Report of Investigation into
the fatal accident of
a slinger on board Kam Ying
at Kwun Tong Typhoon Shelter
on 9 April 2011
13-7-2012
Purpose of Investigation
This incident is investigated, and published by the Marine Accident
Investigation and Shipping Security Policy Branch (MAISSPB) of Marine
Department pursuant to Merchant Shipping (Local Vessels) Ordinance Chapter
548 Section 40, is to determine the circumstances and the causes of the incident
with the aim of improving the safety of life at sea and avoiding similar incident
in future.
The conclusions drawn in this report aim to identify the different factors
contributing to the incident. They are not intended to apportion blame or liability
towards any particular organization or individual except so far as necessary to
achieve the said purpose.
The MAISSPB has no involvement in any prosecution or disciplinary action that
may be taken by the Marine Department resulting from this incident.
Table of Contents Page
1 Summary 1
2 Description of the Vessels 2
3 Sources of Evidence 4
4 Outline of Events 5
5 Analysis of Evidence 11
6 Conclusions 16
7 Recommendations 17
8 Submissions 18
1
1. Summary
1.1 On 9 April 2011 at 1600, a fatal accident happened on board the Hong
Kong licensed Dumb Steel Lighter Kam Ying at Kwun Tong Typhoon
Shelter, Hong Kong.
1.2 Kam Ying was alongside the Chinese registered river trade vessel Bo
Hai Yun 118. Kam Ying unloaded the waste papers bales on board
using her derrick crane to Bo Hai Yun 118.
1.3 After a slinger engaged cargo slings on a waste paper bale in the eighth
bay at the second tier, he walked aside and waited for the next
unloading operation. While the bale was transferring towards Bo Hai
Yun 118, fifteen bales at the fifth, sixth and seventh tiers of the eleventh
bay collapsed and crushed the slinger.
1.4 The slinger was sent to the hospital for treatment and was certified dead
on 10 April 2011.
1.5 The investigation revealed the main contributory factor of the accident
was that there was no proper cargo planning and risk assessment. The
bales were transferred in a way leaving the bales at the eleventh bay
stacking like a wall without securing. The bales collapsed due to
rolling motion of the dumb steel lighter caused by movement of the
cargo, wind and wave motion.
2
2. Description of the Vessels
2.1 Particulars of Kam Ying
Certificate of issuing authority: Hong Kong Marine Department
Certificate of Ownership No. : B22078Y
Type of Vessel : Dumb Steel Lighter Class II B
Year of Built : 1981
Owner : Hand G-Well (International Holdings)
Ltd.
Length : 34.75 metres
Breadth : 13.94 metres
Gross Tonnage: 760.47
Net Tonnage: 532.33
Engine Power: N.A.
Fig 1 Kam Ying
3
2.2 Particulars of Bo Hai Yun 118
Port of registry: Hui Zhou, China
Registration No.: 090410000217
Type of Vessel: Container
Year of Built: 1993
Built at: Panyu Lingshan Shipyard
Owner : Zhou Hui Guang
Length : 45.85 metres
Breadth : 11.85 metres
Depth: 3.3 metres
Gross Tonnage: 737.00
Net Tonnage: 412.00
Engine Power: 434 kW
No. of Crew: 4
Fig 2 Bo Hai Yun 118
4
3. Sources of Evidence
a) The Master of Bo Hai Yun 118
b) The works supervisor of Kam Ying
c) The crane operator of Kam Ying
d) The signaller of Kam Ying
e) Autopsy report by the Department of Health
5
4. Outline of Events
4.1 On 8 April 2011, Bo Hai Yun 118 (the Vessel) departed Boluo, China at
about 1500. She arrived and anchored at Kwun Tong Typhoon Shelter,
Hong Kong at about 0500 on 9 April 2011.
4.2 At about 0830, the Vessel berthed her starboard side at the port side of
Kam Ying (the DSL), by that time the DSL had been moored with her
starboard alongside the pier (Fig 3).
4.3 At about 0830, the DSL started unloading waste paper bales on board
and transferred the bales to the Vessel. The cargo plan of the DSL
before unloading was as shown in Fig 4. Four workers participated in
the cargo handling on board the DSL, they were a works supervisor, a
signaller, a slinger and a crane operator (Fig. 3).
4.4 From 0830 to 1600, about 300 paper bales from the fourth to tenth bays
on board the DSL were unloaded to the Vessel using the derrick of the
DSL.
4.5 At about 1600, the slinger engaged a cargo sling on a bale at the second
tier, fifth row, eighth bay and then stepped aside. The signaller, who
stood on the port main deck, gave a hand signal to the crane operator to
lift the bale.
4.6 When the crane operator used the derrick crane to transfer the bale to
the third bay of the Vessel, he observed that many bales at the eleventh
bay on board the DSL were collapsing. He immediately stopped the
derrick crane.
4.7 The signaller went to the cargo hold and found the slinger lying on the
bale of first tier, fifth row, eighth bay. The slinger was conscious with
blood on his face.
6
4.8 The slinger was sent to the hospital for treatment and was certified dead
later in the hospital.
3rd
Bay
2nd
Tier
Wheelhouse
No.4 bale from
starboard side
Accommodation
1st
Bay
8th
Bay
11th
Bay
4 tier
4 tier
3 tier
3 tier
2 tier
1 tier
1 tier
1 tier
1 tier
1 tier
7 tier
Accommodation
DSL “KAM YING”
BO HAI YUN 118
Signaller
Slinger (the deceased)
Crane
operator
A
B
A
B
4
4
4
6
6
6
6
6
7
6
6
Nos. of tiers at
about 0830am
Nos. of tiers at time
of accident (1600)
Kerry D.G. Warehouse (Kowloon Bay) Limited
Kowloon
Godown
Boarding Access
Works supervisor
Fig 3 Berthing Plan of the Vessels
11th row 1st row
10
Wind
Vessel rolling due to wind and wave motion
wave
Fig 7 DSL rolling due to external forces and movement of cargo
DSL rolling due to movement of cargo
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5. Analysis of Evidence
Working experience & training
5.1 The Master has worked as master on board the Vessel for two years.
He held a Certificate of Competency issued by Huizhou Maritime
Safety Administration, China as a River Trade Vessel Master. He had
completed the mandatory basic safety training of the shipboard cargo
handling and works supervisor safety training in 2010. His training
certificates were valid at the time of the accident.
5.2 The works supervisor of the DSL held a valid basic safety training
certificate of shipboard cargo handling and certificate of training of
shipboard works supervisor. He was certificated to work as a works
supervisor on board the DSL.
5.3 The crane operator of the DSL held a valid basic safety training
certificate of shipboard cargo handling and certificate of training of
shipboard crane operator. He was certificated to work as a crane
operator on board the DSL.
5.4 The signaller of the DSL held a valid basic safety training certificate of
shipboard cargo handling.
5.5 The slinger (the deceased) held a valid basic safety training certificate
of shipboard cargo handling.
Working hours
5.6 All four workers attended the DSL at 0800 on 9 April 2011 and the
cargo operations started at 0830. There was no evidence to show that
the workers had suffered from fatigue.
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The environment
5.7 At the time of the accident, the wind speed was 20 kilometres per hour.
There was moderate breeze, small waves could have generated at sea.
Personal protection equipment
5.8 The slinger (the deceased) worn safety helmet and reflective vest
during cargo operation at the time of the accident.
The autopsy report
5.9 According to the autopsy report issued by the Department of Health,
the direct cause of death was due to retroperitoneal hematoma, pelvic
fracture and vertebral fracture. The injuries were consistent with
crushing by heavy object.
Maintenance of the derrick
5.10 The annual examination of the derrick, its lifting appliances and lifting
gears on board the DSL were examined by a competent examiner on 7
November 2010. The certificates of test and examination were valid at
the time of the accident.
5.11 The weight of a waste paper bale was about one tonne. The safety
working loads of the derrick, lifting appliances and lifting gears are
much higher than one tonne. There was no evidence to show that the
derrick, appliances and lifting gears were overloaded.
Stacked cargo safety practice
5.12 Person in charge of works should conduct risk assessment for each type
of cargo operations. He should also continually review the risk
assessment from fresh risks arising from changes in operational
environment or modes of operation.
5.13 Before unloading, the cargo plan of the DSL is shown in Fig. 4. The
bales were then unloaded to the Vessel and before the accident, the
cargo plan of the DSL is shown in Fig. 5. The bales had been unloaded
in such a way that the bales in front of the eleventh bay (i.e. sixth to
tenth bays) were unloaded to remain only one tier of bales while
leaving the bales in the eleventh bay stacked up to seven tiers high. It
is apparent that the cargoes were unloaded in a convenient manner
without proper cargo planning and risk assessment.
5.14 Shipboard Cargo Handling Safety Guide issued by the Marine
Department stated that effective measures should be taken at all times
to prevent the collapse of stacked cargo. In this accident, the works
supervisor should have assured the stacked waste paper bales being
firmly secured at all times during cargo operation. When the stacked
cargoes became unstable, they should be rearranged and properly
secured before continuing the cargo operation. However, in this
accident, the paper bales were unloaded in a way leaving a single row
of bales of seven tiers stacking like a wall. The wall-like stack of paper
bales possessed high risk of collapse.
Contravention of Merchant Shipping (Local Vessels) Ordinance
and Regulation
5.15 In is apparent that the Person in Charge of the DSL did not conduct any
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risk assessment nor take measures to secure unstable cargoes. As a
result, a single row of bales of seven tiers collapsed. Therefore, he
might contravene the following Ordinance and Regulation:
Merchant Shipping (Local Vessels) Ordinance Cap. 548, section
45(1) stipulates that “ A person in charge of works shall not carry
out, or cause to be carried out, any works in a condition or
manner that does not provide adequately against unnecessary risk
of accident or bodily injury”
Merchant Shipping (Local Vessels) (Works) Regulation, Cap
548I, section 64 stipulates that “ Where stacking, unstacking,
stowing or unstowing of cargo or handling in connection with
such cannot be safely carried out unaided, reasonable measures
to guard against accident shall be taken by shoring or otherwise”.
Possible cause of the accident
5.16 The dimension of a paper bale was about 2.13 metres (length), 1.06
metres (breath) and 1.06 metres (height). When the paper bales were
stacked at a height of seven tiers, it was about 7.42 metres. The base of
the bales was not flat and would become unstable when being stacked
high. Therefore highly stacked bales were vulnerable to collapse
5.17 Fifteen bales stowed at the eleventh bay on board the DSL collapsed
while a paper bale was being transferred from the DSL to the Vessel,
therefore it was believed that the collapse was caused by movement of
the bale. When the bale was transferred from the DSL towards the
Vessel, the centre of gravity of the DSL would shift towards the port
side thus caused the DSL to roll (Fig7). Therefore the bales collapsed
due to rolling of the DSL.
14
15
5.18 The DSL may also be moved by wind and wave motion. At the time of
accident, the wind speed was about 20km/hour and small waves might
have been generated. The degree of movement of the DSL, while
transferring cargo overboard, could be multiplied by effect of wind and
wave motion (Fig.7).
Safety awareness
5.19 Works supervisor involving in cargo operation of stacked cargo should
take effective measures at all times to prevent collapse of stacked
cargo. It is evident that in this case, the person in charge of the DSL
was not aware of the risk and did not take any measures to secure the
stacked bales firmly.
5.20 It is evident that there was no proper cargo planning and risk
assessment of cargo operations and the bales were unloaded
indiscriminately without assessing the hazard of unsecured stacked
bales.
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6. Conclusion
6.1 At about 1600 on 9 April 2011, a fatal industrial accident happened on
board the local dumb steel lighter Kam Ying at Kwun Tong Typhoon
Shelter, Hong Kong.
6.2 Waste paper bales stacking on board Kam Ying were transferring to the
river trade vessel Bo Hai Yun 118 using the derrick of Kam Ying.
6.3 While a paper bale was transferring from Kam Ying to Bo Hai Yun 118,
some top paper bales stacked at the eleventh bay toppled and crushed
onto a slinger staying at first tier, eighth bay on board Kam Ying.
6.4 The investigation revealed the main contributory factor of the accident
was that there was no proper cargo planning and risk assessment. The
bales were transferred in such a manner that the left bales at the
eleventh bay stacking like a wall without securing. The bales collapsed
due to rolling of DSL caused by movement of the DSL, wind and wave
motions.
6.5 Another contributory factor was that there was a lack of safety
awareness of the person in charge and workers of Kam Ying in handling
of stacked cargo.
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7. Recommendations
7.1 A copy of the report should be sent to owners and person in charge of
Kam Yin advising them the findings of the accident.
7.2 The owners and person in charge of Kam Ying are required to:
Take proper risk assessment involved in the operations of stacked
cargoes and preventive measures to minimize the potential risks;
and
Secure stacked cargoes properly in a stable condition at all times.
7.3 A Marine Department Notice should be issued to promulgate the
lessons learnt from the accident.
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8. Submission
8.1 In the event that the conduct of any person or organization is
commented in an accident investigation report, it is the policy of the
Marine Department to send a copy of the draft report to that person or
organization for their comments.
8.2 The final report was sent to the owners and person in charge of Kam
Ying for their comments. There was no comment received from them
at the end of the consultation period.