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BSafe Case Study 11 — A Two-Person Job, Done By One

🕑 5 min read words Safety • Incident

Vessel: Boston Trader, 9,528 GT multipurpose dry cargo ship
Date & location: Port of Oran, Algeria, alongside
Outcome: Serious injury — a falling lashing bar cut through safety footwear, resulting in a toe amputation
Human factors: Understaffed Task by Design · Equipment Behaviour Not Understood · Assumed Familiarisation
Source: Britannia P&I Club, BSafe Incident Case Study No. 11, drawn from Transport Malta Investigation Report 04/2020

1 real case studyTransport Malta Report 04/2020~4 min read

A Routine Securing Job

Containers loaded on the third tier, outboard end, needed a long lashing bar — 5.07 metres, over 20kg — hooked into a corner fitting and connected diagonally to a turnbuckle. The AB stepped onto the hatch cover, hooked the bar into the container's corner fitting, then stepped down to the cross-deck to lift the turnbuckle with his free hand — holding the hooked bar with the other.

Designed to Hook In. Also Designed to Slip Out.

The corner fitting's socket is oval, and the lashing bar is designed to slip easily into it, then lock in place once rotated diagonally across and connected to the turnbuckle. Left hanging vertically, not yet rotated into its locked position, it can slip back out just as easily as it went in. That's what happened — the bar slipped from the socket and fell straight down onto the AB's right foot, cutting through his safety footwear. He was carried to the accommodation, and later transferred ashore for surgery; one toe was amputated.

What Transport Malta's Investigation Found

Risk control measures required by the vessel's own securing risk assessment were not all actually in place at the time.
The AB's PPE was correct and correctly sized, but its protective effectiveness may have been compromised — either worn imperfectly, or his foot slipped at the critical moment.
The crew believed this task could be done by one person. Given the lashing bar's design and the securing arrangement, the investigation found at least two people were actually required — one to hold the hooked bar, one to connect the turnbuckle lying flat on the hatch cover.
A lashing bar left suspended vertically, especially if not hooked correctly, is prone to slipping from an oval corner-fitting socket by design — a known equipment behaviour, not a fluke.
No record existed of any crew member being formally familiarised with this ship's container securing procedures — though the injured seafarer had been aboard three months and the port was called regularly.

Recommended Actions

Direct from the investigation's findings:

Tasks should be staffed according to what the equipment and method actually require, not according to what the crew assumes is sufficient — this specific lashing bar design needed two people, regardless of established habit.
Equipment failure modes worth knowing (a lashing bar slipping from an oval socket when left hanging) should be part of the securing procedure's own risk assessment, not left to individual judgement in the moment.
Formal familiarisation with ship-specific securing arrangements should be documented for every crew member who performs the task, independent of how routine the port call has become.
Risk control measures identified in a securing risk assessment need active verification that they're actually in place during the operation, not just recorded as a plan.

Human Element Analysis

A task understaffed by habit, not by design

The crew's belief that one person could do this job wasn't reckless — it was how the task had always been done. The equipment's own design said otherwise, and nobody had checked that assumption against it.

Equipment behaviour not fully understood

A lashing bar that locks securely once rotated into position is a different object, functionally, from the same bar left hanging mid-process. Treating both states as equally safe to leave unattended is where this incident actually happened.

Assumed familiarisation

Three months aboard and a regularly-called port created a reasonable-looking assumption of competence. No record existed to confirm it — familiarity and formal familiarisation aren't the same thing.

Test Your Knowledge

Think you've got this covered? Put it to the test in Crew Connect's free Knowledge Checker — try a quick cargo securing round and see how you score.