Conflicting work activities were taking place when the incident occurred, and there was no common situational awareness.

The incident’s beginning lies in certain assumptions made by both the crewmembers and the freight driver. The crewmembers operated under the assumption that freight movement would only commence upon explicit instructions from the designated authority figure. Their belief in the red flashing lights being an effective safety measure to regulate freight movement created overconfidence, contributing to the incident. Additionally, they trusted that the presence of the bosun in the freight vehicle’s path would deter any untimely movement of the freight vehicle. However, the bosun, who was in the blind sector of the freight vehicle, could not be seen by the freight driver, so he did not provide any physical deterrence.

Conversely, the experienced freight driver held his assumptions. Upon seeing a thumbs-up signal from the linkspan operator (which actually confirmed the freshwater hose had been connected), the driver interpreted it as a clear directive to proceed, ignoring the red flashing lights.

The presence of the bosun in a blind spot, invisible to the driver, cancelled out the intended human barrier to prevent movement. CHIRP advocates using physical barriers instead of relying on human presence – even a coloured rope is better than nothing. CHIRP also recommends that the linkspan operators who are not ship’s staff should wear different coloured surcoats/hi-vis tabards.

Several significant takeaways emerged from this incident. It highlighted the inherent hazards linked with vehicle decks and underscored the importance of addressing blind spots. Direct eye contact with drivers emerged as a fundamental communication strategy, but one which can be mistaken by the freight drivers, emphasising the importance of unambiguous signals.

The incident also demonstrated that in the absence of a physical barrier, drivers might initiate movement at their discretion, regardless of control measures like the red flashing lights. The incident highlighted the normalisation of risk, underscoring the necessity of sustained vigilance, even for familiar and routine operations.

Ultimately, the incident serves as a reminder that even skilled crewmembers and freight drivers can face danger during routine tasks. It underscores the importance of clear and universally understood communication, particularly within hazardous environments on RoRo cargo ferries. Thankfully, the bosun did not suffer any physical injuries.

An IMCA video highlighting the risks of placing yourself in front of a hazard can be found here: Line of fire – IMCA (imca-int.com)

CHIRP strongly commends the management of the RoRo ferry for such an open and honest review of this incident report. Such incidents are rare, but CHIRP is sure that the company’s safety culture has improved, and the lives of those working on the ferries will be safer.