The New Legend Pearl
Fatal fall from height on bulk carrier, New Legend Pearl, 3 November 2016
Status
Closed
Occurrence Date
Report Publication Date
Jurisdiction
NZ
On the morning of 3 November 2016, the bulk carrier New Legend Pearl was east of Coromandel Peninsula on passage between the New Zealand ports of Bluff and Marsden Point. The crew were attempting to change a hoisting wire on one of its cargo cranes. Part-way through the task the hoisting wire snagged on the crane jib that was resting in its cradle, about eight metres above the hatch cover.
One of the crew donned a safety harness and climbed up onto the crane jib, secured the lanyard of his harness around a luffing wire and walked along the jib to unsnag the wire. However, the lanyard prevented him reaching the snag, and he was in the process of transferring the lanyard to a different securing point when he lost his balance or slipped and fell eight metres to the deck below. He died from his injuries.
The Transport Accident Investigation Commission (the Commission) found that it was about as likely as not that the locking mechanism for the safety harness hook was not engaged, which allowed the lanyard to roll or burst out of the hook when the crew member fell, and that the safety harness was not suitable for the intended task.
The Commission also found that:
- the risk assessment conducted prior to the crew starting the wire replacement on crane number 2 did not fulfil the requirements of the operator's safety management system, because it did not adequately identify and manage the risks associated with the task
- the repeat failures of the crew to comply with safe working practices when working at height and the acceptance of using a substandard wire on a working crane are indications of a poor safety culture on board the New Legend Pearl.
The Commission identified two safety issues: the operator's risk assessment process did not prevent the crew member working at height with an inadequate fall-protection system; and both the safety management system and the underlying safety culture on board did not meet industry good practice.
The Commission made one recommendation to the flag state for the New Legend Pearl to address these safety issues.
The key lessons arising from the inquiry are:
- working at height is a risky activity and all crew should use suitable safety harnesses that are fit for the intended tasks
- working at height is a risky activity that must be properly managed using a formal risk assessment methodology
- attaching a safety harness by passing it through or around the securing point and back onto the lanyard is a dangerous practice that can result in inadvertent release unless the lanyard and hook are designed for that purpose.
One of the crew donned a safety harness and climbed up onto the crane jib, secured the lanyard of his harness around a luffing wire and walked along the jib to unsnag the wire. However, the lanyard prevented him reaching the snag, and he was in the process of transferring the lanyard to a different securing point when he lost his balance or slipped and fell eight metres to the deck below. He died from his injuries.
The Transport Accident Investigation Commission (the Commission) found that it was about as likely as not that the locking mechanism for the safety harness hook was not engaged, which allowed the lanyard to roll or burst out of the hook when the crew member fell, and that the safety harness was not suitable for the intended task.
The Commission also found that:
- the risk assessment conducted prior to the crew starting the wire replacement on crane number 2 did not fulfil the requirements of the operator's safety management system, because it did not adequately identify and manage the risks associated with the task
- the repeat failures of the crew to comply with safe working practices when working at height and the acceptance of using a substandard wire on a working crane are indications of a poor safety culture on board the New Legend Pearl.
The Commission identified two safety issues: the operator's risk assessment process did not prevent the crew member working at height with an inadequate fall-protection system; and both the safety management system and the underlying safety culture on board did not meet industry good practice.
The Commission made one recommendation to the flag state for the New Legend Pearl to address these safety issues.
The key lessons arising from the inquiry are:
- working at height is a risky activity and all crew should use suitable safety harnesses that are fit for the intended tasks
- working at height is a risky activity that must be properly managed using a formal risk assessment methodology
- attaching a safety harness by passing it through or around the securing point and back onto the lanyard is a dangerous practice that can result in inadvertent release unless the lanyard and hook are designed for that purpose.
Location
Northland (-36.573611,176.767500) [may be approximate]