Marine Safety Investigation Unit

MARINE SAFETY INVESTIGATION REPORT

Safety investigation into a stevedore fatality on board the

Maltese registered bulk carrier

TARSUS
at Port Rozi Anchorage, India
on 13 November 2013

201311/011

MARINE SAFETY INVESTIGATION REPORT NO. 29/2014

FINAL
Investigations into marine casualties are conducted under the provisions of the Merchant
Shipping (Accident and Incident Safety Investigation) Regulations, 2011 and therefore in
accordance with Regulation XI-I/6 of the International Convention for the Safety of Life at
Sea (SOLAS), and Directive 2009/18/EC of the European Parliament and of the Council of 23
April 2009, establishing the fundamental principles governing the investigation of accidents
in the maritime transport sector and amending Council Directive 1999/35/EC and Directive
2002/59/EC of the European Parliament and of the Council.

This safety investigation report is not written, in terms of content and style, with litigation in
mind and pursuant to Regulation 13(7) of the Merchant Shipping (Accident and Incident
Safety Investigation) Regulations, 2011, shall be inadmissible in any judicial proceedings
whose purpose or one of whose purposes is to attribute or apportion liability or blame, unless,
under prescribed conditions, a Court determines otherwise.

The objective of this safety investigation report is precautionary and seeks to avoid a repeat
occurrence through an understanding of the events of 13 November 2013. Its sole purpose is
confined to the promulgation of safety lessons and therefore may be misleading if used for
other purposes.

The findings of the safety investigation are not binding on any party and the conclusions
reached and recommendations made shall in no case create a presumption of liability
(criminal and/or civil) or blame. It should be therefore noted that the content of this safety
investigation report does not constitute legal advice in any way and should not be construed
as such.

Copyright TM, 2014.

This document/publication (excluding the logos) may be re-used free of charge in any format
or medium for education purposes. It may be only re-used accurately and not in a misleading
context. The material must be acknowledged as TM copyright.

The document/publication shall be cited and properly referenced. Where the MSIU would
have identified any third party copyright, permission must be obtained from the copyright
holders concerned.

MARINE SAFETY INVESTIGATION UNIT

Malta Transport Centre
Marsa MRS 1917
Malta

ii
CONTENTS

CONTENTS ............................................................................................................................. iii

GLOSSARY OF TERMS AND ABBREVIATIONS ................................................................v

SUMMARY ............................................................................................................................. vi

1 FACTUAL INFORMATION .............................................................................................1

1.1 Vessel, Voyage and Marine Casualty Particulars .......................................................1
1.2 Description of Vessel .................................................................................................2
1.3 Deck Cranes................................................................................................................2
1.3.1 Operation of deck cranes ........................................................................................4
1.3.2 Safety features ........................................................................................................6
1.3.3 Crane jib emergency limit switch ...........................................................................6
1.3.4 Emergency stop button ...........................................................................................6
1.4 Maintenance and Inspection of Deck Cranes .............................................................7
1.4.1 Maintenance of crane no. 2.....................................................................................7
1.5 Stevedores and Work Schedule ..................................................................................9
1.6 Ships Crew and Cargo Watch ...................................................................................9
1.7 Risk Assessment .......................................................................................................10
1.8 Environment .............................................................................................................10
1.9 Narrative ...................................................................................................................10
1.10 Post-accident Events .................................................................................................15
1.11 Autopsy Report .........................................................................................................15
1.12 Structural Damage ....................................................................................................15
1.13 Post-Accident Investigation by the Chief Engineer..................................................16

2 ANALYSIS .......................................................................................................................18
2.1 Purpose .....................................................................................................................18
2.2 Circadian Rhythm and Sleep Deprivation ................................................................18
2.3 Risk Assessment .......................................................................................................20
2.4 Findings by the Service Engineer .............................................................................20
2.5 Crane Operation at Port Rozi....................................................................................22
2.5.1 Slanting operation .................................................................................................22
2.5.2 Reporting of improper crane handling..................................................................23
2.5.3 The bitter end of the luffing wire rope .................................................................25
2.6 Fatal Injury ...............................................................................................................25

3 CONCLUSIONS ...............................................................................................................28
3.1 Immediate Safety Factor...........................................................................................28
3.2 Latent Conditions and other Safety Factors .............................................................28
3.3 Other Findings ..........................................................................................................28

4 RECOMMEDNATIONS ..................................................................................................29

LIST OF ANNEXES ................................................................................................................30

iii
LIST OF REFERENCES AND SOURCES OF INFORMATION

Crew members MV Tarsus

European Commission (2012). A wake up call. Research into the effects of

sleepiness on the cognitive performance of maritime watchkeepers under different
watch patterns, using ships bridge, engine and liquid cargo handling. Research
Report 2012. Retrieved on 03 April 2014 from
http://www.warsashacademy.co.uk/about/resources/final-horizon-report-final-as-
printed.pdf

IHI-WMMP Instruction Manual

International Maritime Organization (2001). Guidance on fatigue mitigation and

management. MSC/Circ.1014. London: Author

Managers MV Tarsus

iv
GLOSSARY OF TERMS AND ABBREVIATIONS

AB Able seaman

Cm Centimetre

E East

ICU Intensive Care Unit

IHI Ishikawaiima-Harima Heavy Industries Co., Ltd.

kW Kilowatt

m Metre

mm Millimetre

MSIU Marine Safety Investigation Unit

N North

OOWs Officers of the watch

PPE Personal Protection Equipment

PMS Planned Maintenance System

RPM Revolutions per Minute

SMS Safety Management System

SWL Safe Working Load

T Tonnes

VTS Vessel Traffic Service

WMMP Wuhan Marine Machinery Plant Co. Ltd.

v
SUMMARY

On 10 November 2013, the Maltese registered bulk carrier Tarsus anchored off Port
Rozi, India to load a cargo of coal from the barges. The crew prepared the vessels
cranes and connected the dual-folding grabs. The port stevedores boarded the vessel
and commenced loading at 14451. The cranes were operated by the stevedores.

On 13 November 2013 at 0450, the crane operator at crane no. 2, simultaneously

lifted the grab and the crane jib. He was guided by a signalman on deck, positioned
abreast of cargo hold no. 2. Whilst the hoisting wire rope lifted the grab, the luffing
wire rope had a contra-movement to the jib-up action and the crane jib started falling
down. The operator released the hoist and luffing lever controls and pushed the
power off button. Instantly, the hoisting wire rope stopped but the crane jib
continued to fall until it hit the air vent pipe on the main deck. The fall was arrested
by the vessels sheer stake. The luffing wire rope had unwound and the bitter end
slipped out of the luffing wire rope drum.

An AB who was on cargo watch escaped uninjured. However, the signalman was
lying beneath the crane jib, unconscious and bleeding from the head. The injured
signalman was administered first aid on board and transported by barge for medical
treatment ashore. He was admitted in the local hospitals intensive care unit. The
signalman succumbed to his injuries on 14 November 2013.

Cognizant of the masters submissions, the fact that the findings of the chief engineer
and the service engineer into the cause of the deck crane damage found no technical,
hydraulic or electrical failure, the Marine Safety Investigation Unit (MSIU) concluded
that the immediate cause of the accident and the subsequent fatal injury to the
stevedore was the falling of the jib beyond its operating limit.

The MSIU has made three recommendations to the managers of the ship and the
manufacturer of the cranes with the scope of enhancing safety during cargo
operations.

1
Unless otherwise stated, all times are ships time (UTC +5.5).

vi
1 FACTUAL INFORMATION

1.1 Vessel, Voyage and Marine Casualty Particulars

Name Tarsus
Flag Malta
Classification Society DNV GL
IMO Number 9487213
Type Bulk Carrier
Registered Owner Tarsus Shipping Limited, Malta
Managers Genel Denizcilik Nakliyati A.S., Istanbul
Construction Steel (Double bottom)
Length overall 189.99 m
Registered Length 182.0 m
Gross Tonnage 31117
Minimum Safe Manning 18
Authorised Cargo Dry bulk

Port of Departure Jaigarh, India

Port of Arrival Port Rozi, Gulf of Kutch, India
Type of Voyage Coastal
Cargo Information Coal
Manning 24

Date and Time 13 November 2013 at 0450 (LT)

Type of Marine Casualty Very Serious Marine Casualty

Place on Board Ship Freeboard Deck
Injuries/Fatalities One fatality
Damage/Environmental Impact No environmental impact. Damages to the
railing, crane jib and other fittings on the
freeboard deck.
Ship Operation Normal Service - Loading
Voyage Segment Arrival
External & Internal Environment Light breeze, calm sea. Mainly cloudy with good
visibility, air temperature 24 C.
Persons on Board 42

1
1.2 Description of Vessel

Tarsus was a 5-hatch, geared, self-trimming bulk carrier. She was registered in Malta
and was owned by Tarsus Shipping Limited. Tarsus was managed by Genel
Denizcilik Nakliyati A.S. of Turkey2. The vessel was built by Zhejiang Shipbuilding
Company Limited, China in 2008 and is classed by DNV GL.

Tarsus (Figure 1) had a length overall of 190 m, a moulded breadth of 32.26 m and a
moulded depth of 17.20 m. The vessel had a summer draught of 12.49 m and a
summer deadweight of 53208 tonnes.

Propulsive power was provided by a 6-cylinder MAN-B&W 6S50MC-C, slow speed

direct drive diesel engine producing 9480 kW at 127 rpm. This drove a single fixed
pitch propeller, giving a service speed of 14.70 knots.

Tarsus had satisfactorily completed Class and Statutory renewal surveys on

09 October 2013.

1.3 Deck Cranes

Tarsus was fitted with four IHI-WMMP electro-hydraulically driven cranes (Figure
2), each of 35 tonnes SWL capacity. The cranes working radii lie between 5 m and
28 m at crane jib angles of 82and 20 from the horizontal respectively. The
maximum SWL in the grab operation mode was 28 tonnes.

The engine-room overhead crane, provisions crane and deck crane nos. 1, 2, 3 and 4
were thoroughly examined and load tested in Shanghai by a DNV surveyor. The
results were satisfactory. The ships cargo gear book was also endorsed. A
Certificate of Test and Thorough Examination of Lifting Appliances was issued on
09 October 2013.

2
The vessels name was changed to Tango following a change in ownership on 04 June 2014.

2
Figure 1: MV Tarsus

3
Figure 2: Crane and machinery room arrangement

1.3.1 Operation of deck cranes

The manufacturers Instruction Manual provided guidance on the preparation and
operation of deck cranes. The Instruction Manual recommended that prior to starting
the cranes, a number of checks had to be carried out including, level check of the
hydraulic/lubrication oil in the hydraulic pump/tank and the reduction gearbox, and
testing of the limit switches for the hoist, slew and crane jib movements. The
instruction label (Figure 3) in the Instruction Manual, and which was fitted in each of

4
the four crane cabins, warned the operator neither to hoist the load slanting nor
diagonally to prevent damage to the crane jib and its luffing wire rope.

Figure 3: Cautionary label in crane cabin

It was also stipulated that the controlling levers, hoist and luffing/slewing controls
(Figure 4) had to be in the neutral position before the electric motors were started.

Figure 4: Luffing and slewing control lever

The cranes are considered ready for cargo operations only after the recommended pre-
start checks were completed.

5
1.3.2 Safety features
In order to carry out cargo handling operations safely, each of the four cranes is fitted
with a safety device. The motion limit switches restricted hoisting between the upper
and lower limits of the crane jib. The slewing limit switches prevented the crane
running into any fixed obstacle. Moreover, the hoist and luffing differential switch
maintained adequate clearance between the crane jib head and the cargo hook. The
cranes were also fitted with interlock switches, which prevented the operation of the
cranes after the limit switches activated at the maximum and minimum angle of the
jib from the horizontal.

The relief valves in the hoist and luffing motor protected the winches from overload,
whereas valves in the slewing motors softened the mechanical shock. The relief
valves in the hydraulic system protected the pump from overload. When the pressure
on the relief valve exceeded a pre-set limit in the hoist, luffing or slewing, all crane
movements stopped.

1.3.3 Crane jib emergency limit switch

A crane jib emergency limit switch was fitted to stop the crane operation in the event
the luffing drum moved the crane jib down when the luffing lever was moved in the
crane jib-up position. Similarly, the crane movement would be stopped when the
luffing lever was moved up, the brakes are released and instead, the crane jib lowers
down as a result of loss of hydraulic pressure from internal leakages in the system.

1.3.4 Emergency stop button

In addition to the above safety devices, and in case of an emergency, the start/stop
button (Figure 5) also served as an emergency stop button. Activating it by pushing
the stop button would stop all crane movements during cargo operations.

6
Figure 5: Plan view of the crane cabin showing relative position of the crane stop button

1.4 Maintenance and Inspection of Deck Cranes

The Instruction Manual recommended periodic inspections and maintenance of the

deck cranes. A maintenance chart was appended to the Manual on the maintenance of
electric, hydraulic and machinery parts. The chart provided an overview of the
preparatory checks required on the cranes for cargo operations. The checks included
function of the limit switches and brakes, which were to be carried out by operating
the cranes without any load.

As part of the safety management system (SMS), the maintenance of cranes was
included in the Companys planned maintenance system (PMS). Each maintenance
job was described in the PMS application.

1.4.1 Maintenance of crane no. 2

The crew had carried out monthly and three monthly checks on 12 October and 07
November 2013 respectively. On 17 April 2013, the brake tests were performed on
the hoist and luffing wire rope drums, and the slewing ring. During the Class and the
Statutory renewal surveys in October 2013, the ships cranes were tested and
thoroughly examined by the DNV GL surveyor. On 09 October 2013, a certificate
attesting the thorough examination and load tests was issued and the ships Cargo
Gear Book was endorsed (Figures 6 and 7).

7
Figure 6: Cargo Gear Inspection Endorsement by DNV surveyor

Figure 7: DNV Class test/thorough examination certificate

The crane operators cabin and equipment were last inspected on 12 October 2013
with satisfactory results. The luffing wire rope drum was checked on 20 August
2013, including the checking / re-screwing of the luffing wire rope fixed bolt (Figure
8) with a suitable spanner (Annex 1). The arrangement was found to be in good
condition.

Figure 8: Securing arrangement on the luffing wire rope drum

8
1.5 Stevedores and Work Schedule

The stevedores working on Tarsus comprised of a supervisor, eight crane operators,

eight signalmen and a cook. The stevedores lived on board and worked in shifts of 6
hours duty and 6 hours rest. During cargo operations none of the stevedores were
wearing personal protection equipment (PPE).

Deck crane no. 2 was operated by a 35 year old port worker who had indicated that he
had 15 years experience in crane operation of which, he had 4 to 5 years operating IHI
deck cranes. Documentary evidence indicated that the crane operator was due for
refresher training on 25 December 2009. No further evidence was submitted to
confirm that this refresher training was actually carried out. He was assisted by a 32
year old signalman who was reported to have five years experience working in the
port.

1.6 Ships Crew and Cargo Watch

All the officers and rating on Tarsus were Turkish nationals. The master, who was 59
years old at the time of the accident, held a Certificate of Competence issued under
STCW regulation II/2, and endorsed by the flag State Administration. He had been at
sea for over 36 years; 20 years of which serving as a master. He had been for six
years with the present Company. He joined Tarsus on 18 August 2013.

The chief mate, who was 31 years old, also held a Certificate of Competence issued
under STCW regulation II/2.

At Port Rozi, the officers of the watch (OOWs) were keeping the anchor and cargo
watches and a watchkeeping schedule was applied as follows:

Second mate 0000-0400 and 1200-1600

Chief mate 0400-0800 and 1600-2000

Third mate 0800-1200 and 2000-2400

An AB and a deckhand assisted the OOWs during their respective anchor/cargo

watches. The chief mate was responsible for the loading operations.

9
1.7 Risk Assessment

Documentary evidence showed that a formal risk assessment of cargo operations at

Port Rozi was done on 11 November 2013. The risk assessment team included the
master, the chief mate, the chief engineer, the first engineer and the bosun.
Communication failure, structural damage, and serious or fatal injuries were identified
as hazards. The safeguards to control hazards to an acceptable level were
implemented by the chief mate and the first engineer on 12 November 2013
(Annex 2). The formal risk assessment document also indicated that the necessary
checks on the deck cranes were carried out on 12 November 2013.

1.8 Environment

The weather on the morning of 13 November 2013 was light breeze with smooth seas.
The swell height was in the region of 0.1 m to 0.5 m and it had no effect on the
vessels rolling or pitching motion. The air temperature was 24 C. The vessel was
upright with trim of 0.48 m by the stern. The diurnal tide in the region ranged
between 1.0 m and 5.50 m.

1.9 Narrative

On the morning of 10 November 2013, Tarsus anchored off Port Rozi in the Gulf of
Kutch, West India. Following port clearance, draft survey and satisfactory
inspections of the cargo holds, Tarsus re-anchored to load coal in position
22 39N 070 04E, i.e. about five nautical miles from the port (Figure 9).

10
 US Dept of State Geogrtapher
2014 Google
Image 2014 TerraMetrics
Image 2014 CNES / Astrium
Data SIO, NOAA, U.S. Navy,
NGA, GEBCO

Figure 9: Anchor position of Tarsus just outside Port Rozi, Gulf of Kutch, India

The crew members prepared the cranes, opened the hatch covers and connected the
dual-folding grab to each of the ships four cranes. At 1430, barges loaded with coal
arrived and moored on the ships portside. The stevedores boarded the vessel and at
1445 commenced loading cargo holds nos. 2, 3, 4 and 5. All the cargo cranes were
operated by the stevedores, who were assisted by signalmen positioned on deck,
abreast of each cargo hatch. No bulldozers were available on the barges throughout
the cargo operation.

On 13 November 2013 at 0400, the chief mate took over the cargo watch from the
second mate. At the time, the vessel was upright with a slight trim by the stern. The
draft was 9.94 m forward and 10.42 m aft. The stevedores were loading cargo in
cargo holds nos. 1, 2, 4 and 5. It was dark but the deck lights provided adequate
luminosity. At 0430, the crane operator and the signalman assigned to
crane no. 2 took a short break for tea. At 0450, they returned and resumed loading.

The crane jib was reportedly positioned between 40 and 45 from the horizontal.
This position gave the loading grab a reach of 5 m to 7 m from the ships port side.
The grab was ready to be lifted from the barge, to be emptied into cargo hold no. 2.
The signalman standing near the aft air vent pipe signalled the crane operator to lift

11
the grab. The crane operator simultaneously moved the hoisting and the luffing lever
in crane jib-up position.

The AB on duty standing near the signalman recalled that soon after the grab had been
lifted to a height of about two metres from the barge, he heard a humming noise and
looked up. At about the same time, the crane operator noticed the crane jibs contra-
movement. He immediately put the control levers to neutral position and pushed the
power off button. The hoisting wire rope instantly stopped. The crane jib, however,
continued to fall albeit slowly until it hit the air vent pipe on the main deck. The fall
was eventually arrested at the vessels sheer strake. The grab fell and rested on the
cargo in the barges hold (Figures 10, 11 and 12).

Figure 10: Crane jib after the accident

Figure 11: Grab position on the barge

12
Figure 12: View of damaged crane jib from the crane cabin

The luffing wire rope had unwound from the drum and the detached bitter end was
lost into the sea. The luffing wire rope strands were found open and the bitter end
securing arrangements were damaged (Figures 13 and 14). Although the AB was
uninjured, the signalman was found lying under the crane jib, unconscious and
bleeding from the head.

13
Figure 13: Damaged securing arrangement

Figure 14: Bitter end with strands open and loose

14
1.10 Post-accident Events

All cargo operations were immediately stopped and the injured signalman was given
first aid. However, since the nature of his injuries was very serious, the VTS at Port
Rozi instructed the vessel to transfer the injured stevedore ashore by one of the
barges.

At 0520, the injured signalman was transferred to the barge and transported ashore for
further medical treatment. On reaching Port Rozi, he was transferred by ambulance to
the hospitals intensive care unit (ICU). Despite the medical care and treatment, the
signalman succumbed to his injuries on 14 November 2013.

1.11 Autopsy Report

A post-mortem examination was held on 14 November 2013. A 5 cm surgical stitch

wound was found on the frontal region of the head (forehead mid-line). Two small
abrasions were observed on the left cheek and below the left corner of the mouth. The
autopsy report concluded that the cause of death was a trauma caused by the severe
head injury.

1.12 Structural Damage3

The surveyors representing the interests of the owners, charterers and the stevedoring
company jointly surveyed the crane for structural damage. The survey was witnessed
by the master, the chief engineer and the chief mate. The following structural
damages were identified:

left and right arms of the crane jib (box frame) were buckled, deformed and
fractured at various locations;

the grab cable auto-tension motor was detached from the housing. The sheave
at the crane jib head was also detached and one of its sides bent;

the lighting cable and two pipe guards on the crane jibs right arm were bent;

3
An inspection for any damages on the cranes machinery was not carried out.

15
 about one metre of sheer strake on the main deck was bent. Three tiered guard
rails and stanchions above the shear strake were broken and deformed;

two runner wire ropes sheaves on the crane jib head and flanges were bent;

the luffing wire rope securing clamps and bolts on the luffing wire rope drum
were detached and bent;

the luffing wire rope strands near the bitter end were opened up over a length
of about 2.50 m from the bitter end. Moreover, wire rope strands were opened
up in other locations; and

the air vent for void space no. 3 had been damaged and detached from its base.

1.13 Post-accident Investigation by the Chief Engineer

Following the accident, the chief engineer carried out a number of checks and tests on
the crane and forwarded his report to the ships managers. In his report, the chief
engineer stated that:

all limit switches were checked and found in order;

the pressure readings on the luffing hydraulic motor were found in compliance
with the manufacturers instructions;

the luffing wire rope drum was operated in both directions and the mechanism
worked properly. There were no abnormal noises or vibration;

the brakes were engaged and tested to verify that they locked tight around the
drum;

the machinery response from the operator controlling levers was satisfactory;

the luffing wire rope drum was operated using the luffing control lever at
small angles. The clearance between the brake band and the brake wheel was
found within limits; and

the luffing lever was operated both in crane jib-up and crane jib-down
positions at five second intervals. The machinery response was good. The
luffing brakes engaged and the hydraulic pressure at each lever movement
were found satisfactory.

16
The chief engineer reported that at Port Rozi, the crane must have been operated
beyond its recommended operating limits. He concluded that the cargo was pulled
slantingly and its limits were violated. The chief engineer stated that the harsh
movements on the controlling levers delayed and weakened the action of the brakes.
He also attributed the crane jibs fall to excessive load caused by the slanting grab lift
and the operators erratic handling of the luffing lever.

17
2 ANALYSIS

2.1 Purpose

The purpose of a marine safety investigation is to determine the circumstances and

safety factors of the accident as a basis for making recommendations, to prevent
further marine casualties or incidents from occurring in the future.

2.2 Circadian Rhythm and Sleep Deprivation

The stevedore on Tarsus were divided into two gangs. They lived on board and
worked alternate shifts of 6 hours. A cabin space and toilet facilities were provided
by the ship. The operator on crane no. 2 was assigned a shift between the periods of
0200 to 0800 and 1400 to 2000. Since the barge movements were affected by tidal
waters in the port area, their arrival alongside the ship was unscheduled. Thus, in
addition to the scheduled six-hour rest, the operator had significant periods of free
time while on shift duties. The crane working hours and free time of the operator on
crane no. 2 are summarised in Table 1.

Table 1: Crane working hours and free time of crane operator no. 2

Crane working hours and free time of crane operator no. 2

(Total time on board 62 hours 20 minutes)
Free time
Crane operation
(including
Date (including tea Remarks
scheduled rest
breaks)
period)
1430: Boarded Tarsus
10 November 5 hr 15 min 0 hr 15 min
1445: Commenced loading
6 hr 00 min
11 November 4 hr 10 min
7 hr 50 min
11 November 2 hr 30 min
9 hr 30 min
12 November 4 hr 20 min
7 hr 40 min
12 November 5 hr 45 min
6 hr 15 min
0450: Work stopped due to crane jib
13 November 2 hr 50 min
accident
Total Hours 24 hr 50 min 37 hr 30 min 62 hr 20 min

18
The analysis was carried out in the light of potential issues with the biological clock
and circadian rhythm. The biological clock is perfectly synchronised to the traditional
pattern of daytime wakefulness and night-time sleep. There are two times of low
alertness in each 24 hour period (0300-0500 and 1500-1700). The working patterns
of the stevedores, crane operators and signalmen conflicted with their biological
clock. Moreover, a recent research project4 on seafarers showed that sleepiness levels
were higher in the 6 on - 6 off system and consistently peaked between 0400 and
0800; and the off-watch disturbance (noise, vibration, etc.) produced significant high
levels of tiredness.

Wakefulness builds up a sleep requirement and prolonged wakefulness results in sleep

deprivation5. Though common in the everyday working life, sleep deprivation
induces fatigue and adverse changes in cognitive performances through decreased
alertness and slow response in simple monotonous tasks.

However, the intermediate periods of free time during and between scheduled crane
operations, which ranged from a minimum of 6 hours to up to 9.50 hours, were also
considered. These periods were utilised for meals, shower, social activities and sleep.
As indicated in Table 1, the crane operator had worked 24.83 hours out of the 62.33
hours, which he had been on board. He therefore had well over 37 hours of free time.
On the morning of 13 November, before reporting on duty at 0200, he had a rest
period of 6.25 hours. In the previous 24 hours, he had rested 13.92 hours. After 2.5
hours of crane operation, he stopped for a 20 minute break.

Though the MSIU could not establish the operators quality or duration of sleep, it
was apparent from the available evidence, however, that the operator was not unduly
fatigued or overwhelmed by the circadian rhythm or, potentially, micro sleep6 when
he resumed work at 0450 shortly after the tea-break.

4
Project Horizon A wake-up call. Research Report 2012. A European Commission part-funded
multi-partner research initiative to investigate the impact of watch keeping patterns on the cognitive
performance of seafarers.
5
Sleep is a physiological need during which restores energy.
6
Micro sleep means sleep of typically 10 to 15 seconds duration.

19
2.3 Risk Assessment

The ISM Code requires vessels to make a risk assessment on safety of operations and
to determine and implement control measures necessary to ensure safe operations.
Tarsus SMS included a formal risk assessment procedure. During the on-site
investigation and collection of evidence, no document on risk assessment was
submitted to the safety investigator.

However, during the course of the safety investigation, the managers obtained a copy
of SMS Form 034001 dated 11 November 20137 on risk assessment for crane
operations at Port Rozi from the vessels master. The document identified a number
of hazards, with mitigating safeguards put in place on 12 November 2013, a day
before the accident8.

It was deduced that since all cranes were recently examined and load tested by a
DNV GL surveyor a few weeks before the accident, a sudden crane jib fall was not
considered as a probable hazard and therefore not included in the risk assessment
exercise.

2.4 Findings by the Service Engineer

At Ningbo and Shanghai, China, a service engineer from WMMP attended the vessel
to carry out an investigation into the cause and extent of the damage.

During the course of the crane inspection, the service engineer found that the brake
liners were in good condition and free from any oil traces, which therefore eliminated
the possibility of brake slippage. The thickness of the liner was within the allowable
limits and the clearance between the brake and the brake wheel was 1.1 mm, which
was also within the maximum allowable limit. This also meant that the brake holding
capacity was not compromised by these two factors. The service engineer also
checked the limit switches of the luffing wire rope system and found them in good
working order. The operation of the luffing control levers and luffing brakes was also
found satisfactory.

7
Cargo operations had started on 10 November 2013.
8
The Risk Assessment Form made no reference to stevedores working on board without wearing the
necessary PPE.

20
Thus, whilst the limit switches were found in good working order, the safety
investigation had to determine why the crane jib transited the lower operating
boundary (i.e. 20 from the horizontal) without the fall being arrested by the brake.

Although the hydraulic motor running pressure was good, damage to the reduction
gear from the reaction force of the crane jib falling on deck was suspected. The
hydraulic motor was dismantled and no damage was found. However, the reduction
gear had sustained severe damages. Parts of the teeth were broken and found in the
luffing wire rope drum. A new reduction gear and flange were ordered and eventually
fitted. The connection between the luffing wire rope drum and the reduction gear was
checked and the crane jib (box frame) was repaired. A new wire rope was installed
and the limit switches re-adjusted. The crane was run for hours and the system was
thoroughly checked. Finally, a load test was carried out with satisfactory results.

At the end of a thorough investigation, the service engineer found abnormalities

neither in the hydraulic system, limit switches, nor in the luffing brakes. In his
conclusion, however, he attributed the likely cause of the crane jib fall to the hoisting
of the load in a slanting manner by the operator.

Since no technical explanation was submitted in support of the service engineers

conclusion (as presented in his report Annex 3), the MSIU requested further
clarifications from the manufacturers, namely:

whether the damage to the luffing reduction gear was the result of the crane jib
fall or whether the crane jibs fall was caused by the damaged reduction gear;

to confirm whether the engineers findings on the crane damage were clear
indications of a slanting hoist and if so, whether the damage could have been
caused by a single slanting load or multiple loads;

to clarify the consequences in the event of crane mishandling and whether

mishandling can lead to a failure of the cranes mechanical and/or electro-
hydraulic system, resulting in a crane jib fall; and

to advise on the possible technical reasons for the crane jib not to stop falling
even if the control levers were neutral and the emergency stop button
pressed.

21
Notwithstanding a series of emails, by the end of the Consultation Period, the MSIU
had not received a reply to these queries, which were aimed to explore the technical
link (hydraulic and mechanical) between the fall of the crane jib and possible hoist
slanting during the cargo operations (either at Port Rozi or even in previous ports).

2.5 Crane Operation at Port Rozi

2.5.1 Slanting operation

The master stated that the stevedores were verbally instructed to operate the deck
cranes safely and to stay clear of the cargo operational area. The masters orders in
the logbook instructed the watch keepers to ensure safe and orderly crane operations.
Moreover, each crane cabin was provided with instructions on the operation of cranes,
with specific warning to the crane operators not to drag or to lift the grab slantingly.

After the accident, the master asserted that the accident had occurred due to the
jerking of the crane and the dragging and slant lifting of the cargo. The master also
suggested that the hoist might have snagged on the barge9. He pointed out that the
bitter end of the luffing wire rope had come off the luffing wire rope drum and that
this was indicative of the damage caused by the operators handling of the crane
beyond its permissible limits. As already indicated elsewhere in this safety
investigation report, the chief engineer, who had carried out various checks and tests
after the accident, also attributed the cause of the accident to the violation of the
cranes operational limits by imposing excessive load on the crane through slanting
cargo hoists.

At the time of the accident, the vessel was upright with a trim by the stern of 0.48 m10.
The crane jib was reported to be at an angle of about 40 to 45 from the horizontal.
In this position, the grab would have reached 5 m to 7 m from the ships side. At 20
(working limit), the crane jib reach would have a maximum slewing radius of 28 m,
giving a reach of 12 m over the ships side (Figure 15). Therefore, within the working
limits of the crane jib, the grab could have easily covered the full 7 m beam of the
barge. Moreover, the barge could be moved up and down under the hoist. The weight

9
An inspection of the barge, however, did not reveal protrusions or obstructions, which could have
snagged the hoist.
10
The vessels trim was not considered to have been a contributory factor to this accident.

22
of the grab with coal at 21 tonnes was well within the maximum permissible limit of
28 tonnes. Therefore, whilst slanting of the grab can neither be confirmed nor
excluded, the reach of the crane jib and the shifting of the barge in the fore and aft
direction would have obviated the need for slanting hoist. However, the MSIU
neither had evidence which would indicate that the barge was moved in the fore and
aft direction, nor that the cargo was shovelled directly under the grab.

Figure 15: Crane jibs operating limits

2.5.2 Reporting of improper crane handling

It transpired that none of the watch keepers had reported poor crane handling, lifting
or attempting to lift the grab slantingly during the cargo operation although it was
claimed that the operators were verbally cautioned by the duty officer and the watch
keeper. The AB who witnessed the accident made no reference to the mishandling of
the crane. Since the start of the cargo operations on 10 November 2014, a log entry
was neither made by the watch keepers nor any protest (other than the one made after
the accident) was lodged by the master on poor and / or rough handling of the crane.

The reporting of crane misuse was analysed from a safety perspective by the MSIU
and in terms of the safety management of the system. Given that evidence did not
indicate that the alleged misuse of the crane was immediately reported to the master
or the chief mate, it may be deduced that any of the crew members who witnessed the

23
cargo operations (and therefore was a potential informant), may have not immediately
seen the value in making this report; the MSIU has been made aware that deck
equipment is commonly not operated in accordance with the manufacturers
directions in a number of ports around the world.

If this was the case, then the issue may be of an inaccurate distinction between
successful/unsuccessful behaviour and correct/incorrect behaviour on the crane
operators side. If slanting hoist was indeed being practiced, then until the accident
happened, the results were perceived successful and the cargo operations were
deemed positive, which may be seen as a measure of successful cargo operations.
This is however, neither necessarily correct nor in accordance with the manufacturers
instructions.

On the other hand, any slanting of the crane jib would have actually been a risk-taking
exercise, which therefore, would have been accepted. In terms of a safety
investigation, the matter remains an issue on the social and commercial value of the
activity being conducted and whether the potential of an accident was foreseen by the
crane operator and / or the crew members.

Even so, the fact that after the accident there was a claim of slanting of the crane jib,
and knowing very well that slanting is specifically mentioned in the Instruction
Manual, but no records of any reports were made and / or no action was taken prior to
the accident, was suggestive that there was a limited understanding on board on the
critical importance of reporting safety occurrence in order to stay ahead on the way
the nature of risk may change and possibly, leading to an accident.

It may be also indicative that whereas the safety management system required that
safety occurrences are reported (e.g. near accidents), the interpretation given to a
number of occurrences is that these are not safety occurrences at all, more so if, as
described above, the outcome is perceived to be positive. Therefore, what may be
classified as an excellent opportunity for an organisation to enhance organisational
learning, can be an unreportworthy event for the crew member on board, who may be
busy doing his job during a cargo operation.

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2.5.3 The bitter end of the luffing wire rope
It was definite that the luffing wire rope did not part but slipped off its bitter end.
Available documentary evidence indicated that at some point in time, the luffing wire
had stripped off its bitter end on the luffing wire drum under shock load conditions.
The findings of the chief engineer and the service engineer were also taken into
consideration. It would seem that on the basis of these findings, a possible technical,
hydraulic or electrical fault had to be eliminated, unless it was of an intermittent
nature which went undetected after the accident. However, according to the masters
explanation to the safety investigator, the luffing wire came off the bitter end of the
wire luffing drum and that this indicated that the crane jib was operated at angles
beyond the permissible limits during the cargo operations.

The nature of the damage on the luffing wire rope drum (Figure 13) at the bitter end,
i.e. deep scratches in the luffing wire rope drums side wall and a bent holding down
bolt also indicated that the securing arrangement fastening the luffing wire rope to the
drum must have been excessively stressed.

In view of the masters explanation above, the findings of the chief engineer and the
manufacturers representative. and given that the bolt on the bitter end of the luffing
wire drum had been satisfactorily tightened using a suitable spanner on 20 August
2013, the MSIU could not rule out that the luffing wire rope had been stressed during
the loading operation with the consequent damage to the fastening arrangement. It
has to be specified that the rigging geometry and the bitter end securing arrangement
were neither intended nor designed to withstand shock loads.

2.6 Fatal Injury

Although the injured signalman was found under the cranes jib, it seemed unlikely
that he was hit by the crane jib itself. The crane operator pointed out that the position
where the injured signalman fell, provided adequate standing room between the deck
and the cranes jib. Without any witness, it was not possible to precisely establish
what had actually caused the injury to the signalman.

However, considering a single (covered by surgical stitches) wound on the frontal

region of the head (forehead midline) and the position where he was found, it was

25
possible that the signalman may have sustained fatal injuries from the uncontrolled
luffing wire rope but more likely from the broken pieces of the smashed air-vent pipe.
Figure 16 indicates numerous broken pieces spread under the cranes jib and at the
location where the injured signalman was found.

Figure 16: Metal debris under crane jib and location of injured signalman

26
THE FOLLOWING CONCLUSIONS AND SAFETY
ACTIONS SHALL IN NO CASE CREATE A
PRESUMPTION OF BLAME OR LIABILITY.
NEITHER ARE THEY LISTED IN ANY ORDER OF
PRIORITY.

27
3 CONCLUSIONS

Findings and safety factors are not listed in any order of priority.

3.1 Immediate Safety Factor

.1 The immediate cause of death was trauma to the head following the fall of the
crane jib on the main deck.

3.2 Latent Conditions and other Safety Factors

.1 Available evidence did not indicate that pre-starting checks were carried out in
the presence of the stevedores.

.2 Available evidence indicated that the hazards or preventive measures during

the operation of the cranes were not confirmed by the stevedores.

.3 The nature of the damage on the luffing wire rope drum at the bitter end, the
luffing wire rope and a bent holding down bolt indicated that the securing
arrangement fastening the luffing wire rope to the drum must have been
excessively stressed.

.4 According to the masters explanation, the luffing wire came off the bitter end
of the wire luffing drum and that this indicated that the crane jib was operated
at angles beyond the permissible limits during the cargo operations.

3.3 Other Findings

.1 The MSIU was not provided with a technical explanation from the crane
manufacturers as to how the slanting of the grab could have led to this failure.

.2 No evidence was submitted to confirm that this slanting of the grab operation
was logged in the ships logbook.

.3 The reach of the loading grab covered the full width of the barge.

.4 An inspection of the barge did not reveal any protrusions or obstructions

which cold have snagged the grab or the hoisting wire rope.

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 .5 Following the accident, both the chief engineer and the service engineer found
the safety limit switches and the luffing wire rope drum brakes in good
working condition.

.6 The mass of the lift of the grab (with coal) was within the manufacturers
permissible limits.

.7 The environmental conditions had no adverse effect on the operation of the

crane.

.8 The formal risk assessment and the risk control measures were implemented
after the cargo operations had started.

4 RECOMMENDATIONS

In view of the conclusions reached and taking into consideration the safety actions
taken during the course of the safety investigation,

Genel Denizcilik Nakliyati A.S. is recommended to:

29/2014_R1 Retrofit audible and visual alarms, which will activate automatically
when the stop button is pressed on the deck cranes fitted on ships under its
management.

29/2014_R2 Conduct safety meetings with crew members to define safety

occurrences and highlight the importance of reporting them to the vessel
management team.

IHI-WMMP is recommended to:

29/2014_R3 Fit audible and visual alarms on new deck cranes, which activate
automatically when the emergency stop button is pressed.

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LIST OF ANNEXES

Annex 1 Job Sheet

Annex 2 Risk Assessment Form

Annex 3 Service Engineer Report

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Annex 1 Job Sheet

31
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Annex 2 Risk Assessment Form

33
Annex 3 Service Engineer Report

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