IC 407 Accident prevention &

Analysis
Assignment 3 -- Critical Incident
Topic: Injuries to crewmembers on board
Shanghai Spirit, 29 Jan 2017

HA Ka Yan, Nicola (18023401D)

LIU Shing Nam, Terry (18029866D)
LEE Yuan Lem, Macy (18023599D)
TANG Hung Leong, Henry (18029187D)
 Content
1. Introduction
5. Impacts on the Community
a. Purpose of the safety
investigation 6. Recommendations
2. Description of the Incident a. Substitution
a. Chronological Order b. Engineering Controls
b. Outcome c. Administrative Controls
3. Investigation and Analysis of d. Personal Controls
the Incident 7. Reflection or Comments on the
4. Causes of the Incident Report
a. Direct Causes
8. Conclusion
b. Underlying Causes
9. References
1.Introduction
Purpose of the safety investigation

● To discover the cause of incidents

● To prevent the similar types of accident recurring
● To fulfill any legal requirements
● To determine the cost of an incident
● To determine compliance with applicable regulations
● To process workers’ compensation claims
2. Description of the Incident
Date:
29 January 2017, 2:10 p.m. (Eastern Standard Time)

Place:
in the cargo holds, board Shanghai Spirit

Person(s) involved:
Two deck crewmembers:
Boatswain (bosun) and able seaman 3 (AB3)

Conditions at the scene:

Two crewmembers fall from height and caused grievous
injuries on the scaffold tower
2. Description of the Incident
a. Chronological Description of the Incident

Source: ATSB
2. Description of the Incident
a. Chronological Order of the Incident -- Morning

1. [8:30 a.m.] The chief mate, the bosun, two able seamen (AB2 & AB3), the ordinary
seaman (OS), and the deck cadet (cadet):
→ Started their work painting and touch-up work in cargo hold number one

2. They gathered equipment like ship’s scaffold tower, spray painting apparatus,
harnesses and safety and securing lines on the tank top in the hold.

3. To ensure the passages and access to the 9 m high tank top, workers joined 5 parts of
the scaffolding together.

4. The bosun & AB3 were painting from the scaffold tower while the supervisor (Chief
mate) were overseeing the work from tank top.

5. [11:30 a.m.]After finishing one section of the painting work, the bosun and AB3’s safety
lines were released and they climbed down for repositioning to the next area.
2. Description of the Incident
a. Chronological Description of the Incident -- Moved to Hold number
four after lunch

Source: ATSB
2. Description of the Incident
a. Chronological Order of the Incident -- Afternoon

7. In the afternoon, the crewmembers were process to handle the touched up of the aft
bulkhead and hopper tank edge on the fifth section of the scaffold tower.

8. After the bosun and AB3 were ready (i.e. clear up the tools from the edge), the cadet and
OS then freed the tower securing lines and got down from the scaffold tower for moving it.
2. Description of the Incident
a. Chronological Description of the Incident

7. In the afternoon, the crewmembers were process to handle the touched up

of the aft bulkhead and hopper tank edge on the fifth section of the scaffold
tower.

8. For the purpose to contact with the topside tank surface, they needed to
make the scaffold tower near to the hopper tank edge.

9. After the bosun and AB3 were ready (eg: clear up the tools from the edge),
the cadet and OS then freed the tower securing lines and got down from the
scaffold tower for moving it.

10. At 14:10, when the scaffold tower was moved 0.5m, it fell down and
collapsed toward to the deck.
2. Description of the Incident
a. Chronological Description of the Incident

11. With the bosun and AB3, they were involved in the incident when the
scaffold tower came apart.

12. The master made an announcement, called other crewmembers for help
and came immediately after he realized an incident occurred.

13. The bosun and AB3 layed down on the tank top deck, first aid and helped
were made directly. At 15:04, emergency services informed the rescue
helicopter to conveyed them.

14. At 17:00, the bosun was sent to the hospital by the helicopter first; at
18:30, then AB3 was sent to hospital.
2. Description of the Incident
b. Outcomes

a. Type of accident b. Injuries, ill health c. Creation of hazards

damage to property
● fall from height ●The unequal and
●The bosun: pelvis, chest toppled forward of the
and arm injured; lived in scaffold tower onto
the hospital for 19 days the deck due to it was
moved with the
●The AB3: continuous
insecure
fractured sternum and
crewmembers
back injured; lived in the
hospital for 8 days
3. Investigation and Analysis of the Incident
Investigation Analysis

Evaluation of shipboard procedures - Safety management system

- Risk assessment
- Working aloft procedures
- Operating manual

On board inspection of scaffolding - Manufacturer’s identification plate

equipment - Defects of the scaffolding equipment

Contrast of similar occurrences on board - Crew member injury and fatality on

board in Pacific Wisdom, 2003
ships at anchor in 2003 and 2009 - Serious injury on board United
Treasure off Port Kembla, New South
Wales, 2009
3. Investigation and Analysis of the Incident
Evaluation of shipboard procedures
The following tasks were completed by crewmembers
● Safety Management System
● Risk assessment
● Working aloft procedures
Crewmembers completing above tasks did not follow, nor complete required procedures, forms, or any
documents.

Operating manual was provided by the ship’s manager

● Correct assembly steps for constructing a (similar) scaffolding tower
● PPE
○ Safety belt
○ Non-slip shoes
○ Safety helmet
● Requirement for all personnel about the relocation of scaffold
3. Investigation and Analysis of the Incident
Contrast of similar occurrences on board ships at anchor
Crew member injury and fatality on board in Pacific Wisdom, 5 September 2003
● Narrow base of the scaffolding - inherently unstable
● Insecure guy ropes
4. Causes of the Incident
a. Events & Causal Factors Analysis (ECFA)
Lack of
supervision
Inadequate i. Poor scaffolding
training condition

Lack
2 crewmembers
guidelines for
ii. Inappropriate toppled & fell
use & care of
working procedures from the
scaffold
scaffold tower
Poor
system of
work iii. Inadequate use of
PPE
Hot Desire to
weather expedite
condition completion
 a. Direct Causes &

4. Causes of the Incident

b. Underlying Causes

Direct Causes Underlying Causes

i. Poor scaffolding condition Lack of supervision

- Top-heavy and unstable Inadequate training
- Defeats of scaffold tower Lack guidelines for use & care of scaffold

ii. Inappropriate working procedures Lack of supervision

- Fore-aft direction Poor System of work
Desire to expedite completion

iii. Inadequate use of personal Lack of supervision

protective equipment (PPE) Inadequate training
Desire to expedite completion
 4. Causes of the Incident
a. Direct Causes
i. Poor scaffolding condition

- Top-heavy and unstable:

2 crewmembers were on the scaffold tower while repositioning

- Defeats of scaffold tower:

7 defects were found during on board inspection (before the
incident)

1. Ladder frame stub piece

connections without securing pins
2. Loose and bent cross bracing
3. Cross brace locking pins loose
allowing travel up to with 40mm
4. Swivel wheels stub piece connections
without securing pins
5. Corroded platform hooks
6. Inoperative swivel wheel brakes on three
of the four wheels

7. Deficient frame ladder welds.

4. Causes of the Incident
IF repositioned in the direction of the
a. Direct Causes scaffold’s longest base dimension

ii. Inappropriate working procedures Sufficient stability will be provided against

overbalance & toppling
- Fore-aft direction:

Moving along the narrowest base dimension

(Repositioning towards the hopper tank edge)

→ lack of stability

- Reposition while crewmembers are

still on the scaffold tower
4. Causes of the Incident
a. Direct Causes

iii. Inadequate use of PPE

- Safety lines were not attached

BEFORE crewmembers climbed/ descended the structure

- Crewmembers did NOT utilize the available safety

harness/lines
4. Causes of the Incident
b. Underlying Causes

The afternoon work Crewmembers

was not supervised lack the
by officer conscious in
(as required by using of PPE
company procedure)

Shanghai Spirit’s
scaffolding equipment The
was not supported by Hot weather crewmembers
suitable documents & did not follow
Difficult the proper
(No guidance for correct working procedures of
methods & level of conditions scaffolding work
maintenance)
5. Impacts on the Community
The environment ：
•Build a safe working environment after the accident (+)
The people:
•Cause irreparable damage to the victims and family (-)
•Raising the safety awareness among the society after the accident (+)
•Low staff morale (-)
The economy:
•Commercial loss of employer and casualty (-)
•Damage to company’s image (-)
•Low productivity of society (-)
5. Impacts on the Community
Culture:
•Identifying the importance of adhering to procedures after the accident(+)
Health:
•Psychological effects of the accidents for the employees (Two crewmembers got
injuries) (-)
•Psychological trauma to the casualty(-)
Quality of Life:
•To affect their social intercourse (-)
6. Recommendations
● Using scaffold tower for painting is a part of "working at height".
● Recommendations are giving to avoid similar incident happened again.
● Some control measures will be took in based on the hierarchy of control:
substitution, engineering controls, administrative controls and personal
controls.
6. Recommendations
a. Substitution
6. Recommendations
b. Engineering Controls
● Repair, modification, maintenance scaffold tower and equipment by registered
person regularly
● Redesign the working environment and the to ensure it is suitable for
workers to work safely
6. Recommendations
c. Administrative Controls

● Crewmembers should have the permit to work at height or work on

scaffolding before the start their work
● Risk assessment should be involved before work started
● Pre-start meeting should be involved everyday before work
● Training should be provided regularly for every crewmembers
● New crewmembers should be well trained, included know the safety use
of scaffolding
6. Recommendations
c. Administrative Controls

● Provide enough equipment and personal protective equipment to help

crewmembers work safely
● First aid drill should be conducted every 6 months
● Provide first-aid box(es) and show the emergency contacts on it
● Ensure supervisors and crewmembers know the emergency procedures
properly
● Maintain good housekeeping
6. Recommendations
d. Personal Controls
● Wearing enough and proper personal protective equipment
● Stop working under hot, cold, or extreme weather, like typhoon
● Stop working when crewmembers feel unwell
● Wear safety harnesses and safety lines and ensure they hooked in a fixed
position when crewmembers need to work at height