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Unseen, Impaired, in the Wrong Place: The Fatal Crush Aboard Karina C

🕑 5 min read words Safety • Incident • Cargo-operations

Vessel: Karina C, general cargo vessel, Antigua & Barbuda flag
Date & location: 24 May 2019, Port of Seville, Spain
Outcome: Fatal crush — the second officer was fatally crushed between a gantry crane and the vessel's hatch covers during cargo discharge, with a blood alcohol content of 117mg/100ml; the accident was not initially reported
Human factors: Normalisation · Complacency · Workload
Source: MAIB Report 18/2020

117mg/100ml second officer's blood alcohol content0 exclusion zone at the crush point~6 min read + Knowledge Checker

Unseen, in the Gap

On 24 May 2019, Karina C was discharging cargo at the Port of Seville. The second officer entered a gap between the gantry crane and the vessel's hatch covers — a known crush point. The chief officer, supervising the cargo operation, was unaware he had entered the danger zone. The crane moved. The second officer was fatally crushed. His blood alcohol content was subsequently confirmed at 117mg/100ml.

A Second Failure: Not Reporting It

The first failure killed the second officer. MAIB's investigation found a second failure followed immediately after: the accident was not reported to the company or maritime authorities in the normal way. Whatever drove that decision, its effect was to withhold the facts of a fatal accident from the people who could have used them to prevent a repeat — the same underlying failure mode MAIB has found in other cases where a safety culture protects itself before it protects the next person on watch.

Two Broken Safeguards, Not One

No system existed aboard Karina C to prevent personnel from entering the gantry crane's danger zone during cargo operations, and no coordination mechanism tracked where crew were positioned once cargo work began. Alcohol impairment reduced the second officer's own hazard perception at the exact moment he needed it most. Neither safeguard — a physical exclusion zone, or a sober crew member with intact judgement — was in place.

Recommended Actions

  1. Implement a comprehensive safety culture programme including mandatory incident reporting procedures and protections for personnel who report accidents (Rec 2020/134).
  2. Install warning systems at gantry crane crush points to alert both crane operators and deck crew to the presence of personnel in the danger zone (Rec 2020/135).

Human Element Analysis

Normalisation

A gap between a gantry crane and hatch covers during active operations is a known crush hazard on general cargo vessels — and yet no exclusion zone existed to physically keep crew clear of it, suggesting the risk had been quietly accepted rather than actively controlled.

Complacency

The chief officer, supervising the operation, did not know the second officer had entered the danger zone. No process tracked crew position during active crane movements, leaving a fatal gap between where people actually were and where the supervising officer believed they were.

Workload / Reporting Culture

The accident not being reported through normal channels is itself a safety failure, separate from the crush. It reflects an instinct to protect the company over the obligation to investigate and prevent recurrence — and it destroys exactly the data that could stop the same accident happening to someone else.

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