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Summary

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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