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

Investigation number:
273-MO-2010-002
Status: Completed
Investigation completed

Summary

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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

Go to MO-2010-002-SI-01 - Go to MO-2010-002-SI-02 - Go to MO-2010-002-SI-03 - Go to MO-2010-002-SI-04 - Go to MO-2010-002-SI-05 - Go to MO-2010-002-SI-06 - Go to MO-2010-002-SI-07 -

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.

Safety issue details
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.

Safety issue details
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.

Safety issue details
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.

Safety issue details
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.

Safety issue details
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.

Safety issue details
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.

Safety issue details
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: Complex - 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 details
Vessel Vega Gotland  
Flag Antigua and Barbuda  
IMO 9336347  
Type of operation Container ship  
Damage to vessel Nil  
Departure point At berth  
Last update 14 November 2018