It took three years for the Federal Bureau of Maritime Casualty Investigation to thoroughly investigate a workplace accident on board a bulk carrier, in which a 32-year-old seaman was killed in August 2022 by several hundred kilograms of steel plates intended for welding work that toppled over.
In the port of Mukran, on August 3, 2022, a crew member aboard a bulk carrier was to cut the necessary material from a steel plate using a welding torch in order to manufacture a workpiece. The required plate was located in a vertically stacked pile of plates, secured against tipping by a steel crossbar, in a corner of the steering gear room.
The bulk carrier off Mukran. Photos: Hasenpusch/BSU
To remove the approximately 300 kg heavy steel plate from the stock, the later accident victim needed the support of several crew members, who were otherwise occupied on deck.
The seaman was therefore initially only supposed to carry out preparatory work and prepare the tools required for the welding job. About 1.5 hours after the work assignment, the ship's engineer entered the steering gear room and happened upon his colleague wedged between the overturned stack of panels and a shelf mounted on the wall.
The rowing machine room
After his unsuccessful attempt to free the unconscious sailor from his life-threatening situation alone, he rushed to the engine control room and informed three crew members present there. Together they went to the scene of the accident and freed the seriously injured victim from the weight of the steel plates. The rescuers then immediately began resuscitation efforts. In the meantime, a general alarm had been sounded on the ship.
First aid was in vain
The injured man was transported to the ship's aft main deck using a stretcher. The emergency physician arrived on board approximately 15 minutes after being alerted, but despite all efforts, he was unable to save the victim's life. The man died a few minutes later without regaining consciousness.
Since similar accidents with tragic outcomes have occurred very frequently worldwide in the past, the authorities derived numerous safety recommendations from the course of events regarding the storage and securing of such steel plates, which are intended for repair and welding work, are usually stored in the steering gear room, and are often inadequately secured, with weights of up to over 1000 kg stacked next to each other.
Tragic accident scenario
The plates in question were blanks from which the necessary components for onboard repairs were cut using a welding torch. On the day of the accident, the stock of plates consisted of rectangular plates measuring approximately 300 cm x 130 cm x 1 cm and weighing a total of approximately 1800 kg. The stock also included remnants of steel plates from which segments of varying sizes had apparently been cut in the past.
Stack weighing tons
At the start of the site inspection, the stack of planks, which normally leaned against a solid, yellow-painted railing approximately 1.20 m high, had toppled against a wall shelf opposite, used for storing pipes and rods. The railing in question formed the port-side enclosure of a rectangular area where barrels were stored.
Although there was a safety device to prevent tipping over the stack, which ultimately weighed several tons, the distance between the vertically stacked panels and the shelf was less than a meter. The locking point on the opposite side of the stack could only be safely reached by the accident victim working there with difficulty and by taking time-consuming detours.
One rope alone is not enough.
The consequence was that, although the stack – when it was unlocked to prepare for the intended work – could not completely topple over, a person standing between the stack and the shelf would inevitably be crushed at the hips or torso if the stack started moving again. The sailor had no space behind him to escape to safety after releasing the last rope in case the stack of plates suddenly shifted.
Ship movements are unavoidable
The accident victim was properly equipped with protective gear, including a helmet, overalls, and safety shoes. However, he did not have a radio with him at the time. Camera surveillance, which the operator is now considering, was not yet in place in that part of the ship at that time. It is stated that handling and bailing procedures, and the resulting ship movements, are unavoidable on a bulk carrier operating in port. This includes movements that caused the sudden tipping and tilting of the stack of pallets. It is particularly tragic that a safety meeting with the shipping company's management had taken place just the day before.
In 2012/2013, accidents involving such steel plates on board a container ship (ER Stralsund) and a multi-purpose freighter (Red Cat), as well as on board the Maltese tanker Amur Star in 2023, led to serious accidents.
Multipurpose freighter Red Cat in 2022
At the time of the accident, the bulk carrier in Mukran possessed an internationally valid "Safety Management Certificate" and thus also a ship safety manual approved by the flag state's administration. However, the specific topics of stowage, securing, and working with steel plates were not addressed comprehensively in the document, which was designated as a "Health and Safety Manual." This is now set to change.
"If possible, steel plates should be stacked horizontally in a location where lifting equipment can be used to move and lift them. If the steel plates must be stored vertically, they should be stacked in racks equipped with a mechanical device that prevents the plates from tipping over until the locking mechanism is removed and the plates are handled. Suitable lifting equipment and tools must be available at the workplace.".
klk./U.Kaspera
Investigation reports, safety recommendations, lessons learned
