BSafe Case Study 9 — A Sling That Would Have Failed a Visual Check

Gear Stored Where It Would Snag

The ship had no designated storage space for its hatch cover lifting gear — two sets of heavy wire rope slinging legs, each weighing 0.6 tonnes, had been stowed on pallets in a ventilation duct space since the ship was delivered. That space was known to snag the gear on retrieval. It had happened before, more than once; each time, the crew had freed it by hand after the crane stopped, and moved on. No near-miss report was ever filed.

The Snag That Didn't Get Freed in Time

Weather had delayed the day's cargo prep; work resumed that evening once conditions improved. Two ABs entered the duct space, rigged the first set of lifting gear to the crane hook with a fibre sling, climbed out, and stood close to the hatch edge — inside the load's fall zone — ready to guide it clear of snags as it lifted, exactly as they always had. The load snagged around 2-3 metres up; the crew freed it by hand as usual and the lift resumed. A shackle then caught on a ventilation trunk coaming. The chief officer ordered an immediate stop — but at that same moment, the fibre sling parted and the gear fell, striking both ABs.

Post-incident testing of the parted sling and five similar ones from the ship found all six would have failed a basic visual inspection — soiled, with illegible identification markings.

What MAIB's Investigation Found

• The SMS contained no risk assessment or procedure for stowing or handling this lifting gear, and no guidance on conducting a lifting plan or identifying fall zones.
• With no procedure to follow, the crew had developed their own informal method — including standing in the fall zone to manually clear snags, something that had ‘worked’ every previous time.
• The recurring snagging problem was never escalated as a near miss, so it never triggered a review of the storage arrangement or the method being used.
• The ship's design had no dedicated lifting-gear storage; the improvised arrangement the crew built had real snag hazards nobody had formally assessed.
• The sling that failed carried a safe working load more than twice the weight of the load — but its poor physical condition meant it should have been discarded before ever being used.

Recommended Actions

Direct from MAIB's findings:

1. No one should stand within a suspended load's fall zone to manually clear a snag — the correct response to snagging is to lower or stop, not to work around it with people underneath.
2. A recurring near-miss-shaped event (the same snag, repeatedly) needs to be reported and reviewed as one, not absorbed into ‘how the job's always been done here.’
3. Lifting gear needs a real risk-assessed storage and handling procedure, especially aboard a ship with no purpose-built storage for it.
4. Lifting equipment condition should be checked against a real pass/fail visual standard before each use, not judged adequate because its rated SWL is comfortably above the working load.

Human Element Analysis

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Related Reading

• BSafe Case Study 7 – another MAIB deck-operations investigation, a different mechanism, the same gap in situational control