BSafe Case Study 7 — Neither of Them Knew Where the Other One Was

A Schedule Brought Forward

The second officer had come off an overnight watch at 0540. With the pilot's boarding time suddenly moved up three hours, the chief officer asked for him to be called back to help finish cleaning cement dust off the hatch coamings before departure. He arrived on deck at 0930 and began sweeping the aft hold's coaming — wearing overalls, safety shoes, a helmet, but no face mask or eye protection, unlike the AB and cadet working nearby.

Two People, No Shared Picture

The chief officer remained at the gantry crane's controls throughout, moving hatch covers into position. At 0943 he began driving the crane aft. At the same moment, the second officer finished sweeping and started walking forward along the walkway. Neither knew where the other was. At 0944:10, the second officer climbed onto the hatch coaming and stepped into the gap between the crane's ladder platform and the stacked hatch covers — just as the chief officer, having cleared the stack with the lifting bar, drove the crane aft again.

The second officer was trapped and crushed, screamed, and was rolled between the platform and the covers as the crane reversed, then fell to the walkway below, striking his head on the guardrail. CPR began immediately; he was declared deceased just over an hour later. Post-mortem found internal bleeding from organ rupture and multiple fractures — and a blood alcohol content of 117mg per 100ml. The incident happened on his birthday.

What MAIB's Investigation Found

• Neither officer knew the other's position — situational awareness would have been enhanced by effective communication and proper control of the deck operation, neither of which existed in the moment that mattered.
• The chief officer, before moving the crane, should have left the controls to physically check the walkways and confirm the area below was clear.
• The crane's warning bell and amber light only activated while already moving — there was no pre-movement warning to alert someone nearby before the crane started.
• Emergency stop buttons existed at deck level but could not be reached from inside the gap where the second officer became trapped.
• MAIB concluded the onboard safety culture was weak — established safe systems of work existed but weren't being followed.
• The second officer's judgement and risk perception were very likely impaired by alcohol; the company's drug and alcohol policy was not being effectively enforced.

Recommended Actions

Direct from MAIB's findings:

1. Crane operators need a positive, confirmed method of knowing the area is clear before moving — not an assumption based on the last known position of anyone nearby.
2. A pre-movement warning (not just a moving-warning) gives anyone in the vicinity time to clear the area before, not during, a crane's movement.
3. Emergency stop provision needs to be reachable from every position a person could realistically become trapped in, not just from the walkways.
4. A drug and alcohol policy that exists on paper needs active enforcement — its value is entirely in whether it actually changes who's fit to be on deck that day.

Human Element Analysis

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Related Reading

• BSafe Case Study 9 – another MAIB investigation into a deck operation with people standing where a load could fall