Marine safety investigations & reports
Independent investigation into the stevedore fatality on board the Antigua and Barbuda registered container ship Vega Gotland at Port Botany, New South Wales on 28 March 2010
273-MO-2010-002
Summary
At about 1918 on 28 March 2010, a stevedore was crushed between two containers during loading operations on board the container ship Vega Gotland, while it was berthed at the Patrick Terminals' Port Botany terminal. The stevedore, who was the lashing team leader, died instantly from the injuries he received in the accident.
The ATSB investigation found that the lashing team leader had placed himself in a position of danger and that when a twistlock foundation unexpectedly failed during the repositioning of the container, he was unable to get clear of the swinging container.
The investigation also found that the failure of the twistlock foundation was brought about by an attempt to reposition the container and was consistent with its exposure to gross overstress conditions as a result of the leverage forces applied to it by the container and the unsecured hatch cover.
The investigation identified that while the dangers of working between a moving container and a fixed object were taught to Patrick Terminals' new employees during their induction training, the issue was not specifically covered or reinforced in the company's safe work instructions, the hazard identification and associated risk control processes nor, in some instances, followed in practice by stevedores on board the ships in the terminal.
The ATSB identified seven safety issues during the investigation. The safety issues related to: the absence of policies or procedures concerning safety zones near container operations; that Patrick Terminals' safety management system contained deficiencies; the discontinuity between what was taught to new employees and the contents of the safe work instructions and hence the practices on the work site; hazard identification and associated risk controls for lashing and unlashing; review and compliance auditing of safe work instructions and reporting risk-related events; and that the recognised safe practices of not working under or near a container being loaded were not well reflected in national and international guidance.
The ATSB acknowledges the safety action taken by Patrick Terminals and is satisfied that it adequately addresses the safety issues. The ATSB has issued one safety advisory notice concerning national and international guidance not reflecting the recognised safe practices of not working under or near a container being loaded onto a ship.
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Safety Issues
Safe work instructions
Patrick Terminals’ safe work instructions for lashing/unlashing did not specifically cover the recognised safe practices of not working under containers or between moving containers and fixed objects. Consequently, there was a discontinuity between the level of awareness regarding these dangers and the training new employees received during their induction period.
| Issue number: | MO-2010-002-SI-01 |
|---|---|
| Who it affects: | All stevedores |
| Status: | Adequately addressed |
Hazard assessment process
Patrick Terminals’ hazard identification process had not identified the dangers of working near or under containers being loaded.
| Issue number: | MO-2010-002-SI-02 |
|---|---|
| Who it affects: | All stevedores |
| Status: | Adequately addressed |
Risk assessment process
Patrick Terminals’ risk assessment process for lashing and unlashing operations had not anticipated a fatal accident resulting from being struck by items falling from a portainer or cargo, or from being struck by a moving container. As a result, while the appropriate risk control for this occurrence had been covered during employee training, this was not reinforced in safe work instructions, an important risk control measure.
| Issue number: | MO-2010-002-SI-03 |
|---|---|
| Who it affects: | All stevedores |
| Status: | Adequately addressed |
Safety zone guidance
Patrick Terminals had no formalised policy in place to provide clear guidance to its stevedoring employees about where they could or could not work on a ship when cargo was being loaded or discharged.
| Issue number: | MO-2010-002-SI-04 |
|---|---|
| Who it affects: | All stevedores |
| Status: | Adequately addressed |
Terminal safety management
The implementation of Patrick Terminal’s safety management system resulted in an environment where Patrick Terminal management and stevedores were disconnected in relation to the management of some of the day-to-day workplace safety risks. As a result, there was little ownership of the safe work instructions by the stevedores, and some of the more experienced stevedores were probably no longer aware of the risks posed to them when they undertook unsafe ‘workarounds’ in the workplace and these were not identified by Patrick management.
| Issue number: | MO-2010-002-SI-05 |
|---|---|
| Who it affects: | All stevedores |
| Status: | Adequately addressed |
Safety issues not covered in guides for operators
The recognised safe practices of not working under or near a container being loaded is not well reflected in national and international guidance published to assist container terminal operators develop their own safety policies and guidelines.
| Issue number: | MO-2010-002-SI-06 |
|---|---|
| Who it affects: | All stevedores |
| Status: | Adequately addressed |
Risk-event reporting
The culture which existed in the Patrick terminal did not encourage the reporting of non-compliances or unsafe acts. Consequently, two critical parts of an effective safety system, which had a direct impact upon its ability to effectively manage safety in the terminal, the ‘reporting’ culture and the ‘just’ culture, were either not present or were misunderstood in Patrick’s safety system.
| Issue number: | MO-2010-002-SI-07 |
|---|---|
| Who it affects: | All stevedores |
| Status: | Adequately addressed |
General details
| Date: | 28 March 2010 | Investigation status: | Completed | ||
| Time: | 1918 (UTC +11 hours) | Investigation level: | Systemic - click for an explanation of investigation levels | ||
| Location (show map): | Port Botany | ||||
| State: | New South Wales | ||||
| Release date: | 19 December 2011 | Occurrence category: | Accident | ||
| Report status: | Final | Highest injury level: | Fatal |
Vessel details
| Vessel | Vega Gotland | |
|---|---|---|
| Flag | Antigua and Barbuda | |
| IMO | 9336347 | |
| Type of operation | Container ship | |
| Damage to vessel | Nil | |
| Departure point | At berth |