BSafe Case Study — A Signal System That Only Worked If Nothing Went Wrong

A Corner With Nowhere Safe to Stand

The forward corner stowage spaces on the upper vehicle deck were enclosed on three sides by bulkheads and structure — genuinely difficult positions for a banksman to stand clear of a moving trailer while still keeping visual contact with the driver. The crew had painted a wider yellow strip along one lane to protect access to a nearby door and discourage trailers parking too close to the bulkhead — but it wasn't physically segregated, with no barrier, kerb, or refuge protecting it.

This wasn't a new problem. Near misses involving unsafe positioning of personnel had already been formally reported to the operator, resulting in a fleet-wide Safety Flash with preventative measures identified by the Designated Person Ashore. Follow-up and close-out of those measures had not been completed.

A Practice That Had Become Routine, Never Formally Assessed

The bosun was acting as banksman, directing a tractor unit pushing a semi-trailer into stowage space 21. The driver had visual contact initially, then lost it as his own view was blocked by the trailer while aligning it within the lane markings. He didn't stop when contact was lost — reflecting a local practice that had developed specifically for these partially enclosed spaces: the banksman would move out of sight behind an adjacent trailer, then whistle when the trailer reached its final position. This workaround had become routine. It was never formally documented, and never covered by a task-specific risk assessment.

The trailer came to rest slightly angled, encroaching onto the painted (unsegregated) walkway strip. A deck rating noticed the trailer's position, then saw the bosun trapped between its rear and a protruding structural beam. The crew moved the trailer to free him and began CPR immediately; he did not survive.

What MAIB's Investigation Found

• Near misses involving unsafe banksman positioning had been formally reported before, generating a fleet-wide Safety Flash with identified preventative measures — but the follow-up and close-out of those measures was never completed.
• The workaround of moving out of sight and using a whistle signal had become routine local practice, without ever being formally documented or subjected to a task-specific risk assessment.
• The painted refuge strip existed as an informal safety measure but had no physical segregation — no barrier, kerb, or protected refuge — leaving it exposed to exactly the kind of encroachment that trapped the bosun.
• Ship and shore procedures shared broadly similar safety principles, but their practical alignment was incomplete — the actual working practice on the deck had diverged from both sets of formal procedure.

Recommended Actions

Direct from MAIB's findings:

1. A near-miss report that generates a fleet-wide Safety Flash needs genuine follow-through to close-out — identifying preventative measures without confirming they're implemented leaves the original risk exactly where it was.
2. A workaround developed informally to solve a real, hard problem (no safe sightline in an enclosed stowage space) needs to be formally assessed and documented once it becomes routine practice — not left as an unofficial local habit indefinitely.
3. Any painted or marked refuge area needs genuine physical segregation — a barrier, kerb, or protected space — to actually function as a refuge, not just as a visual guide that a trailer can still encroach onto.
4. Ship and shore procedures covering the same operation need active alignment, checked in practice, not just broadly compatible principles on paper.

Human Element Analysis

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Related Reading

• BSafe Case Study 9 – another incident where a recurring, known hazard was never formally reported until it was too late