Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2107
Initial Report
Our reporter wrote: “The cruise ship was on an adjacent pier beside where we were berthed. Three members of their crew were in the process of recovering their paint raft with three seamen onboard from the port side forward mooring station extendable platform when it became stuck underneath one of the pier fenders and tilted badly, causing all three crew members to fall in the water from an approximate height of 2 meters.
All of them were wearing floating devices/lifejackets and managed to climb back onboard the raft as no vertical ladders were on the dock. Once onboard, two other attempts were made to hoist the raft using the telescopic crane fitted on their mooring station. However, it got stuck both times again under the mooring fenders causing the crew to fall again into the water!
Once back onboard, they swapped sides and were finally recovered from the starboard side platform, which was not initially used because of the fresh easterly breeze that created choppy seas in the harbour.
None of them was wearing any safety harness attached to the sling and raft. Unfortunately, this practice (very common in the cruise industry) of lowering/hoisting a manned paint raft is hazardous and should be discontinued. In addition to that, no supervisors and officers were supervising the job, and even after the accidents, none showed up!”
CHIRP Comment
The lack of supervisory leadership enabled a very unsafe situation to develop. A comprehensive plan must be developed for any lifting operation, based on a comprehensive risk assessment. The positioning of the fender made this operation very difficult to carry out safely.
Equipment used to lift people must be designed specifically for that purpose and lifting operations must be adequately supervised by a qualified person. IMCA Guidelines for Lifting Operations is a useful reference: https://www.imca-int.com/product/guidelines-for-lifting-operations/
CHIRP questions why the work party continued working after the first time that they fell into the water. Fortunately, their lifejackets prevented a more serious outcome.
The Flag State has contacted the company about this incident.
Key Issues relating to this report
Local Practices – Lifting people on paint rafts that are not designed for this purpose is a safety violation. If in doubt, ask to see the lifting test certificate.
Pressure – The corporate pressure to maintain the vessel’s cosmetic standards led to poor decision-making: this task should have been rescheduled until weather conditions improved or it was carried out at another port.
Culture – At a minimum, every company’s safety culture should empower its employees to prioritise safety over the achievement of a task and report hazards or incidents that compromise safety. If this is not the case on your vessel, you can report this to CHIRP.
Alerting – Seek ‘stop work’ authority if you believe that a task is unsafe and bring your concerns to the attention of a senior officer. Incident reporting is vital if lessons are to be learned and repeat incidents are avoided.
Pressure – Given the work being undertaken, time pressure was likely a factor in the work not being adequately supervised and rushed. Could this work wait until the ship called at a port where more time was available?
Teamwork – The “group think” by the three crew on the paint raft led to the incident happening three times. Good leadership would have prevented this from happening.