The UK’s Marine Accident Investigation Branch (MAIB) released its investigation findings on a fatal accident that occurred in December of 2015. The investigation and report concluded that the engineer who died in that accident was not wearing appropriate personal protective equipment, that there were serious oversights in deck operations, and major lapses between official company safety policies and the actual working practices of the maritime employees involved.
The Fatal Accident
The accident occurred on December 29, 2015 in Bristol in the UK. An engineer aboard the tugboat Svitzer Moira died in the accident which occurred when the tugboat maneuvered to be alongside another, unmanned tugboat. The Svitzer Moira was supposed to move this other tugboat, the Svitzer Ellerby. The engineer, Kevin Jackman, fell during the process and was crushed between the two boats.
There was no direct witness to what happened to Jackman, but likely events were outlined by the MAIB’s investigative report. The master of the tugboat was probably in the wheelhouse at the time of the accident and could not see the engineer. Another deckhand was also on the boat, but could not see the engineer from his position either.
The report concluded that the engineer likely tried and failed to attach the mooring ropes from the Svitzer Moira to the tugboat from his position on the first boat. As a result, he attempted to move from one boat to the other and fell, probably after slipping or tripping. There were several trip hazards in the vicinity and the second tugboat was not well lit in the darkness.
Deck Operations and Safety Risks
The MAIB investigation into this tragic accident uncovered several errors, mistakes, and omissions in safety that likely contributed to the death of the engineer. One major issue was the fact that there had never been an assessment made of the risks of moving tugboats in the port. Because this was a common maneuver, a risk assessment should have been done to protect workers.
The investigation also found that Svitzer had a safety management system that included control measures for deck operations that if followed could have prevented the accident. These outlined measures were not all followed. For instance the engineer was not wearing the personal protective equipment outlined in the safety management system. He should have been wearing a personal flotation device and slip resistant safety boots, but he was not.
Because the workers involved in the accident were performing a routine job of moving the tugboat, they made assumptions about the procedure and failed to communicate with each other. The master did not communicate with the engineer and couldn’t see him during the maneuver. He assumed the engineer would move from one boat to the other when it was safe, but this was an assumption that led to the accident.
Part of the company’s safety management system for a maneuver like the one performed in this situation included communication between the master and engineers. The engineer was not supposed to transfer to the other tugboat without verbal permission from the master. The lack of communication and assumptions made may have contributed to the death of the engineer.
The accident that occurred in Bristol in 2015 demonstrates how important safety procedures are and how serious it can be to make assumptions, to ignore safety equipment, and to fail to communicate with other workers. While the company had detailed safety management control measures in place, it was the responsibility of the company to ensure they were being used and to enforce their use. If better oversight had been in place for these workers, the death could have been prevented.
In response to the accident and the report, Svitzer has initiated a review of safety procedures. It has also claimed to be dedicated to changing the culture of safety aboard its vessels. It has also promised to investigate risk assessments of routine maneuvers like moving tugboats around the port.