2.1.FIRST INVESTIGATIONS
When the instructions were received, the container vessel had already departed. We
contacted several Euromax departments to gather information.
The accident was not witnessed by the other members of the gantry crane team or crew of the
vessel. The crane driver of gantry crane 35 was busy offloading a cargo hatch and the 3rd
member, the Radioman Shore, had no direct view on the cargo hold. The other members of
the gantry crane team suspected something was wrong after radio contact was lost.
Reportedly crew of the vessel was not present near the accident site.
Since the Euromax employees were mainly focusing on stabilizing and resecuring the victim, not many photographs were taken and the walkway, from where the victim fell, was not properly investigated and photographed.
It was found that an inspector of the Dutch Labour Inspectorate and the Police Department
investigated the accident scene. Via the Police Department 4 photographs of the front
walkways, apparently taken within short time after the incident, were received.
The police photographs showed that several turn buckles were laying around on top of the
front walkway of the cargo hold. (…)
3. INCIDENT DESCRIPTION
(…)
The RAD declared that he instructed the crane driver to remove the cargo hatch whilst he was
still busy closing the walkway passages. Whilst the RAD was busy closing a passage, he
stepped on a turnbuckle and lost his balance. (…)
5. PROCEDURE / PRACTICE
If a vessel arrives at EMX with untidy walkways, covered with lashing material, the RAD has to tackle the crew of the vessel and urge them to remove it.
Unsafe situations always have to be reported to the EMX supervisor. The supervisor contacts
the vessel and discusses who will remove the unwanted items. On payment, EMX can also
remove the lashing material.
In principle, EMX will not start unloading/loading activities if the walkways are unsafe.
In case EMX takes care of the unlashing of containers, employees of EMX are required to
place the lashing material in the dedicated bins. The crew of the vessel will sign a certificate of approval before departure of the vessel.
In practice, lashing material is sometimes temporary stored on the walkways in places were
containers will be re-loaded. Storing lashing material and retrieving it from the dedicated bins
is time consuming. (…)
6 CAUSE OF ACCIDENT:
The accident was caused by a combination of factors.
The container vessel arrived with untidy walkways, with lashing material laying
around. The RAD indicates he spoke to several crew members about removing the material laying around.
Then the gantry crane shifted to [baai] and removed one of the cargo hatches. The
RAD’s first priority was then to close the safety chains of the adjacent walkways.
For this, he had to walk over the untidy walkways which had (yet) not been cleared
by the crew.
As he was walking over the front walkway, he stepped on top of a turnbuckle
which was laying on the floor plate. He lost his balance, tumbled through an
opening in the railing and fell in the cargo hold.”