MAIB: Fatal accident during cargo operations on Karina C

The UK Marine Accident Investigation Branch (MAIB) has published accident its investigation report into a fatal crush incident during lifting operations on the general cargo vessel Karina C on 24 May 2019. See here for details: www.gov.uk/government/news/karina-c-report-published.

The second officer of the general cargo vessel Karina C was fatally injured when he was crushed between the vessel’s gantry crane and a stack of cargo hold hatch covers during post-cargo loading operations. 

The second officer had been working at the aft end of the main deck and was attempting to pass between the hatch covers and the stationary crane. As the second officer climbed onto the hatch coaming, the vessel’s chief officer drove the crane aft, trapping and crushing the second officer against the hatch covers. The chief officer immediately reversed the crane and the second officer fell onto the deck, where he received first-aid and cardiopulmonary resuscitation from the deck crew and shore paramedics.

An emergency services doctor, who was informed that the second officer had fallen from the hatch coaming onto the deck, told the crew that the second offcer probably died after having a heart attack.  Based on the doctor’s initial assumption and the evidence provided by the vessel’s crew, the accident was not reported to the MAIB.  Only following receipt of the second officer’s postmortem report and close examination of Karina C’s closed-circuit television recordings was the incident reported by the vessel management to the MAIB.  The accident occurred on the second officer’s birthday and the postmortem toxicology report showed that he had a signifcant quantity of alcohol in his bloodstream.

What went wrong (IMCA emphasis)

The investigation concluded that:

• Deck operations were not being properly controlled or supervised and the deck officers did not communicate with each other – the second officer did not know the chief officer was about to move the crane and the chief officer did not know where the second officer was, or what he intended to do;
• The second officer’s judgment and perception of risk were probably adversely affected by alcohol;
• Tiredness might also have adversely infuenced the second officer’s actions;
• The master did not adequately investigate or report the accident;
• The safety culture on board was weak; company procedures were not followed, and several unsafe working practices were observed;
• The company’s drug and alcohol policy was not being enforced.

Members may wish to refer to:

• IMCA IMCA M 205/IMCA D 046 Guidance on operational communications
• IMCA HSSE 040 Rev. 0.1 Guidance on Drug & Alcohol Policies and Testing