accident with loss of life onboard of the mv - DPC

Transcription

BRAZILIAN MARITIME AUTHORITY
DIRECTORATE OF PORTS AND COASTS
ACCIDENT WITH LOSS OF LIFE ONBOARD
OF THE MV “ARLOTT”
VITÓRIA – ES, 06 AUGUST 2010
MARINE SAFETY INVESTIGATION REPORT
Reference: IMO Casualty Investigation Code - MSC-MEPC.3/Circ.2 13 June 2008/ Resolution MSC.255(84)
Brazilian Maritime Authority - Directorate of Ports and Coasts
Surveys, Naval Inspections and Technical Expertise Management
Maritime Accidents Investigation and Prevention Committee (CIPANAVE)
Accident with loss of life onboard MV “ARLOTT” - Marine Safety Investigation Report
I - INTRODUCTION
For the purpose of effecting the collection and analysis of evidence, the identification of the
causal factors and the elaboration of safety recommendations that should be necessary, in order
to prevent that in the future occur similar maritime accidents and/or incidents, the Fluvial
Captaincy of Espirito Santo Pantanal (CFES) carried out a Marine Safety Investigation, in
compliance with that laid down in the Casualty Investigation Code of the International Maritime
Organization (IMO), adopted by Resolution MSC. 255(84).
This Final Report is a technical document that reflects the result obtained by CPPE regarding
the circumstances that contributed or may have contributed to trigger the occurrence, and not
refers to any proving procedures for determination of civil or criminal liability.
Also, one should emphasize the importance of protecting the individuals responsible for
providing information regarding the accident, and the use of information contained in this report
for purposes other than the prevention of future similar accidents could lead to erroneous
interpretations and conclusions.
II – SYNOPSIS
The Merchant Vessel “ARLOTT” (Photo 1), IMO NO 9065895, BRAZILIAN flag (Photo
01), sailed from the port of São Francisco do Sul, Santa Catarina, with destination Praia Mole in
this City of Vitória, Espirito Santo, arriving at the anchorage area in the early hours of 06 August
2010. That night , moments before the anchoring, when the ship was in the position pof Latitude
20o 18’ 05” and Longitude 040o 13’ 07”W orders were given to commence the procedure of
anchoring; the Quartermaster of the ship, accompanied by one Deckhand, awaited these
instructions sitting on a bench on the Quarter-Deck where functions the gangway, to starboard.
Upon learning that such procedures would be commenced, they got up to garnish the bow. The
Quartermaster, right afterwards, fell from the ladder that gives access to the main deck, where he
hit his head on a hatchway and died.
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Photo 1 – MV “ARLOTT”
II.1 – THE VICTIM
The deceased, 68 years old, Brazilian, native of Santa Catarina, performed the duties of
Quartermaster and possessed the appropriate certification, for he was a Cabotage Boatswain
(STCW II/3).
He was boarded in MV Arlott in the period from 20 February 2010 to 09 March 2010 and,
according to the Crew List (Annex A), returned to embark again on August 2, 2010 or 4 days
before the accident. The victim had no health restrictions for the performance of their duties
under the Occupational Health Certificate issued on March 9, 2010 (Annex B).
That said, there is no reason to question the victim's state of health before the accident.
According to testimony provided the victim had a good relationship with the other crew
members.
The Report of Autopsies conducted on August 6, 2010 by the Department of Forensic
Medicine of the Civilian Police of the Espirito Santo in the city of Vitoria, showed no evidence
of alcohol or drug abuse by the victim. External examination showed frontal contusion injury
and internal examination detected head trauma and blunt instrument, with internal bleeding in the
brain.
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III – SITUATION OF THE SHIP ARLOTT ON THE OCCASION OF THE
INVESTIGATION
a) Deck of the Quarter-Deck (Gangway):
The space where the Quartermaster awaited the beginning of the task (Photo 2) is the same
where functions the gangway of the ship. The deck is painted with dark paint, there are no
apparent saliences and, in the direction of the bow is contiguous to to a ladder that gives access
to the deck below (main deck). At the gangway there is a board with instructions on the use of
personnel protective equipment (PPE) and in this connection it should be emphasized that the
victim was using adequate PPE (boots, dungarees and helmet). Close to the top part of the ladder
there is a narrow false edge of approximately five centimeters high whose purpose seems to be
the retention of liquids. Such structure also can offer danger (tripping) to who accesses the
ladder. This edge extends over all the deck of the quarterdeck, on both sides. As to the ladder,
only the steps at the top and bottom ends are painted yellow, and, although the painting was
worn by use (Photo 3), its structure was in good for use.
Photo 2 – False edge (Borda falsa)
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Photo 3 - Ladder of access to the main deck (view of lower part)
b) Main Deck
Presents an ellipse (Photo 4) close to the base of the ladder, whose closing is covered with
screws standing out over same.
Photo 4 – place of the fall.
IV - GENERAL INFORMATION
Name of the Ship : ARLOTT
IMO Number of the Ship: 9065895
Registration number of the ship 442-E00015-4
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Type of ship: General cargo (dry)
Place of Building: Bulgaria
Keel laid: 26/05/1993
Material of the Hull: steel.
Owner: CIA. DE NAVEGAÇÃO NORSUL S/A
Operator: CIA. DE NAVEGAÇÃO NORSUL S/a
Flag: BRAZIL
Port of Registry: SÃO FRANCISCO DO SUL
Call Sign PP8341
Gross Tonnage: 7662
Nett Tonnage: 3570
Length of the Ship 125.86 metres
Draft of the Ship 8.09 metres
Breadth of the Ship 20.01 metres
Classification Society: AMERICAN BUREAU OF SHIPPING (ABS)
Obligatory insurance for personal damages caused by craft or their cargoes issued by
BRADESCO bank with validity of one year upto 14/04/2011
Document of Compliance and Safety Management Certificate issued by DET NORSKE
VERITAS
Some more information pertinent to the ship:
The previous name of the ship was CARLOTTA (from December of 2004 to July of 2008),
then under the Panamanian flag. On 26 March of 2010 it was registered in the Brazilian Special
Registry (REB) with the name ARLOTT property of the COMPANHIA DE NAVEGAÇÃO
NORSUL (Annex C).
The ship does not present a record of excellency in the inspections to which was submitted.
Under the aegis of the Viña Del Mar Agreement – Port State Control (PSC), the majority of the
inspections recorded
deficiencies, save when inspected on 13/07/2006 in the port of
Veracruz/Mexico. Some of these inspections occurred in Brazil: two in 2008, in the months April
and December; another in December of 2009 and the last one in October of 2010. It should be
noted that also were made inspections for the issuing of the Certificate of Temporary Registry
(AIT) in May and December of 2009 and in February and March of 2010. In none of them was
there detention. With regard to the rest of the International Agreements of Port State Control
Inspection (MOU of Tokyo and MOU Paris) it is verified that the ship ARLOTT, in the perio of
1998 to 2008 was inspected 25 times and in eleven of them no deficiencies were registered. Also
the ship was not detained in this period.
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V – CREW
Up to the occurrence of the accident the crew of the MV “ARLOTT” met that foreseen in
the STCW Convention (Standards of Training and Certification Watchkeeping) and in the Safety
Manning Card (Annex D), both in quantity and qualifications demanded.
The crew of the ARLOTT is made up of 21 Brazilian crewmembers, and the Sage Manning
Crew is made up of 18 crewmembers. The working language on board is Portuguese.
VI - SEQUENCE OF EVENTS AND CAUSAL FACTORS
The elaboration of this investigation had its beginning seventeen days after the accident,
thus the conclusions, are based, principally, on statements of witnesses, on the Cadaverous
Examination Report and the Death Certificate of the victim.
At daybreak of 06 August of 2010 the ship proceeded to the port of Praia Mole to receive
steel coils. The meteorological conditions were good, with a calm sea. The planning on board
foresaw the anchoring and berthing, in accordance with the routine of the port.
On that beginning of daybreak, the victim and the Deckhand were seated on a bench on the
quarter-deck to starboard, where they awaited the orders to begin the task of anchoring. When
they received the orders from the bridge they stood up and started the walk to the bow. For this
they should make use of the ladder that joined the deck where they were with the deck below
(main deck). Upon using the ladder the Quartermaster lost his balance, fell to the main deck,
around two and a half meters below and hit his head one one of the screws of a hatchway
existing there. Right away other crew members came to render first aid and found that the victim
had a fracture at the top of his face (forehead) and was bleeding a lot. Then he died. The
Cadaverous Report registered death due to cranium-encephalitic trauma.
When examining the place of the fall (Photos 5, 6 and 7 attention is called to a false edge
around five centimeters high along all of the deck of the quarter-deck and is also present in the
intersection of access to the top of the ladder to the lower deck (main deck). This edge is an
obstacle, but it cannot be affirmed that the victim tripped over it. Also it should be mentioned
that the ladder has a strong inclination and its handrails are interrupted at the height of the
seventh step, counting down from the top.
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Photo 5 - Ladder of access from the quarter-deck to the main deck.
The ladder of access from the quarter-deck to the main deck is made of steel, with fourteen
steps and height around 2.50m. It is a steep ladder on which one has difficulty to support the feet.
Its handrails are interrupted at the height of the seventh step with prejudice to the support
of the user from that point onwards.
Photo 6 - Details of the interruption of the handrails.
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P
Photo 7 - False edge of about five centre metres at the top of the ladder
There is no evidence that the illumination of the place was deficient and it should be
emphasized that the victim was using a flashlight which at the moment of the fall was switched
off. However the flashlight of the Deckhand who accompanied him, was switched on. A
simulation of the fall was made on the occasion of the investigation on board, whose pictures 8
and 9 to follow show the result of this work.
The photos show the position in which the victim stayed after the fall. He hit his head on
the cover of a hatchway and, although he was wearing a helmet, he received a strong impact
followed by his death.
Photos 8 and 9 - Simulation made on board.
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Checking the Training Schedule applicable to the vessel, contained in the Safety
Management Manual, was evidenced by the accident investigators that are performed audits,
monthly meetings of the Occupational Safety and Health Group on board, as well as were
applied training on perception risks, prevention of accidents, use of Personal Protective
Equipment (PPE), steering cables and enclosed spaces. However, the investigators found no
evidence about the presence of the victim in such training, since his signature was not on the
attendance sheet.
The information provided by witnesses were not relevant to clarify the cause of the
accident beyond any doubt, since the Deckhand, the only eyewitness to the accident, merely said
he heard a loud noise and then saw the Quartermaste, who was in front, lying on the main deck.
VII– CONSEQUENCES OF THE ACCIDENT
Personal injury: Ladder falling followed by death by head trauma and blunt instrument, of
Mr. VOLNEI RAMOS, according to the Death Certificate issued by the Registry "Dessaune
Cid" - Civil Registry and Notary Notes on August 8, 2010.
Material damages and pollution: There were no damages to the ship as well as there was no
register of pollution related to the accident.
VIII – PRELIMINARY LESSONS LEARNT AND CONCLUSIONS
Investigations into the circumstances of casualties that have occurred have shown that
accidents on board ships are in most cases caused by an insufficient knowledge of, or disregard
for, the need to take precautions. The movement of people on board the ships some times
becomes risky by virtue of the dangers of falling, of slipping and tripping, caused by various
reasons, here standing out obstacles, such as eye bolts standing out on bulkheads and decks,
steep inclinations of ladders or even by the impropriety of the construction of handrails. These
risks are increased at night when the conditions of visibility of the environment are unfavorable.
In the scenario of the accident it became clear that there is not a light specifically for the
steps of the ladder and in the same way the false edge that exists there does not have a clear
signalization.
It becomes therefore, a lesson learnt the necessity to provide adequate illumination to
ladders of that type and in such a particular area, that is, situated between two narrow bulkheads
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and with interrupted handrails. It also becomes relevant as learnt, that protuberances be clearly
signalized to alert all the users of the danger that they represent.
From the facts, it was observed that the company has a Safety Management System
implemented on board the MV “ARLOTT”, and that the training set is applied. However there
was no evidence of the victim's participation in such training, as verified from the lists of
participants. The short time boarding of the victim prior to the accident was considered
insufficient by the investigators to familiarize him properly with the vessel.
As conclusion, based on what was found, the investigators found that the Quartermaster´s
death was caused by an accidental fall, whose cause can not be clarified accurately, that is, if it
was due to a slip, stumbling or even due to the lost of the support of the handrail. The fact is that
security measures need to be adopted to avoid a recurrence of this fact, such as:
– clearly signal the bump on the deck (false edge) giving access to stairs that lead to the
main deck;
–
improve the lighting at the accident site, because was evidenced lighting failure in that
path; and
–
implement training in the Prevention of Accidents, specially the Trailing Hand Technique
useful to help to climb and descend stairs on board. This technique can also provide the crew
with a feeling of security while walking, by allowing them to remain in contact with walls,
countertops, desks, tables, or other types of stationary surfaces. It's important to remember that
this technique will not warn about approaching drop-offs, such as steps and stairs, being
recommended the use of the trailing technique in combination with either the upper or lower
body protective technique, depending upon the needs. More information can be seen at
http://www.visionaware.org/trailing_technique.
IX – RECOMMENDATIONS
First of all, safety recommendations shall in no case create a presumption of blame or
liability. The accident investigated pointed to the need for an improvement in the objectives of
the Security Management Company in accordance with the International Management Code for
the Safe Operation of Ships and for Pollution Prevention (ISM Code), since there was loss of
human life by accident on board that could have been prevented, showing that the instructions
and procedures for ensuring Safe Operation of Ships related to the ISM CODE did not achieve
the expected goal.
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The Company Safety Management shall provide and evaluate all identified risks, providing
the signaling of potential danger spots on board the ship. This System must also undergo internal
audits and management reviews. Risk situations should be identified, assessed and recorded by
the Occupational Safety and Health Group on board, and the corrections considered necessary
should be implemented.
ANNEXES:
Annex A - Crew List (MV “ARLOTT”)
Annex B - Occupational Health Certificate (Mr. Volnei Ramos)
Annex C - Brazilian Special Registry (REB)
Annex D – Safe Manning Document
Annex E - Continuous Synopsis Record (CSR)
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Annex A
Crew List (MV “ARLOTT”)
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Annex B
Occupational Health Certificate (Mr. Volnei Ramos)
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Annex C
Brazilian Special Registry (REB)
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Annex D
Safe Manning Document
16
17
Annex E
Continuous Synopsis Record (CSR)
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accident with loss of life onboard of the mv - DPC

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