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The Trailer That Shouldn't Have Moved: What the Laureline Fatal Crush Means for Every RoRo Crew Member

🕑 5 min read words Safety • Incident

Purfleet, 13 July 2024 — 5:11 pm

Able Seaman Alain Canete had scored 100% in his vehicle deck safety training exam six weeks earlier. He knew the new danger zone procedure. He had passed every assessment his company had put in front of him.

At 17:11 on 13 July 2024, he was crushed between the rear of a reversing trailer and the structure of the RoRo cargo vessel Laureline, moored at the CLdN London terminal in Purfleet. He was declared dead at 17:35.

MAIB Report 7/2026 describes how a 44-year-old Filipino AB, with years of experience on ro-ro vessels, died in circumstances that had played out, in near-identical form, on at least four other ro-ro vessels in the preceding seven years — including a fatal crush on board Clipper Pennant just three years earlier. The procedure designed to prevent it existed. The training had been delivered. The exam had been passed. None of it was enough.

What Happened: The Sequence

Loading operations on Laureline's garage deck were being managed by two ABs — AB1 (Canete) and AB2 — working independently on opposite sides of the deck. A fleet of terminal tugs driven by shore-based tug drivers were loading road trailers into stowage positions under the crew's direction.

At around 17:06, AB2 was relashing a trailer (trailer A) on the starboard side. AB1 was on the port side, working in the narrow space between the ventilation trunking at the aft end of the deck and a stowed trailer (trailer C).

A second tug and trailer (trailer B) arrived and waited. AB1 waved it forward and began walking ahead of it as the tug driver pushed it into the aft loading position. As the tug manoeuvred, AB1 positioned himself in a corner between the vent trunking and trailer C — a position the investigation later confirmed the tug driver could not see without leaning out of his cab window.

The tug paused for about 5 seconds. AB1, believing the trailer had stopped in position and the manoeuvre was complete, stepped behind it. The tug driver — reassessing the trailer's alignment against trailer C — pushed back without checking that AB1 had cleared. Trailer B struck the vent trunking and AB1.

The gap between the rear of trailer C and trailer B when found post-accident was 20.6 centimetres.

Root Causes: Three Failures That Stacked

1. A Safety Procedure That Was Unclear and Not Followed

Anglo-Eastern had introduced a new vehicle deck cargo operations procedure (Section 4.7 of its RoRo and Car Carrier Operations Manual) just three months before the accident, following a separate internal incident. The procedure defined a moving danger zone around each manoeuvring trailer — an 8-page document with diagrams, rules, and exceptions.

The MAIB found that the procedure's safety messages were undermined by their own complexity. Alongside the core rule to stay out of the danger zone, there were listed exceptions (inserting trestles, releasing parking brakes, placing rubber mats). CCTV footage from the two weeks before the accident showed garage deck ABs routinely entering the danger zone behind connected, moving trailers — not as a one-off lapse, but as standard working practice.

AB1 and AB2 had both scored above 96% in their training assessment. The exam did not contain a single question about the danger zone or an explicit instruction not to pass behind a connected trailer. Training that tests knowledge retention without testing application in practice is not training in the skill that matters.

2. A Tug Driver Procedure That Didn't Reflect Reality

Both industry guidance (ILO) and the terminal's own safe system of work stated clearly: if you lose sight of the banksman, stop. The tug driver had attended toolbox talks reinforcing this, as recently as November 2023.

MAIB's review of CCTV footage across Laureline's garage deck in the two weeks before the accident found that tug drivers routinely continued manoeuvring when the marshalling crew member was not in their line of sight. This was not occasional non-compliance — it reflected the physical reality of the task: the geometry of a coupled tug and trailer, in a narrow loading lane, with a driver focused on lane positioning and proximity to adjacent vehicles, made maintaining continuous sight of the banksman practically impossible.

The procedure said stop if you can't see them. The operation, as actually performed, made it routine to not see them. The gap between rule and reality was never addressed.

3. No Supervision on the Deck Where the Accident Happened

On the day of the accident, three of Laureline's four vehicle decks were being worked with two ABs each and no supervisory officer present. The main deck had the bosun as a third crew member. The garage deck — the deck where the accident happened — had only AB1 and AB2, working independently on opposite sides, out of each other's sight.

The MAIB's CCTV comparison is stark: on the main deck where the bosun was present, crew consistently stayed clear of danger zones. On the garage deck without supervision, they routinely did not. The First Officer was in the cargo control room, focused on ballast and trim. The CCTV had limited views of the garage deck. No one was watching.

Anglo-Eastern had introduced the new procedure without any assurance mechanism — no way to verify that the training had been understood and the procedure was being followed. The terminal had audited Laureline's weather deck operations once, found no issues, and had not audited the garage deck before the accident.

What If? — Scenario-Based Escalation

AB1 paused behind a trailer that had stopped moving. He had 20 centimetres of clearance on one side and no exit route behind him. Change one thing.

What if the tug driver had stopped the moment AB1 passed out of his line of sight? Industry guidance, the terminal procedure, and toolbox talks all said he should. CCTV showed he — and other tug drivers — routinely did not. But if even one of those procedural reinforcements had translated into automatic behaviour on that specific day, AB1 would have walked away. This is the accident the ILO's guidance was written to prevent, and the gap between guidance and practice is what killed him.

What if AB1 and AB2 had been working together on the same trailer, rather than on opposite sides of the deck? The new vessel procedure showed two crew members working each trailer. MAIB found no evidence of time pressure — Laureline was scheduled to stay overnight and loading wasn't due to finish until the next day. Had they worked together, AB1 would have been visible to both the tug driver and his colleague throughout the manoeuvre.

What if there had been a positive signal between AB1 and the tug driver to confirm the manoeuvre was complete? The accident happened because AB1 assumed the pause meant the trailer was done; the tug driver resumed without checking. A simple, agreed positive confirmation — one blow of the whistle from the crew member, one horn response from the tug driver — would have broken the cycle of assumptions on which the SSW actually depended.

What if the garage deck had undergone the same terminal audit as the weather deck — or if the company had any assurance process for the garage deck at all? CCTV showed the non-compliant practices that killed AB1 had been ongoing for at least two weeks. An audit in that window would have found them. The terminal's audit of the weather deck, seven days before the accident, found no issues — because the bosun was supervising it. The garage deck was never reviewed.

Role-Based Lessons

ABs and Ratings Working on Vehicle Decks

The danger zone around a manoeuvring trailer is a moving exclusion zone, not a line on a diagram. It exists for as long as the tug is connected — including during pauses. A trailer that has stopped is not a trailer that has finished. If you're in a position the tug driver cannot see — behind the trailer, between trailers, in a narrow corner — the procedure requires you to be there only for trestle insertion, and to wait for a positive signal that the manoeuvre is truly complete before moving to that position. When in doubt, signal stop, confirm, then move.

Work your trailers with your partner. Two people on the same trailer is the intended model — not two people on opposite sides of the deck loading independently. If you haven't run this procedure in a briefing recently, ask for a toolbox talk before operations start.

Officers and Chief Officers

The RCOM required the duty officer to be physically present on vehicle decks as much as possible. On the day of the accident, no officer was on the garage deck. CCTV evidence showed that crew behaviour was measurably different on supervised versus unsupervised decks. Supervision is not a nice-to-have on a vehicle deck — it's a control measure.

If your CCTV doesn't cover the full working area of a vehicle deck (on Laureline, the garage deck camera was blocked as soon as a trailer was stowed in front of it), that's a risk that needs a physical response, not a monitoring workaround.

Masters and Ship Managers

Anglo-Eastern introduced a new 8-page safety procedure with a fleetwide training programme — and then had no way to verify it was working. The MAIB's conclusion is direct: the procedure was not followed, the training did not ensure understanding in practice, and there was no assurance mechanism to detect either of those failures until after someone died.

Procedure rollout without assurance is not implementation — it's paperwork. The question after any new safety procedure goes live is: how will we know if it isn't working? If the answer is “we'll wait to see if there's an incident,” the system has already failed.

Test Your Knowledge

Think you've got this covered? Put it to the test in Crew Connect's free Knowledge Checker — try a quick safety round and see how your answers stack up against the lessons from reports like this one.