Report of Investigation

into the fatal accident of the

Chief Officer of Spring Retriever

at Wu Song Shipyard in Shanghai, China

on 20 June 2011

The Hong Kong Special Administrative Region Marine Department

19 February 20 13

Purpose of Investigation

This incident is investigated and published in accordance with the Code of the International

Standards and Recommended Practices for a Safety Investigation into a Marine Casualty or

Marine Incident (Casualty Investigation Code) adopted by IMO Resolution MSC 255(84).

The purpose of this investigation conducted by the Marine Accident Investigation and

Shipping Security Policy Branch (MAISSPB) of Marine Department, pursuant to Merchant

Shipping Ordinance Chapter 281 section 51, 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.

Table of Contents

Page

1 Summary 1

2 Description of the vessel 2

3 Sources of information 4

4 Outline of events 5

5 Analysis 8

6 Conclusions 15

7 Recommendations 16

8 Submissions 17

1. Summary

1.1. On 20 June 2011 at time about 1120 while the Hong Kong registered general cargo ship Spring Retriever was berthing alongside a shipyard in China for repair, the Chief

Officer on board was killed by the No.1 derrick boom which swung towards him when he pressed the start button to start the hydraulic pump for the hydraulic system.

1.2. The boom of the No.1 derrick had been damaged in the Philippines during discharge

of cargo. Before sailing to China for repair, the boom was dismantled and placed in port-starboard direction across the forecastle deck. It was held in position at the

middle part of the boom by a cargo wire. The top end of the boom was lashed to a

guy post by steel wires. The gooseneck end was tied to the bitts using steel wire and

a tumbuckle. A fabricated steel-frame was used to support the boom and it was

welded on the deck.

1.3. On 19 June 2011, the vessel berthed at the Wu Song Shipyard in Shanghai, China.

On 20 June 2011, the Chief Officer attempted to slacken the cargo wire endeavoring

to prepare for the removal of the boom by the dockyard workers to the repair yard in

the afternoon.

1.4. After confirming that the hydraulic system had been changed-over to "Derrick" mode,

he went to the switch box, which is fitted on the derrick post and facing the boom,

and pressed the start button to start the hydraulic pump. When the hydraulic pump started running, the cargo winch rotated and pulled the boom up in the process. The Chief Officer immediately pressed the stop button to stop the hydraulic pump.

However, as the boom had already been lifted up above the vertical angle bar of the

metal frame. The lateral force acting on the gooseneck end of the boom due to

lashing wire and turnbuckle caused this end to swing towards him. The boom knocked the Chief Officer's helmet off and pushed his head against the hinge of the

switch box. As a result, his head was seriously injured. Despite immediate application of first aid by ship crew and followed by medical treatment in the hospital,

he died at 1230 the same day.

1.5. At the time of the accident, the weather was fine. Wind was northeasterly with force 4. The sea state was slight. The weather condition did not attribute to the accident.

1.6. The investigation into the accident reveals that the main contributing factors to the

accident was that the Chief Officer lacked of safety awareness and did not follow company procedure and instructions for operating the derrick.

2. Description of the vessel

Spring Retriever

2.1 Ship Information

Flag

Port ofRegistry

IMO No.

Call Sign

Type

Keel Laid

Gross Tonnage

Deadweight

Length (Overall)

Breadth

Main Engine

Engine Output (M.C.R.)

Service speed

Classification Society

Shipbuilder

Registered Owner

Management Company

Operator

Hong Kong, China

Hong Kong

9217814

VRCZ6

General Cargo Ship

8 December 1999

4,724

7,734

99.92 m

19.2 m

1 x B&W, Makita Corp - Japan 5L35MC (Mark 6)

3,236 kW (4,400 PS) at 210 RPM

13.3 knots

Nippon Kaiji Kyokai

Shin Kochijyuko Co., Ltd. (Japan)

Concept Shipping Limited (Hong Kong)

Dalian Chun An Ship Management Co., Ltd.

Dalian Chun An Ship Management Co., Ltd.

2.2 Spring Retriever has two cargo holds and four derricks, and the safe working load of

each derrick was 25 tonnes.

2.3 The vessel had a Master, 3 deck officers, 4 engineers, 8 ratings, 2 deck cadets and 2

engineer cadets at the time of the accident. The nationality of all the crewmembers

was Chinese.

2

Figure 1 - Spring Retriever

3

3. Sources of information

3.1 The Master, the Bosun, the Able-Bodied Seamen ofSpring Retriever.

3.2 The ship management company ofSpring Retriever.

4

4. Outline of Events

All times are local

4.1 On 9 June 2011, the Hong Kong registered general cargo ship Spring Retriever ( "the vessel") was alongside berth No. 3 at Hanjin Heavy Industries Corporation Shipyard, Port Subic, in the Philippines. The No. 1 derrick of the vessel was damaged by severe vibration under bad weather due to its improper stowage by the crew. The boom was bent and the gooseneck joint damaged. The crew lowered down the boom and disconnected the gooseneck joint, using the cargo wire of the cargo winch of No. I derrick for lifting the boom at its middle part until it was finally placed on the forecastle deck, as shown in Fig. 2A and 2B, before ship sailing. The cargo winch was operated by the crew at local position beside hydraulic motor of the winch.

4.2 The boom head was secured to the guy post on the port side of the vessel by wire ropes. The other end of the boom near to the gooseneck was supported by a steel-frame made of angle-bar and was welded on the deck to prevent the boom from moving at sea. The gooseneck end was lashed (in a forward direction) by steel wire and turnbuckle to the eye pad at the bitts. The steel wire of the cargo winch was being wrapped round the boom at its middle part with shackle and tautened up.

4.3 On 18 June 2011, the vessel arrived at Changjiangkou, Shanghai, China and dropped anchor in the anchorage. At 1650 on 19 June 2011 , she moored alongside at the Wu Song Shipyard. On the morning of 20 June 2011 , the ship superintendent, the Chief Officer (C/O) and the shipyard engineer inspected the boom and discussed the preparation work required for transferring it to the repair yard in the afternoon. Shipyard workers erected a platform near the boom head for disconnecting the lashing wires and the topping block of the derrick.

4.4 The shipyard workers left the vessel at about I 100. The C/O was in the forecastle deck, while the Bosun, the Able-Body Seaman (ABl) were working together on hatch covers of No. I cargo hold and the AB2 was transporting drums of paint on the main deck near the forecastle storeroom and pump room. Using walkie-talkie, the C/O asked the Bosun to change-over the hydraulic system, which serves either the mooring windlass or No. 1 derrick, from "Windlass" to "Derrick" mode before he starts the hydraulic pump. The Bosun then asked AB2 to change-over the system. After AB2 reported the job was done, the Bosun replied to the C/O that the hydraulic system had been changed over to the "Derrick" mode.

4.5 After a short while, the Bosun heard the starting and running noise of the hydraulic pump followed shortly by a loud bang. He and the two AB ran towards the forecastle deck. When the Bosun was half way up the stairs to the forecastle deck, he saw the C/O collapse on the deck in position between the derrick post and the boom. The C/O's head was seriously injured. He immediately informed the Master of the accident.

5

Boom head lashed and secured to the guy post at the ship's port side by wire ropes

A cargo wire wrapped round the boom at the middle of the boom and it was tautened by the cargo winch

A fabricated metal frame was welded on the deck to support the boom and prevent it from moving at sea

Lower end of the boom lashed with wire. A turnbuckle and a pad eye were used to tie this end in the forward direction to the bitts on the ship's starboard side of the forecastle deck.

Figure 2A - Photo showing the stowage of the boom on the forecastle deck before the accident.

FORECASTLE DECK

Slewing winch

Topping winch

Cargo winch Derrick post

Lower End ofBoom lashed by Wire and Tumbuckle to the Eye Pad at the Bitts

Position ofBoom before Accident

Figure 2B - plan view showing how the boom was secured on the deck.

6

4.6 At about 1120, the Master and other crewmembers arrived at the scene. They saw a

lot of blood on the face of the C/O, and on the deck underneath his head. First aid

was immediately administered to the C/O and he was immediately transported to

shore for medical treatment. He was certified dead in the hospital at 1230 on the

same day.

4.7 At the time of the accident, the weather was fine. The wind was northeasterly with

force 4. The sea state was slight.

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5. Analysis

Certification and experience of the Chief Officer

5.1 The Chief Officer (C/O) held a valid Certificate of Competency as Chief Officer

issued by the Shanghai Maritime Safety Administration of the People's Republic of

China and a Class 2 Licence (Deck Officer) issued by the Hong Kong Marine

Department. He served as a chief officer on board ships since June 2000 and

worked on a number of general cargo ships, including log carriers for about 4 years

and 7 months. He joined Spring Retriever the third time on 22 November 2010.

He was an experienced officer working on board the vessel.

Physical condition of the Chief Officer

5.2 The C/O passed medical examination before joining the vessel. The C/O had a

continuous rest period of slightly more than 12 hours before starting his work on the

date of the accident. Condition of health and fatigue at work of the C/O were not

attributed to causes ofthe accident.

The control system for No.1 derrick and windlass

5.3 The No.I cargo derrick and the mooring windlass on the forecastle deck were served

by one hydraulic system. A change-over valve is provided for manually switching

over between the two systems. Each slewing, topping and cargo winch of the No.1

cargo derrick is provided with a local control unit with an operating handle located

beside the winch. The three winches can be operated at a centralized remote control

station by means of a group of three hydraulic transmitter-receiver units.

5.4 The diagram in Fig. 3 illustrates the control system for No.1 derrick and the mooring

windlass. When the change-over valve is switched over to "Derrick' mode, the

slewing, topping and cargo winches of the derrick can be controlled at their respective

positions locally beside the hydraulic motors, or at a centralized remote control stand.

5.5 Figure 4 shows a hydraulic transmitter-receiver unit for remote control of a winch of

cargo derrick. Three transmitters, one each for the slewing, topping and cargo winch,

are grouped together and placed in the remote control stand. The receivers are

located beside the winches. Hydraulic pipes are used to connect between the

transmitters and receivers. A hand-operated hydraulic pump is provided to charge

up the hydraulic system for the transmitter-receiver units.

8

l ocal

Remote Slewing Cargo Mooring

Control $ Handle Winch Winch Windlass.__- .... .__~ -·"" ., - - - - - !'. ( ._ _ro -·"" .'-- - - - - - - - - - - - - - - ~

Direction control Valve- .- .- .- .- . . - .- .- .- . - .- .- .- .- .- .- .- .- . . - .- .- .-------- .- .

Fig. 3 - Hydraulic control system for No. I derrick and mooring

Transmitter Receiver

b

Figure 4 - hydraulic transmitter-receiver unit for remote control of a winch of cargo derrick.

9

The probable cause of swinging forward of the boom in the accident

5.6 After the accident, investigation by the company found that the gooseneck end of the

boom had been lifted up above the steel-frame for supporting the boom and swung

forward, but the head of boom was still secured to the guy post (Fig. 5, 6 and 7). As

such, it is deduced that the cargo wire had been pulled up as the cargo winch was

started thus caused the lifting of the derrick boom. The boom head secured by steel

wire to the guy post acted as a fulcrum. When it was lifted above the vertical

angle-bar of the steel-frame, the lateral force acting on the gooseneck end caused this

end of the boom to swing forwards. The forward motion of the boom was stopped

when it came in contact with the derrick post.

Figure 5 - the boom was lifted up and held in position by the cargo wire after the accident.

10

FORECASTLE DECK Position of the Boom before Accident

Position where the Deceased collapsed

Position ofthe Boom after Accident

Figure 7 - Plan view indicating the position of the boom before and after the accident and the position

where the deceased collapsed.

The probable cause of lifting up of the boom in the accident

5.7 The management company confirmed that the safety latch (L 1) for locking the local

control handle of the cargo winch in the stop/neutral position was not engaged and

that the brake of the cargo winch was not applied at the time of the accident. The

latch (L2) for linking the local control handle (the receiver) with the remote control

handle (the transmitter) had been engaged (see Figure 8). At the remote control

stand, the three control handles for No.1 derrick were locked in the stop/neutral

position and the by-pass valves were closed (with the bypass valves closed, the

remote control handles could no longer control the local control handles).

5.8 The management company had a previous accident happened on another vessel in

which the cargo hold hatch covers were moved accidentally without being attended

by ship crew when the hydraulic pump was started after the repair to the hydraulic

system was completed. It was found that the control handle for operating the hatch

covers had not been returned back to stop/neutral position before the repair started.

After the accident, the company had added the safety locking latches to all

11

hydraulically operated machineries on board company's fleet and revised the relevant

safety operation procedures.

Local control handle

- Safety latch (L1)

·· Remote control latch (L2)

Fig. 8 - position of the safety and remote control latches at the local control unit of the cargo winch

after the accident

5.9 According to the procedure, the safety latches (Ll) should be engaged after finish

operation of the derricks or before repairing of the hydraulic systems. The brakes of

the winches for the derrick should be applied. Before starting of the hydraulic pump,

safety latches (Ll) should be engaged.

5.10 There is no witness to confirm who had started the hydraulic pump. At the time of

the accident, only the C/O was on the forecastle deck. The start/stop buttons for the

hydraulic pump was fitted inside a metal switch box (with door) mounted on the

derrick post ofNo.1 derrick and coincidently facing the boom.

5.11 After the Bosun reported to the C/O that the hydraulic system had been changed-over

to "Derrick" mode, he heard the starting and running of the hydraulic pump and

followed by a loud bang. When the Bosun arrived at the scene, he found the C/O

collapse on the deck between the derrick post and the boom. The Bosun could also

confirm that the hydraulic pump had been stopped when he arrived at the scene.

5.12 It was deduced that the C/O had pressed the start button to starting the hydraulic

pump. Suddenly, he found the derrick boom was lifted up and swung toward him.

He immediately pressed the stop button. However, the heavy and fast moving

derrick boom continued to swing towards him, knocking off his safety helmet (the

safety helmet was found intact on the deck near the deceased) and pushed his head

against the hinge of the switch box which was level to his head. As a result, he was

12

seriously injured at his head and subsequently died in the hospital.

5.13 Theoretically speaking, the derrick boom should not move even after the hydraulic

pump was started because of the built-in safety devices in the system such as the

winch brakes and the safety latches. As the brake of the cargo winch was not

applied and the safety latch (L 1) was not engaged, there might be two possibilities

leading to the scenario depicted by the evidence.

5 .14 The first possibility was that after the lowering of the derrick boom on deck before

departure from the Philippines, the crew only placed the local control handle of the

cargo winch in the stop/neutral position without engaging the safety latch (L 1) and

they did not put the brake on to lock the cargo winch.

5.15 The second possibility was that while the C/O attempted to slacken the cargo wire

endeavoring to prepare for the removal of the boom by the shipyard workers in the

afternoon, he had disengaged the safety latch (L 1) and the brake of the cargo winch of

No. I derrick by himself or did not check their proper positions in accordance with the

company procedure and instruction before starting the hydraulic pump. The control

valve at the local control of the cargo winch being defective had been ruled out as the

company and the crew had checked and confirmed that the valve functioned normally

before and after the accident. The reason why the cargo winch started running after

the hydraulic pump was started was probably due to the local control lever was not

being placed exactly in the stop/neutral position and the brake for the cargo winch

was not applied. As the safety latch (L 1) was not engaged, it was possible that the

control handle might have deviated, albeit slightly, from its stop/neutral position due

to the fact that the hydraulic fluid in the transmitter-receiver system might leak after

idling for a period of time causing the control handle to move slightly out of its

neutral position.

Safety management system

5 .16 Safety procedure and instruction for operating functional hydraulic derricks is

available on board. In this incident, the No.1 derrick had been damaged and it had

to be dismantled and placed on deck by ship's crew before the ship sailed. That

required the local operation of winches to place the boom down on the deck.

However, there was no risk assessment conducted prior to the operation.

5 .17 When the vessel arrived at the repair yard in China, the ship management company

assigned the job for the removal of the boom of the No. l derrick to shipyard workers.

No risk assessment was conducted by the master. It is questionable whether or not

shipyard personnel had the knowledge and competency to operate the cargo winch

safely.

13

5 .18 The Chief Officer was working alone at the time of the accident. He did not follow

the safety procedure to ensure the engagement of the safety latch (L 1) for the local

control handle and the application of the brake on the cargo winch before starting the

hydraulic pump. It was quite obvious that he had not taken precautionary measures

to guard himself to the surrounding dangers before starting the hydraulic pump.

Moreover, he might not wear his safety helmet properly, as the helmet was found

intact lying on the deck beside his body. The safety awareness of the C/O was

considered inadequate.

Weather Conditions

5 .19 At the time of the accident, the weather was fine. The wind was northeasterly with

force 4. The sea state was slight. The vessel was secured alongside at the shipyard.

Weather conditions are considered not attributing to the accident.

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6. Conclusions

6.1. On 20 June 2011 at the time about 1120 while the Hong Kong registered general cargo ship Spring Retriever was berthing alongside a shipyard in China for repair, the Chief Officer on board was killed by the No.1 derrick boom which swung towards him when he had pressed the start button to start the hydraulic pump for the hydraulic system.

6.2. The boom of the No.1 derrick had been damaged in the Philippines during discharge of cargo. Before sailing to China for repair, the boom was dismantled and placed in port-starboard direction across the forecastle deck. It was held in position at the middle part of the boom by a cargo wire. The top end of the boom was lashed to a guy post by steel wires. The gooseneck end was tied to the bitts using steel wire and a turnbuckle. A fabricated steel-frame welded on the deck was used to support the boom.

6.3. On 19 June 2011, the vessel berthed at the Wu Song Shipyard in Shanghai, China. On 20 June 2011, the Chief Officer endeavored to slacken the cargo wire to prepare for the removal of the boom by the dockyard workers to the repair yard in the afternoon.

6.4. After confirming that the hydraulic system had been changed-over to "Derrick" mode, he went to the switch box, which was fitted on the derrick post and facing the boom, and pressed the start button to start the hydraulic pump. When the hydraulic pump started running, the cargo winch rotated and pulled the boom up in the process. The Chief Officer immediately pressed the stop button to stop the hydraulic pump. However, as the boom had already been lifted up above the vertical angle bar of the metal frame, the lateral force acting on the gooseneck end of the boom due to lashing wire and tumbuckle caused this end to swing forward towards him. The boom knocked the Chief Officer's helmet off and pushed his head against the hinge of the switch box. As a result, his head was seriously injured. Despite immediate application of first aid by ship crew and followed by medical treatment in the hospital, he died at 1230 the same day.

6.5. At the time of the accident, the weather was fine. Wind was northeasterly with force 4. The sea state was slight. The weather condition did not attribute to the accident.

6.6. The investigation into the accident reveals that the main contributing factors to the accident was that the Chief Officer safety awareness was weak and he did not follow the company procedures and instructions for the operation of the derrick (i.e. to ensure the engagement of the safety latch (Ll), which was designed for locking the local control handle of the cargo winch in the stop/neutral position, and applied the cargo winch brake before starting the hydraulic pump).

6. 7. The safety factor revealed by the investigation was that the Master of the vessel did not conduct risk assessment for arranging the damaged boom of the No.1 derrick for rep a Jr.

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7. Recommendations

7.1. A copy of the report should be sent to the owner/management company and the

Master ofSpring Retriever informing them the findings of the investigation.

7.2 The owner/management company of Spring Retriever is recommended to issue

notice/circular to draw the attention of their masters, officers and crewmembers to the

findings of the investigation, and to ensure that company's procedures and

instructions for operating hydraulic deck machineries on board ships are strictly

followed by the crew.

7.3 Copies of the investigation report should be provided to the Shipping Division (the

International Safety Management Section and the Mercantile Marine Office) for

information.

7.4 A Hong Kong Merchant lnforn1ation Note should be issued to promulgate the lessons

learnt from the accident.

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8. Submissions

8.1 In the event that the conduct of any person or organization is commented in a marine

safety investigation report, it is the policy of Hong Kong Marine Department to send

a copy of the draft report to that person or organization for their comments.

8.2 The draft investigation reports, in its entirety, have been sent to the owner I

management company and Master of Spring Retriever for their comments. There

were no comments received.

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