, waiting for a berth, when it met gale force winds with rough seas and heavy swells. On the morning of the accident the bosun and the pumpman went to the main deck to cover deck equipment with tarpaulin to keep seawater out.

They then found that the foam hose box and a mooring rope on the forward mooring deck had been damaged and displaced by the surging seas. They collected the foam hose and nozzle, which had been scattered from the box. While they were trying to tidy the mooring rope, a huge wave struck the bow. Seawater surged over the bulwark, struck them violently and swept them across the mooring deck.

About twenty minutes later the crew were alerted and organised a rescue. At around noon, with the injured crew members' condition continuing to deteriorate, the tanker was instructed to proceed to meet a rescue helicopter, and both were transferred to a shore hospital. The pumpman was declared dead there.

What The Investigation Found

Beyond the heavy weather itself, the notice identifies four contributory factors:

1. The crew did not follow the shipboard SMS procedures for working on deck in heavy weather.
2. The risk assessment and toolbox meeting held on board for deck work in heavy weather lacked relevance and effectiveness.
3. The hazardous effects of the heavy weather were neglected. In particular, the Chief Officer, the bosun and the pumpman lacked sufficient awareness of the potentially fatal risks of working on deck in heavy weather and underestimated them.
4. Medical evacuation for the injured crew members was not arranged in a timely and efficient manner.

The tidying job itself was a sensible, practical instinct: loose gear and a displaced mooring rope on a pitching forward deck look like exactly what a good seaman would want to fix. The notice's point is that the procedure existed precisely to stop that instinct taking people forward in those conditions.

Lessons Learnt (from the notice)

1. Strictly follow the shipboard SMS requirements for working on deck in heavy weather.
2. Make sure relevant and effective risk assessments and toolbox meetings are carried out as required.
3. Provide effective safety training to build the crew's awareness of heavy-weather deck work, and hold to the requirement of not proceeding to the deck area unless safety is ensured.
4. Arrange prompt medical evacuation for injured crew members when necessary.
5. For companies: carry out internal audits from time to time to confirm crews follow the heavy-weather procedures and that risk assessments and toolbox meetings are effective.

Where The Routine Job Broke — Stage By Stage

Every one of these jobs was routine, and each had a chain of checkpoints that could have caught it. Here is where each stage failed in this case, and what a preventive action looks like.