During the early morning of 14 November 2018, the New Zealand-registered deep-sea factory trawler San Granit was engaged in trawling about 55 nautical miles (102 kilometres) east of Banks Peninsula.
At approximately 0350 a deckhand who was working on the factory deck went to talk to the freezerman. The deckhand approached the working area forward of the freezers and noticed that the freezerman was trapped in a piece of machinery known as an accumulator. The deckhand immediately notified the factory supervisor, who in turn notified the bridge and then the master.
The ship’s medic arrived at the scene and with assistance from another crew member removed the freezerman from the accumulator. The medic conducted a primary assessment of the freezerman and determined there were no signs of life.
The vessel immediately returned to port and arrived in Timaru at approximately 1600 the same day.
The Transport Accident Investigation Commission (Commission) found that the freezerman became trapped in the accumulator and received fatal injuries. The Commission was unable to determine why the freezerman entered the guarded area, but it may have been to clear a jammed box of fish.
The Commission also found that the freezerman’s blood methamphetamine level indicated that it was virtually certain that methampthetamine had been consumed whilst at sea. Due to the varying effects this substance has on an individual, it was not possible to determine whether it contributed to the accident.
The Commission identified two safety issues:
- the risks associated with operating the accumulator were not fully understood and the safety controls relied heavily on the machine operator following generic instructions and procedures
- the training in place for the crew around the configuration of the emergency stops likely resulted in confusion on which emergency stops serviced which system.
Sanford Limited (the owner/operator) has since addressed the risks of operating the accumulator by conducting a full safety assessment of the automatic plate freezer area on board the San Granit. It has also implemented engineering controls to mitigate a person’s risk of becoming trapped within the accumulator. The Commission believes that this safety action addresses the first safety issue and therefore has not issued a recommendation.
However, the Commission is concerned that crew members of the San Granit may not have received appropriate training in identifying which emergency stop to use for which system. Therefore, the Commission has made a new recommendation that Sanford implement training for the crew on the configuration of the emergency stops to avoid confusion on which emergency stop services which system. This will reduce the likelihood of crew accessing running machinery after pressing an incorrect emergency stop.
The Commission repeats one key lesson made in a previous report:
- it is not acceptable under any circumstances for workers to be affected by performance-impairing substances, regardless of what roles they are performing.
The Commission identified one new key lesson:
- carrying out a task analysis on any piece of machinery is an important safety function that helps to identify foreseeable hazards associated with its use and identify best practicable control measures that can be introduced to reduce the risk to operators. When it is not possible to eliminate an identified hazard, a task analysis will help to ensure robust operating procedures are in place, which in turn will assist in the development of future user training requirements.
