Subjective Safety Decisions Led to Crushing Fatality
The Australian Transport Safety Bureau (ATSB) has released its investigation report into the fatality on board the Skandi Pacific, off the Pilbara coast, Western Australia on July 14, 2015, citing subjective safety decisions being made in the absence of safety management system guidance.
The offshore support vessel (OSV) Skandi Pacific was loading cargo containers from the semi-submersible oil rig Atwood Osprey at its offshore location, about 90 miles north-west off Dampier in the early hours of the day. Shortly after 0505, cargo transfer was stopped due to worsening weather conditions. Skandi Pacific was moved 30 meters away from the rig with the rough seas still on its port quarter. Two crewmembers then began securing cargo on the vessel’s aft deck.
While securing the cargo, the crewmembers slackened the securing chain they had used to secure the containers on the starboard side to better secure the entire stow. At about 0523, two large waves came over Skandi Pacific’s open stern, shifting the unsecured containers forward. One of the crewmembers was trapped between the moving containers, chains and a skip and suffered fatal crush injuries.
The ATSB investigation found that the risks associated with securing the cargo in the prevailing weather conditions on 14 July had not been adequately assessed. The fatally injured man was standing in a dangerous location near the unsecured cargo containers when they shifted.
The investigation identified that Skandi Pacific’s safety management system (SMS) procedures for working/securing cargo on deck in poor weather were inadequate with no clearly defined weather limits. Further, there were no clearly defined limits for excessive water on deck that necessitated stopping operations, leaving individuals to make difficult, and necessarily subjective, decisions about whether or not to stop work.
The master was not called and remained unaware of the situation and, hence, did not get the opportunity to consider safer options for securing cargo, such as running with the weather or changing the vessel’s heading. Working on deck when water was being shipped was contrary to the master’s instructions. ATSB found that the crewmembers on deck carried out their plans in isolation without the active involvement of the officers on watch.
The ATSB also found that Skandi Pacific’s managers had not adequately assessed the inherent high risks associated with seas coming over the vessel’s open stern when work, including cargo handling operations, was being undertaken on its aft deck.
In June 2016, the International Marine Contractors Association released details of a recent incident involving cargo shift on an OSV’s aft deck in heavy weather while alongside a platform.
The OSV was engaged in cargo handling operations with its starboard quarter to the weather when it experienced a sudden and unexpected squall. A large wave was shipped and flooded the aft deck. The water shifted one container and turned another one over. The backloaded containers had not yet been secured due to on-going backloading. Fortunately, no one was injured.
The ATSB’s predecessor, the Marine Incident Investigation Unit (MIIU), investigated a similar fatal accident on board an OSV in 1995.
Shelf Supporter had a large, clear aft deck that enabled it to carry stores and equipment to/from offshore facilities. It operated off the north-west coast of Australia. On December 29, 1995, Shelf Supporter’s master maneuvered the OSV to approach an offshore platform’s crane position with its bow in (stern to sea). It had cargo on the aft deck, which had been secured by the vessel’s crewmembers using tugger wires and winches.
Two crewmembers went out to the aft deck to prepare for unloading cargo. They released the tugger wires and re-spooled the starboard wire onto the winch drum. However, before they could re-spool the port wire, the vessel arrived under the crane and its lifting hook was lowered just above their heads. They left the port wire flaked on deck, and hooked on the first lift.
On the bridge, the master was maintaining the vessel’s position and saw a wave breaking over the stern. He broadcast a warning to the two men on deck. As the water ran up the deck, he saw one of the men just forward of a skip. He then saw the skip move forward and crush the man against another skip.
The Skandi Pacific report is available here.