PARIMAL BHATTACHARY Death - M/V ¨IBRA LNG¨ _____ Accidents Investigator

Panama Maritime Authority Directorate General of Merchant Marine

Investigation of Wrecks and Maritime Accidents Department Panama, Republic of Panama

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CASUALTY INVESTIGATION

REPORT

S.S. “IBRA LNG”

PARIMAL BHATTACHARY Death - M/V ¨IBRA LNG¨ _____ Accidents Investigator

Panama Maritime Authority Directorate General of Merchant Marine

Investigation of Wrecks and Maritime Accidents Department Panama, Republic of Panama

Page 2 of 63

INDEX

SL. NO. CONTENTS

PAGE NO.

1. SUMMARY 5

2. FORWARD 6

3. DESCRIPTION OF VESSEL 6

3.1 GENERAL DATA 7-8

3.2 MANNING 9

4. INCIDENT VOYAGE 9

4.1 SEQUENCE OF EVENTS 10-13

4.2 DEATH CERTIFICATE 14

4.3 OFFICIAL LOG BOOK ENTRY 15-17

5. ACTION TAKEN BY CREW 18

6. ACTION TAKEN BY COAST GUARD 19

6.1 POST MORTEM REPORT 19

6.1.1 INJURIES 20-21

6.1.2 OPINION AS TO CAUSE OF DEATH 22

6.2 DETAILS OF CASUALTY 22

7. INVESTIGATION 23

7.1 INVESTIGATION INITIATION 24

7.2 ELEVATOR DETAILS 24-25

7.3 LAY OUT OF ELEVATOR 26-28

7.4 PERIODIC MAINTENANCE 29-31

PARIMAL BHATTACHARY Death - M/V ¨IBRA LNG¨ _____ Accidents Investigator

Panama Maritime Authority Directorate General of Merchant Marine

Investigation of Wrecks and Maritime Accidents Department Panama, Republic of Panama

Page 3 of 63

8. FLEET NOTICE 32

8.1 SAFETY SYSTEM OF CAGE AND DOOR 32-33

8.2 SAFETY IN ELEVATOR HOIST WAY 33

8.3 SAFETY IN MACHINE ROOM 34-35

8.4 SAFETY DURING MAINTENANCE 35

8.5 PREPARATION FOR MAINTENANCE/INSPECTION PROCEDU 35-36

8.6 POINTS TO CONSIDER DURING MAINTENANCE 37-38

8.7 CONFIRMATION OF WORK COMPLETION 39

9. COMPANY’S PROCEDURE 39

9.1 FAMILARISATION 39

9.2 IBRA LNG ELEVATOR 40

9.3 MAINTENANCE AS PLANNED 40

10. INCIDENT INVESTIGATION 40-43

10.1 DATA GATHERING 43

10.1.1 PEOPLE 43-53

10.1.2 ENVIRONMENT 54

10.1.3 THE EQUIPMENT 54-55

10.1.4 PROCEDURE 55

10.1.5 THE ORGANISATIONAL FACTOR 56

11. APPARENT CAUSE ANALYSIS 57-60

12. CONCLUSION 60-61

13. RECAPITULATION 61-62

PARIMAL BHATTACHARY Death - M/V ¨IBRA LNG¨ _____ Accidents Investigator

Panama Maritime Authority Directorate General of Merchant Marine

Investigation of Wrecks and Maritime Accidents Department Panama, Republic of Panama

Page 4 of 63

14. RECOMMENDATION 63-65

15. OUTCOME OF THE INCIDENT 65

LIST OF APPENDIX SL. NO. APPENDIX NO. PARTICULARS

01. APPENDIX – 1 : AUTHORIZATION LETTER FROM PMA.

02. APPENDIX – 2 : D.G. SHIPPING’S LETTER TO PMA.

03. APPENDIX – 3 : SHIP’S CERTIFICATES.

04. APPENDIX – 4 : SHIP’S PARTICULARS & CREW LIST.

05. APPENDIX – 5 : CHART SHOWING DIVERSION POINT.

06. APPENDIX – 6 : MASTER’S FORMAL CASUALTY REPORT.

07. APPENDIX – 7 : CALCULATION SHOWING HOW THE ELEVATOR SETTLED AT UPPER DECK.

08. APPENDIX – 8 : LIST OF ABBREVIATIONS.

PHOTOGRAPHS : IN CD.

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1. SUMMARY

LNG vessel SS “IBRA LNG” was on her way from Singapore to Qalat LNG

Terminal in Oman. The vessel had sailed on her ballast voyage from Singapore on

29th January 2007. On 03.02.07 approx at 1425 hrs L.T. ( S.M.T. on board ), some

shouting was heard from the Elevator shaft and was found that the Electrician, Mr.

Ioan Cumpat, was trapped in inverted position at the side of the elevator at level

between “A” and “B” decks of the accommodation levels on the vessel. The vessel

was at position 070 58.9 N and 0760 43.2 E in the Arabian Sea and the speed of

the vessel was reported 15 Knots at that time.

Ship’s crew then made an attempt to rescue him from the trapped condition and

though initially he was found to be in a conscious state although he had an open

wound and a fractured leg. But approx around 1450 hrs L.T. he lost his

consciousness before he could be freed from his trapped position. Vessel then

altered course towards Trivandrum Port in order to receive medical assistance. At

1520 hrs L.T. vessel course was altered towards Cochin as per the advice of the

Owners. He was ultimately made free and was taken to the ship’s hospital at 1530

hrs L.T. and was rendered cardiac compression and artificial respiration. The

vessel was in touch with the local Indian Coast Guard for medical advice. The

electrician was under constant watch by the ship’s crew and whatever medical

advice was received from shore was duly administered by the ship’s staff

continuously. At 1615 hrs L.T. it was felt that no revival of the casualty was

possible. At 1650 hrs L.T., Mr. Ioan Cumpat did not show any vital signs and his

breathing stopped, eyes were dilated and there was no pulse beat in his body.

Finally, as per the instruction of the local Indian Coast Guard, the vessel anchored

at 1755 hrs L.T., in position 080 21’ N and 0760 57’ E. By this time Mr. Ioan Cumpat

had expired. At 1830 hrs L.T. Mr. Ioan Cumpet’s body was lowered into a Fishing

boat Olympia as per instruction of the local Coast Guard. At 1940 hrs L.T. the

Coast Guard confirmed that Mr. Ioan Cumpat was dead when they received the

body in their custody.

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It is reported that the Electrician was carrying out routine maintenance of the

Elevator and while doing so, he accidentally fell in an awkward position which

resulted in his eventual death.

2. FORWARD

On being informed about the casualty on board SS “IBRA LNG”, the Panama

Maritime Authority, Casualty Department was in contact with Director General of

Shipping, Bombay, India, and the Shipping Company, M/s Oman Ship

Management Co. Ltd., who apprised them about the casualty.

The Panama Maritime Authority, Casualty Investigation Branch, appointed

Mr. P. K. Bhattacharyya of Henderson Int’l (India) Pvt. Ltd., Kolkata, India as

Principal Investigator on 28.02.07 to carry out casualty investigation in the matter

of death on board SS “IBRA LNG”, IMO No. 9326689, of Mr. Ioan Cumpet, who

was employed as an Electrician on board the vessel.

The principal investigator met with the Master, Chief Engineer and the, DPA on

05th – 06th March 2007 on board the vessel and inquired about the events prior to

the Accident on 03rd February 2007 and also the subsequent events till the body of

Mr. Ioan Cumpat was discharged from the vessel and handed over to the local

Indian Coast Guard.

3. DESCRIPTION OF VESSEL

SS “IBRA LNG” is an 147000 m3 LNG carrier powered by 36510 PS MCR Steam

Turbine running at 87.7 rpm. The vessel was built at SAMSUNG HEAVY

INDUSTRIES, Korea on August 2006. The vessel is provided with 4 no. cargo

tanks of membrane type.

The vessel is fitted with one set of electric motor driven counter weight type

personnel elevator in the accommodation area which moves from Engine Room

floor upto below navigator bridge deck within an enclosed steel trunk.

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3.1 GENERAL DATA

NAME : S.S. IBRA LNG

CALL SIGN : 3EGE9

TYPE OF SHIP : SEGREGATED BALLAST LNG CARRIER

STEM : BULBOUS BOW & RAKED STEM

STERN : TRANSOM

CLASSIFICATION : AMERICAN BUREAU OF SHIPPING

AIE, LIQUEFIED GAS CARRIER, SHIP TYPE 2G

(MEMBRANE TANK, MAXIMUM PRESSURE 25Kpag

AND MINIMUM TEMPERATURE - 1630 C, SPECIFIC

GRAVITY 500 kg/m3 ),

SH-DLA, SHCM, SFA (40), AMS, ACCU, UWILD,

PMS INCLUDING CMS.

PORT OF REGISTRY : PANAMA.

OFFICIAL NUMBER : 34534 – TJ.

IMO NUMBER : 9326689.

BUILT PLACE : SAMSUNG HEAVY IND., GEOGJ SHIPYARD,

SOUTH KOREA.

KEEL LAID DATE : 23RD MAY 2005.

LAUNCHING DATE : 10TH SEPTEMBER 2005.

DELIVERY DATE : 10TH AUGUST 2006.

OWNER : SNC CORENTIN.

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OWNER ADDRESS : HONGKONG BANK BLDG., 6TH FLOOR, SAMUEL

LEWIS AVENUE, PANAMA, REPUBLIC OF

PANAMA.

MANAGEMENT : OMAN SHIPPING MANAGEMENT COMPANY

S.A.O.C., OMAN

MANAGEMENT ADDRESS : P.O. BOX 104, ALHARTHY COMPLEX, P.C. 118,

SULTANATE OF OMAN.

ENGINE : STEAM TURBINE, MCR: 36510 PS @ 87.7 RP.

SIDE THRUSTER : ELECTRO-HYDRAULIC, 2000Kw, CONTROLLABLE

PITCH.

LENGTH OVERALL : 285.103 M

MOULDED BREATH : 43.40 M

MOULDED DEPTH : 26.00 M

SUMMER DRAUGHT (MAX) : 12.100 M

SUMMER DEADWEIGHT : 81057 M

LIGHT SHIP : 29787

KEEL TO TOP THE MAST : 50.000 M/ 54.995 (MAST LOWERED/ RAISED)

GROSS TONNAGE : 96671

NET TONNAGE : 29001

SUEZ GROSS : 99,956.26

SUEZ NET : 85,759.37

WINDAGE AREA : LATERAL - 6700M2, FRONT- 1369 M2 (BALLAST OR

LOADED)

CARGO CAPACITY : 145,951 M3 - 98.5% @ (-165) DEG CENT

CARGO TANK - SAFETY : 25 KPA

VALVE

INTER BARRIER - SAFETY : 3 KPA

VALVE

INSULATION - SAFETY : 3.6 KPA

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VALVE

DESIGN SPEED : 19.0 KNOTS AT MCR WITH 21% SEA MARGIN

FUEL COMSUMPTION : 156.4 METRIC TONNES PER DAY AT NCR

3.2 MANNING

Ship’s Minimum Safe Manning Certificate dated: 30th March 2006 ( valid )

required 14 persons. The vessel has crew members in excess of minimum

manning requirement. There were 31 crew members on board. The vessel has

mixed crew consisting of British, German, Croatian, Lithuanian, Indians and

Filipinos. All the crew members have valid Panamanian Seaman’s documents.

All Officers have Panamanian endorsement on their certificates, as required by

Panama Flag State.

4. INCIDENT VOYAGE

The vessel SS “IBRA LNG”, under the command of Capt. Robert Grant Valentine

with valid Master’s Licence, sailed from Singapore on a ballast voyage on 29th

January 2007 toward Qalhat, Oman. The sailing draft of the vessel was 8.8 m ford

and 9.3 m aft. On 03rd February 2007, while the vessel was proceeding at an

average speed of 15 knots some noise was heard from the elevator shaft

approximately around 1425 hrs L.T.. The vessel’s position at that time was 070

58.9’ N & 0760 43.2 E, maintaining 3060 (T) course. Condition of the sea was

smooth and wind moderate to fresh. Wind direction and, sea and swell were all

North Easterly. On inquiry of the ship’s staff, it was found that the Electrician, Mr.

Ioan Cumpat, was trapped in on inverted position at the aft side of the Elevator

cage, his right knee was firmly stuck between upper guide rail of ‘A’ Deck door and

upper guide rail of the lift car. It was reported that Mr. Ioan Cumpat was carrying

out routine maintenance on the elevator. He was reported to be assisted by the

wiper. It was further reported that when the routine maintenance was about to be

completed, Mr. Ioan Cumpat dismissed his assistant and for some unknown

reason, he re-entered the lift shaft to gain access to the top of the Elevator cage.

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At 1425 hrs L.T., the Master was alerted first by the 2nd Officer and then by the

Chief Officer that someone was trapped in the elevator. There was also a lot of

commotion and shouting. It was then observed by the Master that Mr. Ioan Cumpat

was trapped at the side of the elevator in an inverted position, being held by the left

foot, which was preventing him from falling below. There was a drop of nearly 20 or

25 M below. Mr. Ioan Cumpat was conscious at that time and he had visible open

wounds. The vessel’s crew tried to administer first aid in that position. But the

position was so awkward that it was virtually impossible to do so. The casualty had

to be removed from the trapped position after gaining access through ‘B’ deck door

to the ship’s hospital. It took nearly 1 hour and 5 minutes to shift him to the ship’s

hospital after initial alarm was raised. The casualty fell unconscious at 1450 hrs

L.T.. However, once the casualty was made free from his trapped position in the

elevator shaft, he was given cardiac massage and artificial respiration by the ship’s

staff and continued to do so till he was pronounced dead by the Master and his

body was handed over to the local Indian Coast Guard.

4.1 SEQUENCE OF EVENTS

03RD FEBRUARY 2007

0745 Hrs : During the morning meeting it was decided that Elevator

routine maintenance is to be carried out in the afternoon.

Elevator was functioning normally during all this time.

1300 Hrs : It was decided in the afternoon meeting to change oil of gear

box of the elevator and to carry out normal maintenance

schedule. Meanwhile each elevator door switch was marked

“Lift under Maintenance”.

1300-1400

Hrs

: Electrician, together with wiper, started work in the elevator

trunk.

1400 Hrs : Wiper went to collect work materials.

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1415 Hrs : Wiper took mat out of elevator to clean it to Upper Deck on

electrician’s instructions. Electrician then went into the

elevator and went down.

1425 Hrs : After this heard somebody screaming and a loud noise came

from the elevator trunk.

1430 Hrs : Called Captain and informed him that someone is stuck in the

elevator on a deck.

1435 Hrs : To investigate the shouting of Mr. Ioan Cumpat access to the

elevator lift shaft was made through “B” deck door when it

was found that he was trapped in an inverted position at the

side of the elevator by the ladder, his leg was twisted and

trapped thereby preventing him from falling. Casualty was

conscious and coherent.

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1435-1530

Hrs

: Attempting to free the casualty

1440 Hrs : Captain called O.S.M.C and informed them of the situation.

1440 Hrs : Altered course toward Trivandrum, South India.

1450 Hrs : Casualty became unconscious.

1515 Hrs : Transmitted Security Message on VHF Ch 16 for Medical

Help.

1520 Hrs : Transmission of security message was repeated.

1522 Hrs : Coast Guard Vessel “Ankleshwar” instructed vessel to

contact Cochin Port for medical assistance.

1526 Hrs : O.S.M.C. instruct vessel to proceed to Cochin, India.

1530 Hrs : Casualty was finally freed from the elevator and taken to the

hospital in an unconscious state. He was found not breathing

and with a very weak pulse. Commenced CPR. The pupils

were dilated and there was no response to the torch light

when directed towards his pupils. CPR was continued but no

response by the casualty. Oxygen was also administered

continuously until the Coast Guard boat had arrived.

1540 Hrs : Repeated the transmission of security message on VHF Ch

16.

1545 Hrs : Repeated the transmission of security message on VHF Ch

16.

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1615 Hrs : Altered course towards Kovalam point ( India South West

Coast ).

1632 Hrs : Transmitted ship’s position to Indian Coast Guard, who

instructed the vessel to head for Vilinjam light.

1650 Hrs : Indian Coast Guard vessel instructed the vessel to anchor

approx 5 NMPs off Vilinjam coast. Casualty showed No vital

signs & no response to CPR. However, CPR was still

continued.

1715 Hrs : Coast Guard informed they were preparing for the Doctor and

he would be underway very soon.

1735 Hrs : Exchanged relevant information with Coast Guard like

Master’s Name, Crew nationality and casualty name etc..

1742 Hrs : Commenced walking back Stbd Anchor.

1755 Hrs : Stbd Anchor brought up in position 0800 21N 076-57E.

1755 Hrs : Casualty showed no vital signs. Casualty was declared dead

by Master.

1806 Hrs : Coast Guard informed the vessel that they were underway.

1820 Hrs : Observed one fishing boat “Olympia” standing off port

quarter.

1830 Hrs : Coast Guard boat approached from the port quarter. But

could not come alongside SS IBRA LNG due to choppy seas.

It was decided to lower the casualty from the stbd side (

which was the lee side ).

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1845 Hrs : Coast Guard Boat “C-34” approached own vessel from stbd

quarter. Casualty could not be disembarked by crane

because of the super structure of the Coast Guard Boat “C-

34” coming in the way.

1852 Hrs : Coast Guard boat instructed the vessel to disembark the

casualty in the fishing boat “Olympia”.

1855 Hrs : Fishing boat “Olympia” approaching vessel from stbd side.

1858 Hrs : Casualty disembarked by crane into Fishing Boat “Olympia”

1940 Hrs : Coast Guard informed vessel to await at anchor till further

notice whilst also confirming the casualty as deceased.

4.2 DEATH CERTIFICATE

Death Certificate signed by the Master gives following details :

(a) Date of death : 03RD FEBRUARY 2007.

(b) Place of death : 080° 21’ N 076° 57’ E

(c) Name : IOAN CUMPAT

(d) Sex : MALE

(e) Date of Birth : 17 MAY 1958

(f) Occupation : ELECTRICIAN

(g) Domicile at : ROMANIA

(h) Time of death : 1755 Hrs L.T. / S.M.T.

(i) Passport No. : I 1669423

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4.3 OFFICIAL LOG BOOK ENTRY

Official Log Book Entry of the incident is reproduced below :

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5. ACTION TAKEN BY CREW

When the crew learnt about Mr. Ioan Cumpat getting trapped in the elevator, they

made an attempt to open the elevator door from ’B’ deck, which took nearly 4 to 5

minutes to open. After opening the door, the crew learnt the position of Mr. Ioan

Cumpat, who was trapped in an inverted position. Considering the risk involved in

making an attempt to remove the casualty with the help of the elevator. Mr. Ioan

Cumpat, was tied to a safety harness and heaved-up, and finally was brought to

the ship’s hospital. He was continuously given cardiac massage and artificial

respiration. As the condition of Mr. Ioan Cumpat, with open wounds and

multiple injuries, was considered critical, the Master informed the Owners and also

the Indian Coast Guard requesting immediate medical attention. The vessel was

diverted to off the South Indian Coast, as advised by the Owners and the Coast

Guard. The position from where the vessel was diverted is shown in the chart

below.

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As the vessel was moving towards the position instructed by the Coast Guard, the

casualty finally died. The time of his death was 1755 hrs L.T., the vessel’s position

at that time was 080 21’ N, 0760 57’ E. The death certificate issued by the Master

recorded the time as 1755 hrs. L.T. / S.M.T.. At 1858 hrs L.T., the mortal remains

of Mr. Ioan Cumpat was finally handed over to the Indian Coast Guard.

6. ACTION TAKEN BY COAST GUARD

After taking the dead body in the custody of the Coast Guard, the Deputy

Commandant, Mr. Deepak Singh, filed a First Information Report ( F.I.R. )

with Vizhinjam Police Station for the necessary action. Subsequently, the body of

Mr. Ioan Cumpat was sent for post-mortem and the findings of the post-mortem

report had been handed over to the vessel.

6.1 POST MORTEM REPORT

P.M. No. 284/07 Date

: 04.02.07

I, Dr. C. S. Sreedevi, Asst. Professor of Forensic Medicine, certify as hereunder:-

Dead body of a male by name IONA CUMPAT, aged about 49 years, was sent

by Sub Inspector of Police, Vizhinjam Police Station, with a requisition dated 04th

February 2007 through the H.C. No.7633, for conducting postmortem

examination and report.

The body was in-charge-of the H.C. No.7633, who identified it as that of the

deceased in Crime No. 52/07 of Vizhinjim Police Station. The post-mortem

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commenced at 2.30 p.m. L.T. on 04th February 2007 and was concluded at 3.30

p.m. L.T. / I.S.T. The following findings were observed.

Body was that of a well built and nourished fair skinned adult male of height 170

cm and weight 94 kg. Eyes were closed. Conjunctivae congested. Pupils dilated.

Blood stained fluid present at nostrils. Other external body orifices were normal.

Finger nails were blue. Old scar 25 x 2 cms, vertical, on the abdomen in the

middle. 5 cm below the lower end of breast bone.

Corneae clear. Rigor mortis fully established and retained all over the body. Post-

mortem staining at the back and sides of body, not fixed. No sign of

decomposition ( Body was kept in the cold chamber ).

6.1.1 INJURIES (ANTEMORTEM) :

1. Contusion of scalp 9 x 5 x 0.5 cms on the left side of head just above the

ear.

2. Abrasion 1.8 x 0.2 cms on right side of chin 6 cm outer to midline. Brain

showed subdural and subarachnoid haemorrhage. Sulci were narrowed and

gyri flattened.

3. Lacerated wound 5.5 x 4 cms enterining into the abdominal cavity of the

perineum just behind the scrotum. Fracture separation of pubic symphasis.

The soft tissues around were seen infiltrated with blood.

4. Multiple small abrasions over an area 22 x 2 to 7 cms on the front aspect of

right arm 7 cms below the shoulder tip with fracture of humerus underneath.

5. Abrasion 9 x 1.5 to 3 cms on the back of right forearm 13 cms above wrist.

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6. Abrasion 1 x 0.3 cms on the back of the right wrist.

7. Abrasion 1 x 0.3 cms on the outer aspect of right forearm 4 cms above

wrist.

8. Abraded contusion 7 x 4.5 x 1 cms on the inner aspect of the right arm 7

cms above elbow with an abrasion ( 6 x 4 cms ).

9. Multiple small abrasions over an area of 4 x 3.5 cms on the back of right

elbow.

10. Abraded contusion 18 x 7 x 2 cms involving the inguinal area and adjacent

part of front of thigh.

11. Abrasion 6 x 4 cms on the inner aspect of right thigh 20 cms above knee.

12. Abrasion 8 x 4 cms on the back and inner aspect of right knee and adjacent

part of thigh.

13. Lacerated wound 5 x 1 x 0.4 cms on the front of right knee with multiple

small abrasions over an area 30 x 7 cms around and adjacent parts of front

of thigh and leg.

14. Multiple abrasions over an area 30 x 13 cms on the inner aspect of left thigh

and knee.

15. Abrasion 7 x 0.5 cms on the front aspect of left thigh 32 cms above knee.

16. Abrasion 4 x 2 cms on the left groin.

17. Multiple abrasions over an area 30 x 3 to 8 cms on the left side of front of

chest its upper outer and just below the front fola of armpit.

18. Abrasion 29 x 6 to 12 cms on the right armpit and adjacent part of left side

of chest.

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Air passage contained blood stained fluid. Lungs were congested and

oedematous. Liver was fatty. Stomach was full with starchy food materials and

other unidentifiable food materials having no unusual smell, mucosa normal.

Urinary bladder was empty.

All other internal organs were pale, otherwise appeared normal.

Sample of blood was preserved and sent for chemical analysis

6.1.2 OPINION AS TO CAUSE OF DEATH:

Death was due to injuries sustained to head and pelvis.

6.2 DETAILS OF CASUALTY

Name : Mr. Ioan Cumpat.

Rank : Electrician.

Date of Birth : 17th May 1958.

Manning Agency : AZA LEA MARITIME B.V.

Years in Rank : More than 20 years.

Date of Joining vessel : 23rd January 2007.

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Hours worked on previous day : 8 hours.

Hours worked on the day of

accident

: 5.5 hours.

Nature of work : In charge of maintenance & operation

of all electrical installations on board

including personnel elevator.

Passport No. : I 1669423

7. INVESTIGATION

The investigation was carried out on board the vessel on 5th & 6th March 2007 at

whilst she lay safely anchored at Fujairah Anchorage, Fujairah Port, U.A.E.. It was

carried out as per American Bureau of Shipping incident investigation methodology

MARCAT guidelines and also as MINICAM guide. The objective of the

investigation is to conduct RCA of the loss of human life on board and to determine

whether the loss was related to safety environment or human element. However, in

this particular event, which resulted in the death of an officer on board, RCA was

not possible as nobody was witness to the incident. Therefore, the analysis is

based on ACA technique as the various available data related to the incident were

viewed after more than a month of the actual date of occurrence.

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7.1 INVESTIGATION INITIATION

The vessel SS “IBRA LNG” is fitted with one set of electric motor driven counter

weight type personal elevator capable of moving in an enclosed steel trunk from

engine room floor below Navigation deck.

As the incident of death occurred during the discharge of routine maintenance

work of the Elevator, it is essential to take a closer look at the design specification

of the Elevator and its maintenance requirement.

7.2 ELEVATOR DETAILS

TYPE OF ELEVATOR CREW ELEVATOR

CAPACITY 500 KG (6 PERSONS)

SPEED 45M/MIN

DRIVE VVVF

TYPE OF CONTROL 2 BC (SELECTIVE COLLECTIVE CONTROL

SYSTEM)

TRAVELLING HEIGHT 33900

CAR INTERNAL SIZE 950 (W) X 1300 (D) X 2100 (H)

NO. OF SERVICE 9 STOPS (MAIN, 4TH, 3RD, 2ND, UPP, A, B. C. D

DK)

CLEARANCE OF DOOR 800(W) X 1200(H)

DOOR OPERATION 1 SPEED CENTER OPENING DOOR (ISCO)

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LANDING DOOR (E/R) GAS TIGHT SWING DOOR WITH A-60

INSULATION

LANDING DOOR (ACCOM) 1 SPEED CENTER OPENING DOOR WITH A-0

INSULATION

TRACTION MACHINE TM 400

DIA OF MAIN SHEAVE O 570

MAIN ROPE O 12 X 4 (1:1 ROPING)

CAR RAIL 13K RAIL

CWT RAIL 8K RAIL

MOTOR CAPACITY 5.5 KW

POWER SUPPLY MAIN 3 PH 440 V 60 HZ

LIGHT 1 PH 220 V 60 HZ

PAINTING COLOUR CAR INSIDE & DOOR STAINLESS HAIRLINE

FINISH CAR CEILING STAINLESS HAIRLINE

FINISH LANDING DOOR MAIN - 2ND DK

MUNSELL NO. 2.5 Y 9/2 UPP-D DK

STAINLESS AIRLINE ELECTRIC EQUIPMENT

MUNSELL NO. 7.5 BG 7/2.

FLOORING LUCKSTRONG ( TYPE : RS-90028 )

RULES & REGULATIONS AMERICAN BUREAU OF SHIPPING (ABS)

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7.3 LAYOUT OF ELEVATOR

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7.4 PERIODIC MAINTENANCE

Mr. Ioan Cumpat, being the person entrusted with the responsibility of

maintaining all electrical items under the able guidance of the Chief Engineer, he

had to follow a proper maintenance guideline as stipulated in the manufacturer’s

manual. The manual and also company guidelines stipulates a routine

maintenance programme, which he undertook to carryout in that fateful day. The

relevant program is detailed below :

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8. FLEET NOTICE

The Owners M/s Oman Ship Management Co. Ltd., Oman, by their Fleet Notice

OSMC–06–01 dated : 27th March 2006, which was subsequently updated on 17th

February 2007, specifies that basic safety measures should be taken during

maintenance & inspection of Elevators as per “Marine Elevator” handling

guidelines. The guidelines are given below :

Marine elevators tend to be regarded as ‘simple and convenient machines’ by

those who use them, but they are actually a combination of several dozen different

pieces of equipment and devices. Mishandling and wrongful maintenance /

inspection of any one of these components can lead to not only damage to the

equipment itself, but also accidents causing injury or death.

All crew members are expected to understand some of the basic structures and

operations, and to be able to take appropriate responses during an emergency.

In general, rope-type elevators are used for marine elevators.

Elevator performs as a type of “well bucket”, with a “cage” to contain the

passengers / load on one side of the pulley, and a counterweight on the other side

to raise or lower the cage with the minimum of power.

8.1 SAFETY SYSTEM OF THE CAGE AND DOOR

The part of the elevator which holds people or cargo is called a “cage”. The

size of the cage decides its capacity, or the maximum number of persons it

can hold, with one person calculated as 65 kg.

Generally, an elevator is equipped with the following safety systems ( though

they may vary by manufacturer or type ) :

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a. Gate switch : a type of safety switch that becomes operable once the door of

the cage is completely shut.

b. Door switch : a type of safety switches that becomes operable once the

hoistway door on each floor is completely shut.

c. Emergency switch : the switch used to stop the elevator when there is an

emergency in the cage.

d. Safety edge of door : a device to open the door automatically when

passenger(s) or cargo get caught in the door of the cage.

e. Emergency bell and telephone : used to communicate with the outside in the

case of an emergency.

f. Emergency light : a lighting apparatus which receives electricity from a battery

and illuminates in the event of a blackout.

g. Safety switch : blackout / operating switch used for maintenance, provided on

cage top.

h. Door locking device : once the hoistway door closes, this device prevents the

door being manually opened.

8.2 SAFETY IN ELEVATOR HOISTWAY

Safety to be implemented in Elevator Hoistway involving :

1. Termination switch

2. Overrun limit switch

3. Buffer

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8.3 SAFETY IN MACHINE ROOM Safety system to be implemented in Machine Room involving the following :

a. Electromagnetic brake : also known as an “eddy-current braking”, this type of

brake utilizes the braking torque between the electric current and magnetic

field generated when the magnet and metal plates on both ends of the poles

are in motion; that is, the brake moves with the friction from the

electromagnetic power. When the overrun limit switch or emergency switch is

activated, the cage is brought to a sudden stop, and the brake keeps the cage

in that position. In general, the brake works as follows:

1 The buttons in the cage operating panel or on the floor are pressed to operate

the elevator.

2. Electricity is supplied to the motor.

3. Auxiliary contact on the main relay of the control panel turns ON.

4. Electricity is supplied to the coil attached to the top of the brake device, and

the core is activated.

5. The link mechanism sets the brake shoe apart from the brake drum, and the

brake opens.

In this way, the elevator starts to move. When the cage arrives at its

destination, electricity is supplied to the motor, the coil is cut-off, and the

spring located at the bottom of the brake device thrusts the brake shoe

toward the brake drum. The friction at the brake lining stops the elevator

cage.

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b. Speed regulator : also known as the governor, this device utilizes centrifugal

force to adjust the spinning body so that a constant rotary speed can be

maintained regardless of the shift in the load applied to the revolving

machine. The speed regulator is activated not only when the overrun limit

switch or other safety system is turned on, but also when the speed of the

elevator exceeds the rated speed. At the first motion, the speed regulator cuts

off the electric circuit to the motor when the speed reduction is below 130%,

and activates the electromagnetic brake to stop the cage. If the cage does not

stop and speed reduction approaches 140%, then the speed regulator grabs

the speed regulator rope to bring the cage to an emergency halt.

8.4 SAFETY DURING MAINTENANCE

In order to maintain the safe operational status of the elevator, planned

maintenance and regular inspections are important, as is true of all engines

and equipment. When conducting routine maintenance and inspection work,

“Under inspection/ Do not use” announcements must be clearly

communicated to all other personnel, not just the maintenance workers. Close

communication between the maintenance workers must be kept, and relevant

equipment and devices be appropriately used at all times.

8.5 PREPARATION FOR MAINTENANCE / INSPECTION PROCEDURES

a. Before commencing these procedures, obtain all necessary permissions

from the Captain and the Chief Engineer.

b. Always hold a meeting, and confirm the following before starting work:

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1. Who will take part in the work and what is the role of each worker ( Note

: work should always be conducted by two or more workers ).

2. What should be worn, and what equipment is needed to carry out the

work ( work clothes, safety shoes, helmet, torch, transceiver, etc. )

3. Means of communication during the work ( in-cage telephone,

transceiver, etc. )

4. Special / general tools required for the work.

c. Clearly and comprehensively announce that the elevator is “Under

inspection - Do not use”

d. Put up a sign “Under inspection / Do not use” in front of the hoistway door

on each floor, and cover the “cage call button” with vinyl, duct, or other

suitable tape. To prevent the button from being accidentally pressed, a

plastic / wooden cover hung over the button on each floor can be effective.

e. Make sure that the emergency alarm and telephone are operational.

f. Personnel other than maintenance / inspection workers must not perform

any of the maintenance / inspection procedures.

g. Ensure that there is sufficient light in the work area.

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8.6 POINTS TO CONSIDER DURING MAINTENANCE

a. Perform the inspection procedures according to the checklist, and make notes

on any necessary information required.

b. Activate the emergency stop switch in the cage top operating panel so that

the cage cannot move, and make sure that all openings are closed.

c. Elevator machine room :

1. When conducting inspection/ adjustment of moving parts such as the hoist

or the deflector sheave, make sure that the power supply is turned off.

2. When checking the controller (insulation, resistance measurements, etc.),

make sure it is turned off.

3. Use the telephone in the elevator machine room to communicate with the

worker in the cage ( if vessel has a telephone equipped ). When

communicating with other parts of the vessel use the transceiver, and

keep in close contact with each other throughout the maintenance/

inspection procedures.

4. Take extra care not to spill oil / grease on the pulley of the hoist, defector

sheave, or wire rope. The presence of oil / grease can cause slippage of

the wire rope, which is extremely dangerous.

d. Top of the cage and hoistway :

1. Turn on the inspection light on the cage top, and ensure that there is

adequate lighting.

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2. Always keep the area tidy, and make sure that there is enough space to

put up a scaffold.

3. Once on the cage, turn the AUTO-MANUAL switch in the cage top

operating station to MANUAL.

4. While these procedures are being carried out, keep the emergency switch

in the cage top operating station active.

5. When moving the cage, or opening / closing the door manually, contact

the other workers to ensure that the surrounding area is secure ( beware

of the counterweight or projections in the hoistway ). When operating,

release the emergency stop and make sure that the worker knows what

buttons to press.

6. After finishing these procedures, contact the other workers to ensure that

the surrounding area is secure, and turn the AUTO-MANUAL switch in the

cage top operating station back to AUTO.

e. Bottom of the hoist way :

1. Turn off the control panel main switch in the elevator machine room.

2. When conducting counterweight - clearance measurements, bring the

cage to the top floor, press the emergency stop button in the cage, and

put up an “Under inspection / Do not use” sign.

3. Use the release key to open the lowermost door manually, and go down to

the bottom of the hoistway keeping the door open with a wedge or rope.

4. If the pit of the hoistway is stained with oil, wipe it clean to avoid slippage.

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8.7 CONFIRMATION OF WORK COMPLETION

a. Check the number of tools ( to ensure none have been left behind ).

b. Test elevator operation, and make sure that there are no abnormities.

c. Report to the captain and chief engineer that the procedures have been

completed, and let the personnel on the bridge know that the inspection is

finished. Make an in-vessel announcement, and then remove all plates

around the elevator doors on each floor and tapes covering the buttons.

9. COMPANY’S PROCEDURE

M/s Oman Shipping Co. maintains a familiarization programme for every officer

joining the vessel, as a standard procedure.

9.1 FAMILIARIZATION

As per the company’s familiarization programme and the ISM requirement, the

Electrician was required to familiarize himself as to the working of the Elevator and

its maintenance aspect. It was reported that having worked on a sister ship of the

company, Mr. Ioan Cumpat had adequate knowledge about the elevator

maintenance and its working principle.

However, he still had to carry out the familiarization of all electrical hardwares as

per the company procedure towards requirement of the ISM. It appears that Mr.

Ioan Cumpat had complied with the familiarization programme immediately after

joining the vessel.

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9.2 “IBRA LNG” ELEVATOR

The Elevator, as fitted in the vessel, is a modern Elevator built by Hyundai It has

all the safety systems incorporated in it such as gate switch, door switch,

emergency switch, safety edge of door ( a device do open the door automatically

when passengers or cargo get caught in the door of the case ), emergency bell

and telephone, emergency light etc. The elevator is also provided with safety

switch which is the operating switch used for maintenance. The switch is

provided on cage top. There is door locking device which prevents the door from

being manually opened once the hoistway door closes.

9.3 MAINTENANCE AS PLANNED

It was decided to carry out a normal routine maintenance of the passenger lift.

Accordingly a safety meeting was held on 3rd February 2007, in the morning.

During the safety meeting the Electrician was advised to take the ‘wiper’ along

with him during his maintenance work.

The work was started soon after the afternoon safety meeting. The normal

maintenance routine was then reportedly carried out as per the manufacturer’s

instructions after taking all necessary safety precautions. However, during the

course of his normal maintenance work, the Electrician, Mr. Ioan Cumpat,

expired at 1755 hrs L.T. on 03rd February 2007 at the Elevator trunk ( the

sequence of events have been very elaborately narrated elsewhere in this Report

). During the course of investigation, the place where the accident took place was

identified by the principal investigator.

10 INCIDENT INVESTIGATION

Once identified the place where Mr. Ioan Cumpat got trapped in the elevator, the

incident site was examined for a quick overview. Whatever data were available at

the time of our visit were duly examined and various witnesses were interrogated

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in order to ascertain the veracity of the written statements of the witnesses which

were made earlier .The findings were noted as below :

• Position of the Casualty was identified as being trapped in the inverted position

inside the elevator trunk.

• Ship’s position: 08 58.9 N Latitude, 076 43.2 E Longitude.

• Routine maintenance was being carried out on Elevator cage.

• Tools used to carry out the maintenance were normal electrician tools.

• Safety devices in use were the normal safety gears that include safety boots and

boiler suit. There was no sign of helmet whereas the safety harness was found

outside the elevator trunk.

• The top of the elevator cage was provided with a safety guard above the

emergency escape. Escape ladder was also provided all the way from Floor

Deck to Navigational Bridge Deck. Electrician had a walkie talkie with him at the

time of the incident.

• As far as safety was concerned, the elevator cage was equipped with an

emergency switch ( and was reportedly found not activated ) inside the cage. The

control box on top of cage had the following :

1. Auto / Inspection Selector switch which was left on Auto.

2. Door Open / Close Switch which was left in the Open Position.

3. Door Switch ( No indication ).

4. Emergency Stop that was not activated.

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• A Remote Control that has 2 buttons ( Up / Down ) and an Emergency

stop, which was not activated.

• The elevator is also equipped with an emergency stop at the Elevator

Switchboard in the Elevator Machinery Room. This stop was not activated

in order to be able to move the cage using the Remote Control on the top

of the Elevator Cage.

• Warning signs were posted at all levels ( Elevator Under Maintenance ).

• There was no apparent damage to the equipment. However, the door at

‘A’ deck did not open using the Emergency Opening Key at the time of the

rescue operation and had to be opened from inside the trunk. It was

noticed that the bulkhead openings doors at all decks were provided with

3 sides frame instead of 4 sides frame, although means of fixing the fourth

side were provided.

• The area was kept at very good housekeeping. No signs of oil leaks.

• The weather at the time of the incident was fair with slight sea and low

swell. Air temp +30C. Vessel moving easily at 14.75 knots.

• Lighting level was adequate as the trunk is equipped with fluorescent

lights all throughout.

• No unusual noise was detected.

During the investigation, as many relevant facts as possible were collected. Many

photographs for both the general area and specific items were taken. Some

photographs were taken by the ship’s staff earlier which were carefully studied and

analyzed in order to help revealing any conditions or observations that might be missed

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out. Sketches of the specific location and the position of the casualty as seen by the

ship’s crew were also made.

The photographs and sketches had a major role in understanding the incident and the

event leading upto it.

10.1 DATA GATHERING

The collection of data contributing factors were divided into the following main

areas :

1. People

2. Environment

3. Equipment

4. Procedure

5. Organization

10.1.1 PEOPLE

People who might have information about the incident were identified and the

following statements were obtained from them :

MASTER’S STATEMENT

“03rd February 2007, shortly after 1425 hrs L.T., I was alerted to the fact that

someone was trapped in the lift, initially by 2nd Officer, then the Chief Officer. On

leaving my cabin and proceeding to bridge, I heard much commotion and shouting

from lower in the accommodation.

When I was informed of the situation and went to the scene, I was able to see Mr.

loan Cumpat in inverted position. At this time he was quite conscious and coherent

although his position was very awkward and he had obviously suffered severe

trauma, with open wounds and a fractured leg.

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I alerted OSMC ( Owners ) of the situation requesting their assistance in arranging

medical rescue assistance etc. and initially altered course towards Trivandrum Port.

Meanwhile attempts to release Mr. Ioan Cumpat were made by the crew, his

situation was extremely dangerous being supported by his trapped leg and foot in an

inverted position trapped between the Lift Cage, Trunk Ladder and angle Iron

brackets, there being a 12 - 15 meter drop beneath him.

Around 1450 hrs L.T., before he could be freed, he slipped into unconscious state,

ship’s crew secured line around casualty. Pan Pan message was transmitted with

little response. This was repeated several times.

1526 hrs L.T., vessel was instructed by Company to make full speed to Cochin, for

assistance, vessel’s course was adjusted accordingly.

1530 hrs L.T., he was finally freed and taken to ship’s hospital where cardiac

compression and artificial respiration with oxygen were administered by ship’s crew,

his pulse very rapid and very weak, his breathing stopped.

At 1538 hrs L.T., Radio Medical advice was sought via 32# Netherlands Coastguard,

who on being told our situation advised that what we had done was the most

appropriate action, and to continue until help could be received. But, however, that

we were probably not going to revive the casualty.

1615 hrs L.T., on gaining contact with local Coast Guard vessel was advised to

make for Kovalam point where Coast Guard would meet vessel with medical

assistance. Course was adjusted accordingly.

1650 hrs L.T., we were requested to anchor 5 miles off Vilinjam light. At this time

Mr. Ioan Cumpat was showing no vital signs, he was neither breathing nor was there

any pulse, his eyes were dilated and no response to light, attempts to resuscitate Mr.

Ioan Cumpat continued throughout.

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Throughout there was frequent communications between Vessel, OSMC Casualty

Room and Coast Guard, both by telephone and VHF.

Vessel as requested anchored safely off Vilinjam at 1755 hrs local time, in

position 080 21’ N 0760 57’ E. At this time it was apparent that Mr. Ioan Cumpat

was in fact dead, however, crew continued attempts to revive Mr. Ioan Cumpat

until finally the Indian Coast Guard arrived.

1830 hrs L.T., Coast Guard were unable to board vessel due to sea state hence

it was decided to land Mr. Ioan Cumpat’s to the Coast Guard boat using the

crane, this was also not easy due to superstructure of the Coast Guard boat, so

on coast Guard instruction, we landed body to fishing boat “Olympia”, which was

standing-off nearby.

At 1940 hrs L.T. Coast Guard confirmed that Mr. Ioan Cumpat was dead upon

his being received to their custody. Vessel was instructed to remain anchored

until further notice/ formalities completed.

It appears that whilst completing routine maintenance on vessel’s Elevator Mr.

Ioan Cumpat accidentally fell resulting in his becoming trapped until further

precarious position, leading to his tragic death.

I believe that my crew did everything possible in the circumstance, and commend

them for their efforts”.

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CHIEF OFFICER’S STATEMENT

“Around 1425 hrs L.T. I heard the shouting from the elevator. I advised the

Bridge and all the crew over the VHF public system.. I rushed to the ‘A’ deck and

with Chief and First Engineer was decided to open the ‘B’ deck elevator door.

All crew were mustered and Medical team was instructed to prepare first aid

equipment.

After few minutes we access the top of the elevator and we found Mr. Ioan

Cumpat ( ship’s electrician ) trapped at side of elevator in inverted

position.

His leg was twisted and trapped between elevator and casing preventing him

from failing.

Bridge (Captain) was updated with situation.

After we insured him from failing, elevator was manually operated from the E/R

and Electrician leg was freed obstruction.

After several attempts from the outside, we manage to open the Upper Deck

elevator doors from inside of elevator trunk, Electrician was .lowered to upper

Deck and taken out from the elevator trunk space.

Electrician was found unconscious with stopped breathing and pulse very rapid

and very weak.

We rushed to the hospital and artificial respiration was given together with

cardiac massage. Above attempts continued until Indian Coast Guard arrived

without signs of life from injured person.

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At 1755 hrs L.T. the casualty was declared dead by the Captain.

I solemnly pledge that the above statement is true and in the best of my knowledge. Ch / Off SS IBRA LNG Dated: 3rd

February 2007

Nenad Martinovic”

STATEMENT OF 1ST OFFICER

“I received a call from the Chief Officer at 1430 hrs saying that there is somebody

stuck up in the elevator and needed to be given First Aid. I rushed to the ‘B’ deck

to find the Electrician hanging in an inverted position hanging by his foot/leg

outside the elevator cage (in the maintenance area). Rescue work was in full

swing to remove the casualty from the elevator area and bring him to the hospital

on the stretcher. Meanwhile, I got the First Aid equipment ready. Casualty Mr.

Ioan Cumpat (Electrician) was tied a safety harness to heave him up. The door of

the elevator on the upper deck was opened by emergency key and he was finally

taken out and brought to the hospital on the stretcher. He was found to have

external as well as internal bleeding. He was immediately given artificial

respiration followed by oxygen resuscitation via the resuscitator. His pulse was

very weak and he was showing no vital signs. Artificial respiration continued till

the Coastal Guard vessel arrived but the casualty still did not show any sign of

improvement.

1755 hrs the casualty was declared dead by the Captain.

I solemnly pledge that the above statement is true and to the best of my

knowledge.

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-sd/-

(Gaurav

Choudhary)

1st Officer

SS IBRA LNG

03 February 2007”

STATEMENT OF CHIEF ENGINEER

“Work carried out on ship’s elevator was part of routine maintenance prepared and

discussed at morning meeting and in Engine Room just before work.

Before work starts warning signals posted “ELEVATOR UNDER MAINTENANCE” at all deck elevator doors. All preparation works carried out.

Elevator was functioning normally during all this time.

Electrician and wiper was assigned for maintenance work.

Just before accident happened, wiper took mat out of elevator cabin to clean it in

upper deck on electrician instructions. Then Electrician went into the elevator

cabin and went down. It seemed that the Electrician decided to further routine

maintenance on top of the elevator cabin. At the time accident happened,

elevator was switched off.

The electrician was experienced in his rank. His last contract spent on sister ship

equipped with same elevator.

At the time of accident I was in the Engine Room workshop and I was called

immediately after the accident happened. I went to ‘B’ deck to do as much as

possible help to release injured electrician Mr. Cunpat. After ‘B’ deck was opened

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to access and electrician released, I went down to the Engine Room to handle

main engine to full speed (course altered towards Trivandrum).

- sd/-

CH. ENG. HIGIN BASIC

At and on 04 Feb 2007”

STATEMENT OF 1 A/E ( Assistant Engineer ).

“I heard a scream around the elevator trunk around 1425 hrs. I went to elevator

entrance door on ‘A’ deck where I heard voice from electrician calling for help.

After a few minutes we managed to access inside elevator trunk via door ‘B’

deck. I noticed E/E was trapped in an inverted position at the side of elevator, by

the ladder, his leg was twisted and trapped thereby preventing him from falling. I

realize it to be risky to try to get him out at that position by moving the elevator.

So we decided that one team will tie a safety harness of rope around him and

other in engine room will manually operate the elevator. After a while he was

finally taken out and brought to the hospital. He was found with external bleeding

and inside hospital I realized also with internal bleeding. He was immediately

given artificial respiration. Oxygen was also given continuously. Artificial

respiration continued till the Coast Guard vessel arrived but the casualty never

gave signs of life.

1755 hrs L.T. the casualty was declared dead by the Captain.

I solemnly pledge that the above statement is true & in best of my knowledge.

sd/-

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1 A/E MARIO

MATISAS

04th February 2007

STATEMENT OF 2 A/E ( Assistant Engineer )

“I Patel Afzal Hajimubarak, 2nd Assistant Engineer on SS IBRA LNG testify the following. On 3rd Feb’ 2007, at 1300 hrs, as usual we had a job meeting with the engine

staff in the Engine Control Room. At 1310 hrs, I along with one of the oiler went

to the forward heavy fuel oil transfer pump room to purge the suction filters of the

transfer pumps and to start the forward fuel oil tank heating.

At 1415 hrs I returned back to the Engine Room. At 1425 hrs I was informed by Third Assistant Engineer on the radio that

electrician was stuck inside the elevator trunk so I along with Third engineer took

the elevator door opening key from Engine Control room and went to the upper

deck. As instructed by the Chief Officer there, we tried to open the elevator door

of the upper deck but it was stuck. Then, as per First Engineer’s instructions, I

went to the elevator machinery room to prepare for emergency manual operation

of the elevator if in case required. We were standby there for any instructions

from the rescue party to manually move the elevator cage. At 1500 hrs, I was instructed by the First Engineer to go to the Engine Control

Room and take care of the operation as we were increasing the ship’s speed to

full rpm. Since then I was in the Engine Control Room with the Chief Engineer till

the arrival anchorage point.

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After arrival anchorage, as per First Engineer’s instructions, I along with Third

Engineer & wiper opened the main floor (M/F) deck elevator door to clean the

elevator trunk bottom. We found blood drops and some tools and one shoe in the

elevator pit. We removed the tools & shoe and cleaned the blood. There were

some blood drops on the tools which we washed and then secured the tools in

workshop.

Date – 06th February

2007

-sd/- Patel Afzal Hajimubarak

( Second Assistant Engineer )

STATEMENT OF 3 A/E ( Assistant Engineer ).

“I, Kanwar Udyan Rathore, 3 A/E on SS IBRA LNG testify the following.

On 3rd Feb’ 2007 at 1300 hrs, as usual we had job meeting in the Engine Control Room.

At 1310 hrs., I went for testing E/R fire dampers and funnel flaps. After finishing

this I started overhauling package Air Conditioner, F.W. booster P/P in workshop

where I heard on radio that electrician stuck in the elevator, then I call on the

radio to the 2 AE & we took the elevator key from ECR. We opened the B deck

door with rescue team. Then we tried to open the upper deck door which was

stuck and we could not open it. Then as per C/O instructions we went to elevator

machinery room for manual emergency operation of elevator. Then as per

instructions we lowered the elevator few centimeters manually. Then I went up to

Upper deck. Then rescue team opened the upper deck door from inside & we

tried to lower the electrician with the help of ropes. Electrician was recovered

from upper deck and we sent him to the hospital. After that I came back to

Engine Control Room for maneuvering/anchorage.

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After arrival anchorage as per 1st Engineer instruction, I along with 2nd Engineer

& wiper opened the main floor deck elevator door to clean the elevator trunk

bottom. We found blood drops and some tools and one shoe and cleaned the

blood. There were some blood drops on the tools, which we washed and then

returned the tools in workshop.

Date : 06th February 2007

-sd/-

Kunwar Udyan Rathore

( Third Assistant Engineer )

STATEMENT OF WIPER

“During morning safety meeting in ECR, I received a job order from 1st Engineer

to work together with electrician in his monthly maintenance routine of elevator.

1300 hrs, after receiving an order from 1st Engineer, I & electrician posted a

warning sign “ ELEVATOR MAINTENANCE” from ‘D’ deck down to main floor.

After that, we proceeded to 4th deck where electrician turned off the power of

elevator. He then opened the door of main deck for inspection. After a while he

told me to clean the bottom of elevator trunk. 1345 hrs I called up electrician to

look & see if I would still need to mop the bottom trunk or not. After seeing,

electrician told me to secure my cleaning gear & so I did. Assuming that

everything is finished, I went to ECR to get a cleaning foam and proceeded to

upper deck when I saw that the elevator cage landed there. 1400 hrs I met

electrician at upper deck & he asked me to clean the elevator mat. After that he

went inside the elevator cage. I just saw that the elevator landed on 4th deck of

the main floor (I don’t remember the exact deck No. it had landed). With the new

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job order from electrician, I went to “B” deck to take the vaccum & clean the mat

on the upper deck. After cleaning I was not satisfied so I decided to go to A deck

at the cleaning gear locker to take a mop and cleaned the mat once again. After

a few minutes of cleaning, I decided to return the cleaning gear to their

respective decks when I heard some body screaming inside the elevator. I knew

it was electrician because he is the one working inside the elevator. I met oiler #

1 & informed him that electrician was screaming for help. Then instructed me to

inform 1st Engineer or anyone from the engine room what I did.

- sd/-

Fritz Andrew B. Rosel

Wiper, IBRA LNG

Broad questions such as Who, What, When, Where, Why and How were asked to all

parties. All concerned were interrogated in order to elicit information related to the

incident.

All individuals were assured that the investigation / interviews were being conducted

to promote safety and not to apportion blame at any of them.

Everyone explained in his own words what happened and the action taken on

occurrence of the incident. They were asked if they knew of any near-miss history of

the Elevator.

During the interview / interrogation of all individuals been interviewed were observed

to be in physically & mentally sound condition. From the interviewers / interrogation

of the concerned person, it was found that the casualty was an experienced person

who had just signed off a sister ship with exactly the same elevator system. Looking

into the fact that he had been an electrician in the past twenty years, it could be said

that Mr. Ioan Cumpat was well experienced in the task and was fit for the job.

It was reported that the casualty was neither under stress nor under the influence of alcohol.

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10.1.2 ENVIRONMENT

The Environmental Factor was not found to be applicable to the causes of the

incident as the weather was fair and the air temperature was good. No signs of

toxic or hazardous gases, dust or fumes presented in the site.

10.1.3 THE EQUIPMENT

The electrician was carrying out routine maintenance on the equipment. The

elevator was reported to be in good condition and nothing untowards noticed

about its normal operation since the vessel was built. The only thing noticed

was the distorted bottom guide underneath the right hand side of the bulkhead

opening slide door ( looking from inside ). This may be due to a missing frame

side, as mentioned earlier above. This could not have contributed to the

accident as it would keep the sliding door in the open position, in which case

the electrician could easily escape from the scene. The possibility of the

accident was more likely with a closed door.

Other important issues with the equipment were checked. There was no apparent

equipment failure at the time of the incident.

The purpose of the Electrician being on the top of the cage was purely for routine

maintenance that involved the following :

1. Cage emergency stop switches test, 2. Cage telephone communication test, 3. Cage bell - call to the bridge test, 4. Wire rope visual inspection, 5. Elevator motor gear case oil check, 6. Greasing of electric motor bearings,

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7. Landing door interlock switches inspection, 8. Safety devices and alarm test, 9. Electric motor insulation resistance test, 10. Oil level in the lubricator of the cage, 11. Oil level in the lubricator of the counter weight, 12. Tightness of mounting bolts of the rail, 13. Trunk lighting inspection, 14. Clearance between brake lining and brake drum, 15. Clearance between counter weights and buffer springs.

The work was carried out as per the checklist which points out the possible hazards

and the safety countermeasures that should be adopted. The vessel has the

COSWP and Company SMS Fleet Notice No: OSMC 06-01 which gives guidelines

for handling marine elevator. Both documents were reported to be understood by the

Electrician. However, no risk assessment was made as it was a routine work.

The Electrician was in charge of both maintenance and operation of the elevator.

Total running hours of the machine was reported to be 652 hours since the date of

delivery of the vessel.

10.1.4 PROCEDURE

The work procedures, as well as the scheduling of the work, were examined in

order to ascertain whether they contributed to the incident or not. It was found

that the work was planned in advance and the Wiper was assigned to assist.

However, the Electrician dismissed the Wiper who was assigned to help and to

be part of the team in case something went wrong. The Wiper was dismissed

before the job was completed. This had changed the condition making the

normal procedure unsafe. Although safety harness was provided, it was not

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being worn at the time of the incident. No safety helmet was found in or around

the accident location. All emergency stops were not activated and interlock

switches were put to Auto position.

10.1.5 THE ORGANISATIONAL FACTOR

From the above it appears that the organizational factor as reflected in this

incident clearly shows that the ship used all possible sources to enhance the

safety during this task but was violated by the Electrician. From the

interrogation of concerned higher management, it appears that the safety rules

were communicated in a way that they were understandable by all crew

members. The written procedures were provided such as the COSWP, on

board OPM, SMS Fleet Notices and Safety campaigns. Safety procedures

being enforced but unfortunately dismissing the Wiper resulted in a broken

safety chain. Going into the elevator trunk with all the safety interlock /

emergency stops not activated had resulted is a devastating incident.

Although the Electrician was experienced and well trained, a risk assessment

had to be carried out. This was not done due to unknown reason. There was, of

course, no direct violation of the safety rules. The reason for not conducting risk

assessment was because the task involved was of routine nature which does

not appear to be convincing.

However, the Chief Engineer being the Head of Engineering Department under

whose guidance the Electrician works on any vessel, cannot escape his

responsibility for not enforcing Risk Assessment of the task prior to undertaking

the maintenance work in a potentially risk prone area. It appears that just

because the Electrician was an experienced person, and just because the

maintenance work was of routine nature, entire task was left on to the

Electrician and his assistant. During the course of Lift Maintenance no feed

back of work progress was obtained and no cross check was carried out by the

Chief Engineer (as reflected in his statement).

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The Chief Engineer was expected to carry out a proactive analysis of the

situation during safety meeting and decide on the maintenance strategy to be

adopted by the Electrician and his assistant.

It was reported that the Elevator did not have any previous history of any

operational problem. Therefore, elevator maintenance work need not have

been done at ‘A’ deck / UD level. The ideal position for maintenance should

have been the lift’s Lowermost position, and the lift operation should have been

done manually and not electrically. The Chief Engineer should have instructed

the Electrician accordingly.

11. APPARENT CAUSE ANALYSIS

The following analysis had helped to classify the facts in the ICAM model for

inclusion in the investigation report and for briefing the PMA on the investigation

findings :

1. A series of mistakes were made by the casualty. This was initiated by

dismissing the direct assistance from the job, followed by not putting the full

PPE, entering the elevator trunk on self initiative and changing the safety

switches settings, missing the facts that this might be very dangerous as

proved later. These errors had an adverse effect associated with the person

having a direct contact with the equipment. It is believed that these acts have

led directly to the incident.

2. The location of the incident reportedly made the rescue operation very difficult

as the casualty was in the inverted position with his knee trapped between two

iron brackets, there being a drop of about 25 meters beneath him.

3. At first the sliding door reportedly did not open using the emergency key from

‘A’ deck. A crew member had to enter from the above deck and open the door

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by releasing the locking mechanism from the inside. The total time used to

secure the casualty into the ship’s hospital was 1 hour 5 minutes. The casualty

was reported to be bleeding and blood drops could be traced all the way down

from ‘A’ deck to the bottom floor. It was believed that the casualty had suffered

from broken leg, twisted ankle, broken arm, internal and external bleeding. The

casualty confirmed to be deceased by the Indian Coast Guard doctor at 1940

hrs L.T. The time when the incident first happened was about 1425 hrs L.T..

4. Organizational factor presented as inadequate procedures were used i.e. No

Risk Assessment made for this specific operation.

5. Failures into Organizational Factor using the Organizational Factor Type (OFT)

were not applicable as far as the hardware is concerned. However, when it

came to training, it could be seen that making assumption about the Electrician

knowledge and skills seemed to be over-confident as he dismissed the

assistant provided for him. The Electrician failed to assess the sequences of

that decision as well as being inside the elevator trunk with no safety measures

to stop the elevator from moving.

6. As far as organization is involved, it could be seen that the Electrician had

missed the definition of the objectives of the Wiper being with him due to

unclear accountability and the understanding of the wiper being not directly

trained on that particular job. This led into wrong decision making.

7. With regards to communication, a poor feed back could be noticed as neither

Bridge nor ECR were informed of the dismissal of the Wiper prior to completion

of work.

8. Incompatible Goals were demonstrated by the presence of conflicts between

safe work and production priorities. The Electrician went into the Elevator Trunk

as a conscious person who was trying to produce a good result out of his job

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being the person looking after the Elevator. Seemingly, he did not consider the

safety aspects and the hazards involved.

9. Error Enforcing Condition did not apply in this incident as there was no

apparent human limitation, external disturbance, social factors and personality

factor which are not known. The Electrician had recently joined the ship (12

days prior to the date of the incident).

10. Procedures should have been easily identified as they are clearly written,

documented and controlled. The missing risk assessment could have resulted

in a poor feedback on practicality.

11. Maintenance management was enforced as the job was pre-planned from early

morning to take place in the afternoon. There had been enough time for

everything to be set and for the safety measures to be considered.

12. Although the maintenance manual does not provide any safety instruction

before undertaking any maintenance work, it does provide “Escape method in

an emergency”. However, considering the place of work being Elevator shaft,

the general risk perception is obvious and hence additional guidelines as to

‘safety preparation’ is considered not necessary and code of safe works

practice is considered adequate.

13. Apart from the missing frame side, which believed not to have contributed to

the incident, there is no apparent design failure on the Elevator cage. During

the rescue operation and while carrying out the investigation, it was noticed that

the bulkhead opening sliding door could not be opened using the emergency

key. This had happened at ‘A’ deck and ‘B’ deck and UD.

14. Once the elevator started to move upwards ( will be explained later in this

Report ), the Electrician was able to understand the hazardous conditions

which could occur but he failed to control the recovery defense and could not

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get out of trouble without injury due to the fast moving cage and the restricted

area inside the elevator trunk.

15. The casualty tried to prevent escalation of the injury by applying a containment

defense procedure using his left leg to prevent him from falling all the way down

to the elevator floor ( 25 meters drop ).

16. Due to the restricted area failure to open the bulkhead slide door as quickly as

possible, the emergency team could not manage to evacuate the potential

casualty from the danger zone at a relatively good time. Medical first aid

although given but could not improve the condition of the casualty. The site was

isolated since then.

12. CONCLUSION

1. Usual practice of wearing PPE was not adhered to. Necessary PPE were left

outside the elevator trunk.

2. The Electrician appeared to be over-confident so much so that he entered the

elevator trunk without assistance resulting in vital human error.

3. Deliberately caused break in safety procedure by dismissing safety team,

although he was specifically instructed to the contrary during safety briefly in

the afternoon of 3rd February 2007.

4. Emergency stops were not achieved and “Inspection” selector switch was

changed into Auto position.

5. Vital time was lost as the lift door could not be opened in time.

6. Rescue operation became difficult due to space restriction.

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7. Considering the awkward position of the casualty who was trapped in an

“Inverted” position, appropriate decision making process was delayed for quick

rescue operation.

8. The casualty had been unconscious for about 40 minutes before he was finally

freed and shifted to ship’s hospital before first aid could be started.

9. The casualty was reported to be bleeding for nearly an hour before actual first

aid could be commenced.

13. RECAPITULATION

1. Electrician at Deck ‘A’ opened the elevator trunk door using emergency keys,

slides onto the top of the elevator car (cage) which is at Upper Deck ( UD ),

Door closed automatically ( as designed ),

2. Electrician carried out routine maintenance that involved checking of all fittings

and lubrication etc.,

3. He decided to go out through ‘A’ deck so took the elevator (using the remote

box) to a position where he could reach and unlock the door locking

mechanism, approximately 50 cms above floor of ‘A’ deck,

4. Changed over from Inspection to Auto (Maintenance control box), taking into

account that there is a delay period for the system to re-set, so he can reach

the door,

5. Re-set time complete ( around 40 seconds ) before he succeeded in opening

the door and elevator moves towards the nearest deck. ‘A’ deck being the

nearest ( 1700 mm to travel up towards ‘A’ deck, where as it needed

2050 mm to travel downwards to UD level ),

6. Initial movement caused the electrician to panic and therefore he turns towards

the ladder for easy escape,

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7. Right foot get trapped at the top of the elevator car corner ( 1 piece of safety

boot found at the bottom of the corner ), ankle twisted,

8. Electrician kneeled on his right leg and tried to hold / grab the ladder,

9. Due to potentially high speed of elevator he was held in the empty space

(between the ladder and the bulkhead brackets),

10. Inertia of high speed caused him to fall into this empty space, breaking his leg

due to weight and at the same time slamming the ladder with his left arm and

breaking it,

11. Elevator moving up fast and reached the correct position of ‘A’ deck level in

very few seconds,

12. Electrician knee got trapped between the moving and stationary brackets taking

all the weight;

13. Wounded Electrician screamed for help.

The entire incident is illustrated in a sketch below :

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14. RECOMMENDATION

The following corrective actions were identified in order to prevent recurrences of

such incident. At first a proactive analysis is to be carried out to identify

significant risks and safeguards to prevent and mitigate the associated

consequences as to what could go wrong, what are the consequences and what

could cause these consequences. Based on this analysis, a Management

System has to be set-up in order to control risk so that maintenance, strategies,

methods and procedures could be developed. Although not all causes can be

completely eliminated, effort must be made to enhance the safety awareness of

the crew and the fleet as a whole. The corrective actions recommended are

specific, measurable, accountable, timely, effective and can be reviewed

whenever required. The Principal Investigator is of the opinion that the following

formulated recommendations, if implemented, will reduce the risk of recurrence

of the incident and the consequences thereof.

• The job is to be planned well in advance to allow for all safety measures to

be carried out,

• A risk assessment should form a part of the planned maintenance and must

be obtained prior to carrying out maintenance,

• At least two persons should be involved when elevator maintenance is

carried out,

• A good communication must be established between all parties involved at

all time. A time interval can be agreed between the involved parties,

• All safety procedure must be strictly observed. Every person involved in the

work must have clear understanding of their duties and associated risks.

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• Elevator trunk must be treated as a confined space, therefore, an entry

permit must be obtained,

• Elevator door at specific deck to be locked open during maintenance,

• Instruction for emergency opening of elevator doors should be posted by

each door,

• Clear warning of both the presence and the nature of a potentially

hazardous situation must be explained to all members involved,

• Must ensure that the team members understand the nature and severity of

the hazardous conditions presents at the worksite,

• Under no circumstances an individual is to be allowed to enter the Elevator

trunk with the emergency stops not activated,

• An announcement must be made through the ship’s PA prior to carrying out

any maintenance on elevator,

• The controls in cage maintenance call box must be configured in such a

manner that it would not be possible to activate them accidentally.

• No “complete maintenance” announcement is to be carried out until a full

head count is conducted,

• Owners must obtain makers recommendation towards safety enhancement

for prevention of accidental fall (when opening the doors using emergency

keys).

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• Person involved in elevator maintenance must demonstrate the capability of

doing such task to the Chief Engineer before conducting the first routine

maintenance.

• Warning notices must be posted so that accidental use of all call buttons is

prevented.

• Design of the Elevator should include a safety barrier around the cage.

• Company OPMs must include instructions on elevator maintenance.

• All maintenance on the elevator must be carried out at lowermost position

unless the situation demands otherwise.

15. OUTCOMES OF THE INCIDENT

1. Loss of life of one of the ship’s officer,

2. This incident will not be forgotten by any of the crew members due to the

psychological effect on the individuals,

3. Equipment is left isolated since the day of the incident,

4. Lessons learnt and more precautions will be adhered to when attending

any maintenance in future.

P. K. Bhattacharyya PRINCIPAL INVESTIGATOR, HENDERSON INT’L (INDIA) PVT. LTD., KOLKATA, INDIA.