Transcript
Report of Investigation into the Crew Fatality Caused by a Deck Lifter Onboard M.V. Dyvi Adriatic on 30 June 2005
Purpose of Investigation This incident is investigated, and published in accordance with the IMO Code for the Investigation of Marine Casualties and Incidents promulgated under IMO Assembly Resolution A.849(20). The purpose of this investigation conducted by the Marine Accident Investigation and Shipping Security Policy Branch (MAISSPB) of Marine Department is to determine the circumstances and the causes of the incident with the aim of improving the safety of life at sea and avoiding similar incident in future. The conclusions drawn in this report aim to identify the different factors contributing to the incident. They are not intended to apportion blame or liability towards any particular organization or individual except so far as necessary to achieve the said purpose. The MAISSPB has no involvement in any prosecution or disciplinary action that may be taken by the Marine Department resulting from this incident.
1.
Summary
1.1
At about 0600 (local time) on 30 June 2005, when the vessel was standing by at the position 350 05.4’N 1290 38.9’E about 25 miles off Ulsan, Korea await for berthing instruction, the crew members of Dyvi Adriatic carried out car deck “lifting” operation with 2 deck lifters, No. 1 and No. 2 on Deck No. 5 and Deck No. 7 respectively.
1.2
During the “lifting” operation on Deck No. 5 at about 0920, a crew member was accidentally crashed by the No. 1 deck lifter.
1.3
The injured crew member was admitted to hospital and was certified dead by the attending doctor.
2.
Descriptions of the Vessel and the Mobile Deck Lifter
2.1
Dyvi Adriatic (Figure 1) Port of Registry IMO No. Type Year Built Gross Tonnage Net Tonnage Length Overall Breadth Summer Draft Service Speed
: : : : : : : : : :
Hong Kong
8519710
Vehicle Carrier
1988
39,187
11,756
182.50 m
29.6 m
9.015 m
17.0 knots
Figure 1 Dyvi Adriatic
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2.2
The Mobile Deck Lifter (Figure 2)
2.2.1 Particulars Capacity Lifting Mechanism Platform Size Platform Travel Chassis Drive Braking
: : : : : : :
Steering
:
Engine
:
Speed Lifting Speed
: :
20 Tonne Single Scissor Mechanism 5,250 mm x 2,800 mm 2,800 mm Steel RHS sections with front steering axle Hydrostatic Hydraulic drum brakes on all four wheels and parking brake on rear wheels Ackerman geometry via hydraulic steering cylinders and steering pump 4 cylinder direct injection turbo charged diesel engine Approx. 15 km per hour on horizontal Approx. 5 meters/minute with full load
2.2.2 The controls for the deck lifter 1. Push buttons There were 3 push buttons located on the left hand side of Dash Facia for transmission neutral, forward and reverse respectively. 2. Foot pedal for speed adjustment The lifter speed can be regulated by foot operated accelerator when the driver is on the driver seat. 3. Hand operated accelerator for rpm adjustment When the deck lifter is in the location for lifting a deck panel, the hand operated accelerator is to be used to regulate the diesel engine rpm for raising up the deck lifter on the four stabilizers. 4. Hand operated brake The hand operated brake is located on the right hand side of the driver’s seat. The brake handle is connected to the rear tire’s brake drum with a wire.
� Figure 2 The Deck Lifter
3.
Sources of Evidence
3.1
Statements from the Masters and crew members of Dyvi Adriatic; and
3.2 Fatal accident report from Dyvi As Company
4.
Outline of Events
4.1
At 1904 on 29 June 2005, Dyvi Adriatic sailed from Kwangyang to Ulsan, South Korea.
4.2
At about 0400 on 30 June 2005, the vessel arrived at Port of Ulsan. The arrival time was earlier than the scheduled berthing time, it therefore stopped the engine and was on standby at the position 350 05.4’N 1290 38.9’E, about 25 miles off Ulsan.
4.3 The weather conditions were calm with dense fog. 4.4
At about 0600, the Chief Officer instructed the Bosun and 4 deck ratings to carry out “lifting” operation (adjusting the height of the car Deck No. 5 and No. 7 by lifting the car platforms up) as per charterer’s instruction.
4.5
As the progress of the “lifting” operation was slow, the Chief Officer decided to divide the ratings into 2 teams working simultaneously to complete the “lifting” operation before berthing.
4.6
The Chief Officer instructed the Deck Cadet to drive the No. 1 deck lifter on Deck No. 5 because the Deck Cadet had a driving licence.
4.7
At about 0930, to adjust the position of the deck lifter, the Deck Cadet drove it forward and stopped it in front of a bulkhead under the panel No. 6p4. He was ready to move it backward to the lifting position.
4.8
Just then, the Deck Cadet left his driver seat and walked towards the back of the deck lifter attempting to raise up the deck lifter on the four stabilizers to reduce the weight on the steering wheel. He stated that he had a problem to operate the steering wheel and he had informed the Chief Officer about it. He had applied the hand brake before he left the
driver seat whereas the Chief Officer stated that he did not know why the Deck Cadet left the driver seat. 4.9
The deck lifter suddenly moved forward and crashed the sailor who stood in between the forward bumper of the deck lifter and the bulkhead (Figure 3). The sailor was badly injured. First aid was immediately given to the sailor.
4.10 The injured sailor was not part of the deck lifter team at Deck No. 5 and had not function in relation to the operation. 4.11 The vessel immediately proceeded to pilot station of Ulsan at full speed and anchored in position 350 24.47’N 1290 26.60’E at about 0956. A rescue boat arrived and took the sailor ashore to hospital for treatment.
Deck No. 5 Hold 1
Bulkhead
The deceased
Deck Cadet
Deck No. 5 Bumper Hold 2
Ventilation
Deck
A.B. C/O
Inner Ramp Deck No. 5 to Deck No. 4
Deck Lifter
Pillar
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Figure 3 The deceased was crashed by the Deck Lifter
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5.
Analysis of Evidences
5.1
The Deck Cadet joined the vessel on 24 January 2005. As he had been working for 6 months on board Dyvi Adriatic. Driving a deck lifter was totally different from driving an ordinary car on the road; the former requires a safety consciousness whereas the latter requires more technical skills. Furthermore, it is stated in the instruction manual that only trained and competent personnel should operate and maintain the deck lifter; therefore it was considered that the Deck Cadet might not be the most suitable person to operate the deck lifter despite he had a driver licence.
5.2
The weather conditions at the time of the accident was calm with dense fog. According to the Master, the vessel neither rolled nor pitched while standing by at sea.
5.3
The two deck lifters are not class items. They are important cargo equipments which are periodically checked by the crew members who are responsible for maintenance of deck lifters. They are tested every week. Before the accident, they were last tested on 21 June 2005.
5.4
Both deck lifters had been serviced 6 to 8 months ago. The push buttons had been replaced with one combined lever-switch controlling the forward-neutral-backing movements (Figure 4). It is not known when the modification has been carried out. The lever-switch handle was rather long that could easily be dislocated by coincidence. Combined lever-switch
Figure 4 The push buttons had been replaced with one combined lever-switch
5.5
It was the first time the crew members used the No. 1 deck lifter to lift the deck since it was returned from the service.
5.6
The deck lifter should be positioned on appropriate location mark on deck under car platform to be raised or lowered (Figure 5). When the deck lifter was in such location for lifting a deck platform, the diesel engine rpm was regulated by the hand operated accelerator which was connected to the foot operated accelerator with a wire. The wire was found broken so that the hand operated accelerator could not be used. Instead, a steel plate was used to press down the foot operated accelerator for the diesel engine rpm adjustment.
� Figure 5 Yellow marks on deck under car platform to be raised or lowered
5.6 The statements given by the Chief Officer and the Deck Cadet conflicted with each other. Nevertheless, the Chief Officer is responsible for raising the deck lifter on the stabilizer. It was inappropriate for the Deck Cadet to make decision to raise the deck lifter on the stabilizer. 5.7
The hydraulic operated handles are located on the side of the Deck Lifer. When the Deck Cadet press the steel plate down to the foot operated accelerator for the diesel engine rpm adjustment, he should keep an eye on the accelerator instead of going to the side of the deck lifter to operate the handles. He should inform the Chief Officer who would make
decision to assign another person to operate it. 5.8
The hand brake was tested by the Korean police and was found in good order. It was suspected that as the Deck Cadet got off from the deck lifter, his body touched the Combined lever-switch. It triggered the No. 1 deck lifter to move forward since the hand brake is not designed to hold the deck lifter in position with the gear engaged and engine running at full rpm.
5.9
It is stated in the operating instructions that the driver should ensure area of deck lifter movement is clear of obstructions and personnel. At the time of the accident, the Deck Cadet had no intention to move the deck lifter.
5.10 It was stated that the distance between the No. 1 deck lifter and the bulkhead was about 30 to 40 cm, the deceased should not stand in such dangerous position.
6.
Conclusions
6.1
At about 0920 on 30 June 2005, during the “lifting” operation on Deck No. 5 on board Dyvi Adriatic, a crew member was accidentally crashed by the No. 1 deck lifter. The crew member was not part of the deck lifter team at Deck No. 5, and had no function in relation to the operation.
6.2
The injured crew member was admitted to hospital and was certified dead by the attending doctor.
6.3
The probable caused of the accident was the Deck Cadet dislocated the long handled combined lever-switch by coincident resulted the No. 1 deck lifter moving forward. The moving deck lifter crashed the deceased who stood in between the bulkhead and the front bumper of the No. 1 deck lifter.
7.
Recommendations
7.1
A copy of this report should be sent to the management company and the Master of Dyvi Adriatic drawing their attention on the findings of this incident. It is stressed that the driver of the deck lifter should be properly trained and should keep an eye on the accelerator until the deck lifter was fully lifted on the stabilizers.
7.2
It is recommended that the management company of Dyvi Adriatic should ensure that all concerned personnel working on board the vessel fully understand the safety instructions and devices for the safe operation of the deck lifter before it is being operated.
7.3
The deck lifter should be properly maintained; all defects if found should immediately be repaired and reported to the company. Furthermore, the deck lifter should not be modified without the approval of the company/maker.
