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Accident Investigation Report 16/2024

Summary

At 1353 on 20 July 2021, the bosun of the roll-on/roll-off cargo vessel Clipper Pennant was fatally crushed while working on the vessels vehicle deck. Clipper Pennant was alongside in Liverpool, England, loading a cargo of semi-trailers. A tractor unit driver pushed a semi-trailer into a corner space, marshalled by the vessels bosun in their assigned role as banksman. The accident was not seen by the driver, who disconnected the tractor unit and drove away. Shortly afterwards, two crew members found the bosun trapped between the rear of the semi-trailer and the vessels structure.

Safety issues

• The banksman was fatally crushed while standing in an unsafe area in the path of an approaching semi-trailer.

• The driver of the tractor unit pushing the semi-trailer did not monitor the banksmans position because they were relying on other visual cues to manoeuvre the semi-trailer and had assumed the banksman would keep out of the path of the advancing semi-trailer.

• The bosun did not act as expected and instead stood on an unprotected walkway that had been painted inside the vehicle lane.

• The loading operation was unsupervised because the bosun had become involved in marshalling, and the crew did not continuously monitor one anothers positions on the vehicle deck.

• Neither the port nor the vessels manager had developed a safe system for loading high-risk stowage spaces.

• The accident reflected routine and widespread divergence from safe working practices on vehicle decks in the ferry industry because the local procedures and guidelines did not reflect how people worked, and there was no common standard.

• The vessels managers had an insufficiently robust approach to organisational learning and continuous improvement.

• There were shortcomings in the standards of tractor unit driving at the port, resulting in a tacit acceptance of some unsafe practices that had become normal.

• There was no national occupational driving standard for tractor unit drivers.

Statement from the Chief Inspector of Marine Accidents

Recommendations

The MAIB made nine recommendations, including:

• Three safety recommendations to industry bodies to develop a jointly agreed and consolidated industry Code of Practice for vehicle deck safety on roll-on/roll-off vessels (2024/148 and 2024/149) and to develop a national occupational driving standard for tractor unit drivers (2024/150);

• A recommendation to the Maritime and Coastguard Agency and Health and Safety Executive (2024/151 and 2024/152) to, subsequently, amend their relevant codes and guidelines to reflect industry best practice and to consider the consolidated industry Code of Practice for vehicle deck safety on roll-on/roll-off vessels developed in accordance with recommendation 2024/148;

• Recommendations to CLdN RoRo Limited (formerly Seatruck Ferries Limited) to improve its organisational safety culture and ensure effective supervision of vehicle deck cargo loading operations (2024/153 and 2024/154); and

• Recommendations to P&O Ferries Limited (2024/155 and 2024/156) to review how it achieves assurance that its ports adhere to its vehicle deck safety procedures and that a jointly agreed safe system of work is in place on chartered vessels

Related publications

A safety bulletin, advising operators of vessels with roll-on/roll-off vehicle decks to review cargo handling procedures and identify the hazards associated with stowage areas that have limited means of escape and take appropriate action, was published on 4 November 2021.

MAIB report 9/2019 - Fall from height on ro-ro freight vessel Seatruck Pace with loss of 1 life

MAIB report 4/2020 - Grounding of ro-ro freight vessel Seatruck Performance

MAIB report 10/2020 - Accident on the stern ramp of the ro-ro freight ferry Seatruck Progress with loss of 1 life

MAIB report 8/2021 - Grounding of ro-ro freight ferry Arrow

Other related publications

HSE - A guide to workplace transport safety

HSE - Banksmans signals

HSE - Safety in docks. Approved Code of Practice

ILO Code of practice on safety and health in ports

MAIC 44E/2019 - Fatal accident on board Isle of Inishmore

MCA - Code of safe working practices for merchant seafarers (COSWP) 2024

MCIB report 273 - Fatal accident on board European Endeavour

MGN 341 Ro-ro ships vehicle decks: accidents and access

MGN 621 roll-on/roll-off ships - guidance for the stowage and securing of vehicles

Port Skills and Safety - SiP001 Guidance on Workplace Transport Port and Terminal Planning

Port Skills and Safety - SiP010 Guidance on Ro-Ro & Sto-Ro

Port Skills and Safety - SiP012 Guidance on Ro-Ro Passenger and Cruise Operations

UK Chamber of Shipping - Vehicle Deck Guidelines

UK Chamber of Shipping - 10 Golden rules of vehicle deck safety