The Case Of The Bosun’s Omen
May 14th, 2008 by bobcouttie
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When Lee played pontoon, the heavyweights were inclined to clobber him.
He should have seen it coming.
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We’ll call him Lee. Not his real name, but he was a real person. He’d worked for his manning company as a deck rating for more than two decades and was promoted to Bosun in 2003, around two years before the incident, so he had years of experience under his belt before his ship, the general cargo vessel J. Real docks at the Taiwan port of Suao in January 2005.
The J. Real is 110 metres length overall, registered in Hong Kong and in class with Japan’s Nippon Kaiji Kyokai.
m/v J. Real
She has two cargo holds equipped with MacGregor hatch covers. This type of hatch cover consists of a series of steel pontoons linked by steel chains, each weighing around 1.5 tonnes, which move along the hatch coamings. They’re opened by winching them to the forward or aft end of the hatch, where they tip up into the vertical in a continuous action. They’re fitted with interlocks and rubber packing to make them watertight when closed. To prevent them opening accidentally, a metal pin is inserted through an eye on either side of the first of each series of pontoons and fits into a hole in the hatch coaming. It is a simple enough safety device.
Arrangement of the hatch covers on m/v J.Real
On the J. Real Number 2 hold, the forward part of the hatch cover consists of five pontoons and the aft part covered by four pontoons, closed by a winch.
It’s 21st January 2005 in the port of Suao, Taiwan and at 1156 the J. Real comes alongside No. 10 berth to load cargo. She’s trimmed about 2 metres by the stern.
At 1500 the hatch covers are opened for loading but the weather promises rain, and it delivers within fifteen minutes. Cargo operations are suspended at 1515 and, to keep the cargo holds dry, the crew start to close the hatch covers.
By 1625, the four aft pontoons are in place but there’s a problem. The pin stoppers won’t fit into place because the pontoons are misaligned with the holes in the hatch coaming. So the crew find a thin, rusty piece of wire, thread it through the pontoon tab and the hole in the hatch coaming, job done.
Safety arrangements on the hatch covers
Lee climbs on top of the closed hatch covers, toward the rear, to supervise the closing of the forward covers. From there he’ll pass signals to the winch operator aft.
Bosun’s position before the incident
The forward hatch covers start to close, then, the already closed aft hatch covers on which Lee is standing suddenly start to move backwards, opening by themselves, each pontoon swivelling to the vertical and slamming together. Lee tries to jump clear but the covers are moving too fast, he’s slammed between three tonnes of steel pontoon. He’s crushed.
There’s no easy way to separate the pontoons. The crew quickly find a hydraulic jack and pull what remains of Lee from between the pontoons.
In hospital, at 1753, Lee is pronounced dead.
The bosun is caught between the hatchcovers
If you’ve seen the movie The Omen you’ll see how bad things happen not because a single element goes wrong, but several little things combine to create disaster: A senior American official is trapped in a traffic jam at an intersection, a petrol truck is parked on a steep hill with just a bit of stone to stop it moving back, someone is smoking, an old man pulls a steel manhole cover on a piece of rope. The manhole cover knocks the stone holding the petrol truck, the truck rolls downhill into the official’s car and petrol pours out, the smoker throws down his cigarette butt, the petrol reaches the cigarette butt and ignites, causing an explosion that kills the American official in a dramatic and horrible way.
Lee’s death could have been a scene in that movie. Let’s see how it was constructed.
The J. Real was trimmed 2 metres by the stern. That gave her an incline of about 1 in 50. Not much, but enough to give the heavy steel pontoons on the aft hatch cover a tendency to open if other conditions were in place.
When the aft hatch covers were closed, the holes for the pin stopper didn’t align so a thin piece of rusty wire was used. If the hatch covers moved, that wire would be expected to hold back six tonnes of steel.
Of course, the weight of those six tonnes might have been enough to induce sufficient friction to overcome their tendency to close automatically. And they did, for a while.
The fore and aft hatchcovers moved along the raised hatch coaming, so when the fore hatch covers were being winched closed, the vibration of their seven and a half tonnes would have been transmitted along the coaming to the aft covers, prehaps enough to overcome friction, put the full weight on the thin rusty wires which snapped, allowing the aft hatches to close automatically.
Even with all that, it only became a disaster because Lee was standing on top of the hatch covers. The winch operator had a good field of view across the deck so Lee could have given his signals from almost anywhere, he didn’t have to stand on the pontoons.
But he did. And that’s what killed him.
More sadly, not only was it a predictable event, it was one that had been predicted and recommendations made to avoid it. Let’s look at the company SMS.
First, the SMS for hatch cover operations says “two safety pins or two wire ropes to be used”. In other words, it predicted the possibility that there might be a problem inserting the pin stoppers and gave a solution, two wire ropes. What was used was one rusty bit of wire. If the SMS had been followed, the hatch covers would not have opened.
Second, the SMS says that trim and list should be reduced as much as possible. It wasn’t.
Third, it says that no-one should stand on top of the hatch covers for signalling. The risk was foreseen, and that is the tragedy.
The official report by the Hong Kong Marine Department Maritime Accident Investigation and Shipping Security Policy Branch puts the incident down to the crew’s lack of safety awareness, poor working practices and not following procedures laid down in the SMS.
It doesn’t ask why safe procedures were not being followed.
There several reason why they might not have been working safely: They might not have received adequate training; they might have been trained correctly but got into bad habits or just forgotten their training;they might have been in such a hurry to close the hatch covers that they forgot about safety; they might not have read the SMS or even, as has happened in other cases, been forbidden from reading it, they might have thought it was weak, cowardly or unmanly to think about safety; or maybe they just weren’t interested in staying alive. What is certain is that there was no safety culture at that time aboard the vessel that killed Lee.
In the majority of cases that we come across that involve seafarer deaths and injuries the procedures laid down in the SMS haven’t been followed.
The real objective of an SMS is to ensure that crew members don’t get hurt and the ship is sailed safely. But, the fact is that it’s often seen as just another piece of paperwork that’s onboard just because some regulation says it should be. That’s the wrong attitude.
Perhaps the problem is that, too often, a ship’s SMS is a passive presence sitting in a binder or on a hard disk, and someone has to make the effort to read it and put it into play.
It may be that if the SMS is to make a more functional contribution to safety then we have to look at how to make it an active part of a seafarer’s working life, something he regards as an essential tool.
As seafarer you have a right to working conditions that are as safe as they can reasonably be but you also have a responsibility to work as safely as you reasonably can and be pro-active. You owe it to your workmates and you owe it your family.
It doesn’t matter how long you’ve been at sea, Lee, after all, was a mariner with long experience, and those who get injured, or die, often do have a lot of experience.
Look around your own ship at the work you do and how you do it and what hazards there might be. Take a look at the SMS, especially those parts that relate to the work you do, check that you are following the right procedures. Look for those ‘omens’ that something isn’t right.
Make a point of occasionally talking about safety with your crewmates and, yes, share Maritime Accident Casebook podcasts with them and other seafarers.
And next time you play pontoon, remember Lee.
This is Bob Couttie wishing you safe sailing.
Here’s someone else who found out that standing on hatch covers isn’t a good idea.
Click here
This case has another name 2 it. It is called complecency which is the result of ennui imbedded in actions and reactions of all humans who have served at the same job for years.
I have often observed this in my long carrier of 45 years in the marine field at sea as well as ashore. Those who continue to work in the same field appear to consider themselves to near God if not God. In the end God punishes them for their erroneous isms.
The solution has always been to bring them face to face with the realities. The Management is accountable for the innovative manner in which it filfills this responsibility.
The Bosun should have under surveillance by the Chief Officer or the Mate. Where were these great men?
SMS is nothing very gr8. It only empathises with the human beibgs and it’s implied message is that the life of u’r crew is more precious than u’r own.
Service before self is the underlying motto.
When we review implementation strategies we must follow this motto.
Mr. Mistry