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What happened

On 7 October 2013, a crew member on board the general cargo ship Toucan Arrow was crushed between the ship’s aft gantry crane and a cargo hold hatch lid while the crane was being prepared for cargo loading operations in Portland, Victoria.

First aid treatment was provided to the injured crew member on-site and he was transported by ambulance to the local hospital where he died as a result of his injuries.

What the ATSB found

The ATSB found that the crew member did not comply with the ship’s safe working procedures and did not ensure that the crane driver was advised and that the gantry crane’s electrical power supply was isolated before he began working in the vicinity of the crane. The investigation also found that the audible and visual crane in motion warning devices were not fully operational and effective.

The ATSB further found that there was a lack of mapping information available to assist the emergency services ‘triple zero’ operator in providing the emergency responders with directions to a defined location within the port area. It was also found that the ambulance service had not ensured that its officers were familiar with the port area and the protocols for opening the locked port access gates.

What's been done as a result

Toucan Arrow’s managers have updated the checklist titled ‘Induction for new joiners’ to ensure that all new crew members are informed of the precautions required when working on deck while the gantry cranes are in operation. Limit switches which detect the presence of a person on the cargo hatch ladder and stop the crane’s travel have also been fitted to the gantry cranes.

The Port of Portland has changed its procedures and informed its tenants that all emergency services are to be met at the port gates and escorted to the scene of an emergency. The updated emergency response plan has been distributed to all port users including shipping agents and the ambulance service.

Marker signs are also being placed around the port. The location of each sign, along with its GPS co-ordinates has been provided to the Emergency Services Telecommunications Authority, the operator of the ‘triple zero’ phone service, to better direct emergency services to the scene or meeting point for further directions.

Ambulance Victoria has requested the Emergency Services Telecommunications Authority to change its procedures so that when an ambulance is tasked to the Port of Portland, a telephone call advising the port’s emergency response controller is made.

Safety message

This accident highlights the importance of adhering to the requirements of on board safe working procedures, the effective assessment of risk and the implementation of appropriate risk controls.

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Safety issues

MO-2013-010-SI-01 - MO-2013-010-SI-02 - MO-2013-010-SI-03 -  

Crane warning devices

The gantry crane in motion warning light nearest to the assistant electrician’s location was not operating and the warning sirens were not audible from his location. As a result, he was not provided with either a visual or audible warning of the crane’s movement.

Safety issue details
Issue number:MO-2013-010-SI-01
Who it affects:All ship owners, operators and seafarers
Status:Adequately addressed


 

Crew familiarisation

The on board familiarisation process did not ensure that new crew members were informed of the precautions required when working on deck while the gantry cranes were in operation.

Safety issue details
Issue number:MO-2013-010-SI-02
Who it affects:All ship owners, operators and seafarers
Status:Adequately addressed


 

Emergency response

There was a lack of mapping information available to assist the ‘triple zero’ operator in providing the emergency responders with directions to a defined location within the port area.

Safety issue details
Issue number:MO-2013-010-SI-03
Who it affects:Emergency service agencies
Status:Adequately addressed

 
General details
Date: 07 October 2013 Investigation status: Completed 
Time: 1000 CST Investigation type: Occurrence Investigation 
Location   (show map):Portland  
State: Victoria  
Release date: 16 June 2014 Occurrence category: Accident 
Report status: Final Highest injury level: Fatal 
 
Vessel details
Vessel: Toucan Arrow 
Flag: Bahamas 
IMO: 9105023 
Type of Operation: Cargo operations 
Damage to Vessel: Nil 
 
 
 
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Last update 16 June 2014