NZ TAIC released results of investigation into an accident with Moana Chief crew
Actions to retrieve the accommodation ladder were not consistent with the procedures documented in the vessel's Safety Management System
Transport Accident Investigation Commission (TAIC) reports that on the morning of 10 December 2021, the container vessel Moana Chief was preparing to leave the Port of Auckland. The crew had started retrieving the telescopic accommodation ladder when a crew member’s lower leg got trapped between the fixed upper ladder and the moving lower ladder, resulting in serious injury to their leg.
As crew members were retrieving the accommodation ladder, it slipped off the Port platform on which it was resting. The slack side chains allowed the ladder to drop and the weight of the ladder was transferred to the fall wire, which caused the lower ladder to slide upwards. A crew member, who was standing in an area that had previously been identified and designated as a danger area, was seriously injured.
Actions to retrieve the accommodation ladder were not consistent with the procedures documented in the vessel's Safety Management System. Several control measures listed in the risk assessment for deploying and retrieving the accommodation ladder were not implemented.
It is very likely that the accident could have been prevented, if other crew members standing in the vicinity had intervened and alerted the winch operator to a crew member standing in the designated danger area.
Deploying and retrieving accommodation ladders can be a dangerous operation, and often involves ships’ crews working over the side of the vessel. A telescopic accommodation ladder has several moving parts that further increase risk of injury. It is important that users understand how to operate the equipment safely in accordance with the manufacturer’s instructions.
Risk assessment and management of a hazard does not end with the implementation of risk controls. Monitoring and reviewing the effectiveness of the risk controls is an ongoing process and should be formalised into the Safety Management System.
Operators of telescopic accommodation ladders, vessel owners and operators, maritime training facilities and shore-based emergency response agencies may all benefit from the findings in this report.
Any organisation using a safety management system to assess risks and manage hazards, including monitoring the effectiveness of their processes which is essential for safe outcomes, may also benefit.
