Ladder Accident Attributed to Weak Safety Culture

The New Zealand Transport Accident Investigation Commission (TAIC) has released its report on the injury of a crew member during ladder operations on the container ship Moana Chief, citing weak safety culture on the part of the vessel’s operator.

The incident occurred in the Port of Auckland on December 10, 2021 when the container ship Moana Chief was preparing to leave port. The crew had started to retrieve its telescopic accommodation ladder for stowing. A crew member’s leg was seriously injured when trapped between the fixed upper ladder and the moving lower ladder.

The crew member was standing in an area that had previously been identified and designated as a danger area. The accommodation ladder slipped off the Port platform on which it was resting. The slack side chains allowed the ladder to drop; the ladder's weight transferred to the fall wire, which caused the lower ladder to slide upwards, trapping and seriously injuring the crew member's leg.

TAIC says its final report shows why equipment should be operated by people who understand how to use it safely, and why safety management systems should require ongoing monitoring and review of risk control effectiveness. It further states that it is very likely that the accident could have been prevented by other crew members nearby if they had told the ladder winch operator that a crew member was in the danger area.

Two key safety issues were identified:

Weak safety culture at Moana Chief's operator: The operator did not identify the possibility of the accommodation ladder falling off the platform, as a hazard and it took no measures to control the risk. TAIC Recommendation 006/23 is that Swire Shipping review its safety management system to ensure that safety leadership is developed at all levels within the organisation.

Lack of safety guidance for telescopic accommodation ladders:  Non-conformance to operating procedures, and a diffusion of responsibility with respect to oversight and supervision are symptomatic of more systemic issues regarding the safety culture onboard. TAIC Recommendation 007/23 is that Maritime NZ develop and disseminate clear guidance to highlight the inherent risks associated with telescopic accommodation ladders.

TAIC further notes that the crew retrieving the accommodation ladder did not take appropriate safety measures, as specified in the vessel's Safety Management System. Deploying and retrieving accommodation ladders can be dangerous and often involves ships’ crews working over the side of the vessel. Telescopic accommodation ladders have moving parts that further increase risk of injury. All users should understand how to operate the equipment safely in accordance with the manufacturer’s instructions.