Report of investigation

into the fatal accident of

a crane operator on board

dumb lighter “Chun Wah”

in Shenzhen Waters

on 13 September 2007

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Purpose of Investigation

This incident is investigated, and published in accordance with the IMO Code for the Investigation of Marine Casualties and Incidents promulgated under IMO Assembly Resolution A.849(20). The purpose of this investigation conducted by the Marine Accident Investigation and Shipping Security Policy Branch (MAISSPB) of Marine Department is to determine the circumstances and the causes of the incident with the aim of improving the safety of life at sea and avoiding similar incident in future.

The conclusions drawn in this report aim to identify the different factors contributing to the incident. They are not intended to apportion blame or liability towards any particular organization or individual except so far as necessary to achieve the said purpose.

The MAISSPB has no involvement in any prosecution or disciplinary action that may be taken by the Marine Department resulting from this incident.

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Table of Contents Page

1 Summary 1

2 Description of the Vessels Involved 2

3 Sources of Evidence 4

4 Outline of Events 5

5 Analysis of Evidence 9

6 Conclusions 13

7 Recommendations 14

8 Submissions 15

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1. Summary

1.1 An industrial accident happened on board a Hong Kong licensed dumb lighter "Chun Wah" loaded with boulders when under tow in Shenzhen waters, near Bao An Airport on 13 September 2007. While a crane operator was carrying out repairs to the braking system of the winch of derrick crane near an open edge at the 3rd level of the “A”-mast, he lost his balance and fell down to the bottom of the cargo hold and sustained fatal injuries.

1.2 The investigation revealed that the accident was caused by the failure to observe the safe working practice of wearing safety harness while working aloft.

1.3 The accident was also contributed by the loss of concentration of the deceased under the influence of medications and tiredness.

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2. Description of the Vessels Involved

2.1 "Chun Wah"

Certificate of Ownership No.: B21655V Certificate Issuing Authority : Hong Kong Marine Department Type of Vessel : Class II, Dumb Lighter, Cat.B Year of Built : 1994 Built At : Wuxi Shipyard, Jiangsu Owner : Ming Fat Petroleum Company Limited Length : 44.49 metres Breadth : 19.20 metres Depth : 4.88 metres Gross Tonnage : 1,878.92 Net Tonnage : 1,315.24 Engine Power : N.A.

Fig. 1: Dumb Lighter "Chun Wah"

"Chun Wah" (hereinafter referred as the “Lighter”) (see Fig.1), is a locally licensed single-hold dumb steel lighter. It usually engages in transporting constructional materials in Hong Kong waters and river trade limits. It is fitted with a derrick crane with safe working load ranging from 10 to 60 tons to facilitate cargo handling operations. The derrick crane with an “A”-mast is located at forward part of the Lighter. A winch for driving the crane is located on the 3rd level at the “A”-mast.

“A”-mast

Winch of derrick crane at 3rd level

of “A”-mast

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2.2 "Chun Ming 3"

Certificate of Ownership No.: B3634 Certificate Issuing Authority : Hong Kong Marine Department Trade of Vessel : Within river-trade limits Type of Vessel : Class II, Tug, Cat.A Year of Built : 1993 Built At : Xiangzhou Shipbuilding Repair Factory, Zhuhai,

Guangdong Owner : Eastwell Marine Engineering Limited Length : 23.42 metres Breadth : 6.82 metres Depth : 3.26 metres Gross Tonnage : 145.86 Net Tonnage : 91.82 Engine Power : 637.83 kW No. of Crew : 2

Fig. 2: Tug "Chun Ming 3"

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3. Sources of Evidence

a) Coxswain and engine operator of the tug “Chun Ming 3”

b) Assistant crane operator of the Lighter

c) Weather report of the Shenzhen Meteorological Administration

d) Autopsy report of the deceased

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4. Outline of Events

4.1 On the afternoon of 11 September 2007, the Lighter was under tow by a tug “Chun Ming 3” (hereinafter referred as the “Tug”) leaving Tuen Mun to Shenzhen. There were a crane operator and an assistant crane operator on the Lighter. At about 0200 of 12 September 2007, the Tug and Lighter arrived at a pier of a quarry at Fuyong, near the Bao An Airport (previous name “Huang Tian Airport”), Shenzhen.

4.2 The cargo handling work was then commenced. Boulders of weight ranging from 10 to 20 tons on shore were picked up by a steel grab of the derrick crane of the Lighter and loaded into its cargo hold. The two crane operators of the Lighter worked in a roster, each in charge of the derrick crane for 3 to 4 hours and then had a rest of 3 to 4 hours. The cargo loading work was carried out day and night.

4.3 At about 1100 of 13 September 2007, the cargo loading work was finished. The Lighter was then towed by the Tug leaving the quarry pier to Shekou.

4.4 After the vessels had left the quarry pier, the crane operators of the Lighter went to the 3rd level of the “A”-mast at the forward part of the Lighter to carry out repairs to the braking system of the winch of derrick crane because it had been found not functioning properly during boulders loading.

4.5 They removed the machinery guards from the wheels of the winch. The assistant crane operator placed the guards on the floor. The crane operator crawled into the space in between the wheels of the winch near the open edge of the floor to adjust a screw of the brake band. Suddenly the assistant crane operator heard the yelling of the crane operator. He found the crane operator lying at the bottom of the cargo hold of the Lighter (see Figs.3, 4 & 5). It was about 1200.

4.6 The assistant crane operator rushed down to the hold and found the crane operator was unconscious with bleeding from his head. He went to the deck of the Lighter and operated the mooring winch to heave the towlines in order to alert the Tug since there was no other means of direct communication with the Tug.

4.7 The coxswain of Tug found his vessel had slowed down. He looked at aft and found the towlines being shortened. He realized that an incident had happened on the Lighter and he steered the Tug to alongside the Lighter. Then the assistant crane operator dropped anchors to keep the Lighter stationary in emergency.

4.8 The coxswain and engine operator of Tug went on board the Lighter. They managed to remove the unconscious crane operator from the cargo hold to the Tug. The coxswain of

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Tug telephoned the quarry at Fuyong for help. Then the Tug left the Lighter hurry back to the quarry pier.

4.9 After about 20 minutes, the Tug arrived at the quarry pier. A doctor came on board and certified that the crane operator was dead after examination.

4.10 At about 1400, the Tug left the quarry pier conveying the deceased back to Hong Kong.

Fig. 3: Approximate Position of “Chun Wah” in Shenzhen Waters at the Time of Accident

Shenzhen Bao An Airport

Shekou

Lau Fau Shan New Territories

Approximate position of Lighter

Quarry Fuyong

Pearl River

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Fig. 4: The Deceased Fell from “A”-mast at the Time of Accident on "Chun Wah"

“Chun Wah”

“A”-mast

Derrick boom

The deceased at bottom of cargo hold after falling

The deceased

Assistant crane operator

Falling path

Winch of derrick crane

Boulders

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Fig. 5: The Deceased Fell from 3rd Level of “A”-mast to Bottom of Cargo Hold on "Chun Wah"

5. Analysis of Evidence

The deceased

The deceased after falling

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Working experience & training

5.1 Both the deceased and the assistant crane operator (the deceased’s younger brother) had more than twenty years experience working on dumb lighters. From time to time they used to carry out minor repairs to the winches of derrick cranes.

5.2 The Merchant Shipping (Local Vessels) (Works) Regulation requires that there should be at least one person on board a vessel who has completed the works supervisor safety training in order to supervise the safety of works carried out on board. But such requirement will not be mandatory when a local vessel is outside Hong Kong waters, such as in Shenzhen waters. Both crane operators of the Lighter had not attended the works supervisor safety training course.

5.3 Even though it is not mandatory, for safety of work an employer should ensure that all repair work carried out on board is supervised by a works supervisor who has completed the works supervisor safety training.

Fatigue

5.4 During the cargo handling from 12 September 2007 to the day of accident (i.e., 13 September 2007), the deceased and the assistant crane operator worked 3 to 4 hours and then had the rest of 3 to 4 hours. Such interrupted resting periods might have made them tired and easy of loss of concentration.

5.5 The Maritime Labour Convention 2006 of ILO recommends that hours of rest may be divided into no more than two periods, one of which shall be at least six hours in length, and the interval between consecutive periods of rest shall not exceed 14 hours.

Autopsy report

5.6 According to the autopsy report of the deceased furnished by the Department of Health, the cause of death was multiple injuries which is consistent with a fall from a considerable height.

5.7 Codeine, a narcotic analgesic drug commonly used in cough mixtures, was found in the blood of the deceased. Chlorpheniramine, an antihistaminic drug commonly used in cold medications, was also found in the blood. Both drugs may cause side effects of drowsiness and sedation. The side effects may add up in an individual who takes the two drugs at the same time.

The workplace

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5.8 The winch of derrick crane is located on the 3rd level of the “A”-mast on the forward part of the Lighter.

5.9 At the time of accident, the deceased was working at the aft side of the winch. He was near the open edge of the floor where no fencing was erected to prevent fall of persons (see Figs.6 & 7). When he was adjusting the screw of the brake band of the winch, he was located at less than 300 mm from the open edge.

Fig. 6: The Winch of Derrick Crane at 3rd level of “A”-mast on "Chun Wah"

Fig. 7: The Open Edge at Aft Side of Winch of Derrick Crane on "Chun Wah"

5.10 As the deceased worked near the open edge, there was a risk for him to fall more than 11

Guardrails

No fencing to prevent fall of person at aft side of winch

Winch of derrick crane

Winch of derrick crane

Open edge

Cargo hold

Brake band

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metres to the bottom of the cargo hold. At the time of accident, the deceased might lose concentration due to irregular resting periods or drowsiness under the influence of the medications he had taken, he lost his balance and fell over the open edge down to the cargo hold.

The environment

5.11 At the time of the accident, the state of weather was normal. The weather condition was not considered to be a contributory factor of the accident.

Towing voyage

5.12 There is no requirement of towing survey on the Lighter and Tug for towing voyages plying river-trade limits.

5.13 When a dumb lighter is under tow, it would be subject to sudden movements as affected by sea conditions. Under such conditions, it would be risky to carry out works aloft without taking adequate safety precautions.

Safe working practices

5.14 The Code of Practice on Using Protective Clothing and Equipment for Works on Local Vessels issued by Hong Kong Marine Department in January 2007 states that all persons working at height (aloft), outboard, below decks or in any other area where there is a risk of falling more than two metres, should wear a safety harness attached to a lifeline as far as reasonably practicable.

5.15 The Shipbuilding and Ship-Repairing Safety Guide issued by Hong Kong Marine Department states, “A safety harness, which is to be suitably anchored while in use, should be worn when working aloft.”.

5.16 Working aloft is risky. It is not advisable to work aloft on board a dumb lighter when it is under tow. If the work has to be done due to urgency, suitable safety measures such as wearing a safety harness attached to a lifeline should be taken. There was a safety harness kept on board the Lighter but it had not been used at the time of accident. Had it been used, the accident could have been prevented.

Communication

5.17 There was no means for direct communication between the Lighter and Tug at the time of accident. The assistant crane operator of the Lighter had to heave the towlines in order to

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alert the Tug for help.

5.18 Suitable means of communication device such as walkie-talkie or mobile telephone should be provided between the towing vessel and the vessel being towed to facilitate communications in an emergency.

5.19 When a vessel is in an emergency in Shenzhen waters, the local maritime authority, i.e., the Shenzhen Maritime Safety Administration, should be called immediately for help.

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6. Conclusions

6.1 An industrial accident happened on board a Hong Kong licensed dumb lighter "Chun Wah" loaded with boulders under tow in Shenzhen waters, near Bao An Airport on 13 September 2007. While a crane operator was carrying out repairs to the braking system of the winch of derrick crane near an open edge at the 3rd level of the “A”-mast, he lost his balance and fell down to the bottom of the cargo hold and sustained fatal injuries.

6.2 The investigation revealed that the accident was caused by the failure to observe the safe working practices of wearing safety harness while working aloft. Safe working practices recommended in the Shipbuilding and Ship-Repairing Safety Guide and the Code of Practice on Using Protective Clothing and Equipment for Works on Local Vessels had not been observed.

6.3 The accident was also contributed by the loss of concentration of the deceased under the influence of medications and tiredness.

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7. Recommendations

7.1 A copy of this report should be sent to the employer of crane operators of the Lighter, owner of the Tug and Shenzhen Maritime Safety Administration advising them the findings of this accident.

7.2 A Marine Department Notice should be issued to promulgate the lessons learnt from this fatal accident, drawing the industry's attention on the findings of this accident and urging them to observe the following safety practices in order to prevent recurrence of similar accidents:

when working aloft where there is a risk of falling more than two metres, workers should wear a safety harness attached to a lifeline as far as reasonably practicable. Such recommendations are stipulated in the Code of Practice on Using Protective Clothing and Equipment for Works on Local Vessels and the Shipbuilding and Ship-Repairing Safety Guide;

workers should be aware of the danger of carrying out high risk work such as working aloft when feeling tired or under the influence of medications. Any worker on board who has taken medications should inform his employer or person in charge of vessel;

no repair work should be carried out on board unless it is supervised by a works supervisor who has completed the works supervisor safety training.

suitable means of communication device such as walkie-talkie or mobile telephone should be provided between the towing vessel and the vessel being towed to facilitate communications in an emergency;

when a vessel is in an emergency in Shenzhen waters, the local maritime authority, i.e., the Shenzhen Maritime Safety Administration, should be called immediately for help; and

workers should have reasonable rest period in order to prevent onset of fatigue, particularly at high risk work. A tired worker may endanger himself as well as other workers working with him.

7.3 The General Guide to Safety during Towing and Lightering Operation issued by Marine Department should be enhanced with the lessons learnt from this accident.

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8. Submissions

8.1 In the event that the conduct of any person or organization is criticized in a casualty investigation report, it is the policy of the Hong Kong Marine Department that a copy of the draft report is given to that person or organization so that they have the opportunity to rebut the criticism or offer evidence not previously available to the investigating officer.

8.2 The draft report was forwarded to the following:

Assistant crane operator of the Lighter

The employer of crane operators of the Lighter

The owner of the Tug

8.3 No submission was received from the above-mentioned parties.