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Report of Investigation into

the death of Bosun

on board Hong Kong registered

vessel Great Harvest at the outer

anchorage of Samarinda, Indonesia

on 10 September 2011

Completed on 11 December 2012

Purpose of Investigation

This incident is investigated, and published in accordance with the IMO Resolution MSC

255(84), the Code of the International Standards and Recommended Practices for a Safety

Investigation into a Marine Casualty or Marine Incident (Casualty Investigation Code)

adopted on 16 May 2008.

The purpose of this investigation conducted by the Marine Accident Investigation and

Shipping Security Policy Branch (MAISSPB) of Marine Department, in pursuant to

Merchant Shipping Ordinance Chapter 281 Section 51, 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 VESSEL ............................................................................. 2

3. SOURCES OF EVIDENCE.......................................................................................... 4

4. OUTLINE OF EVENTS ............................................................................................... 5

5. ANALYSIS..................................................................................................................... 7

6. CONCLUSION .............................................................................................................11

7. RECOMMENDATIONS ............................................................................................ 12

8. SUBMISSION.............................................................................................................. 13

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1. Summary

1.1. At 0712 on 6 September 2011, the Hong Kong registered bulk carrier vessel Great

Harvest arrived at the outer anchorage of Samarinda, Indonesia and anchored in

position 00˚16.17’S 117˚40.43’E.

1.2. At 2230 on 7 September 2011, loading of coal cargo commenced. A crane barge

was used to transfer coal cargo from feeder-barges into the cargo holds of Great

Harvest.

1.3. At about 0600 on 10 September 2011, the loading of coal cargo into No.2, 3 and 5

cargo holds was completed and the Bosun, Deck Fitter and Deck Cadet were

asked to close the hatch covers and the access hatch covers of these cargo holds.

At about 0732, while the Deck Cadet and the Deck Fitter were moving the air

motor and the air hose from No.3 cargo hold and connecting them to No.2 cargo

hold, the Deck Fitter saw the Bosun sitting unconsciously on deck with his back

leaning against the coaming of the access hatch of the No.2 cargo hold.

1.4. The incident was reported to the duty officer immediately. The crewmembers

arrived at the scene and the Bosun was applied with first aid and cardiopulmonary

resuscitation. Later, he was sent to the hospital at shore for treatment. The

Bosun was certified dead on arrival in the hospital at 1230 on 10 September 2011.

1.5. At the time of the accident, it was raining and the ship was not rolling.

1.6. The investigation into the accident revealed that the Bosun was most probably

stepped on the slippery coal paste on deck and fell. His abdomen accidentally

hit the hinge of the access hatch cover of No.2 cargo hold, and the hitting of the

hinge probably ruptured his liver and kidney consequently.

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2. Description of the Vessel

Vessel Name: Great Harvest

IMO Number: 8501610

Call Sign: VRZW9

Flag: Hong Kong

Port of Registry: Hong Kong

Trade of Vessel: International

Ship Type: Bulk Carrier

Gross Tonnage: 37057

Net Tonnage: 224421

Length (LOA): 224.520 metres

Breadth (molded): 32.24 metres

Depth (molded): 18.32 metres

Summer Draft: 13.224metres

Deadweight 68,192 tonnes

Main Engine: Direct drive diesel engine (Type: 5L70MC), 1 set

Engine Power: 8131.4 kW

Propulsion: Single screw

Service speed: 13.6 knots

Year of Built: 1985 (Koyo Dockyard Co., Ltd)

Owners: Great Shipping Co Ltd.

Managers: Wallem Shipmanagement Ltd.

Class: America Bureau of Shipping (ABS).

Casualties: l

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Fig.1 – Great Harvest

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3. Sources of Evidence

3.1 Information provided by the ship management company, the Master and

crewmembers of Great Harvest.

3.2 The autopsy report provided by the Indonesia Authority.

3.3 The investigation report provided by the ship management company.

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4. Outline of Events

4.1 On 26 August 2011, Great Harvest (“the vessel”) arrived at Hadong, Republic of

Korea for unloading coal cargo which had been carried from Vostochny, Russia. After

completed discharge of cargo, the vessel sailed on 29 August 2011 to Samarinda,

Indonesia.

4.2 At 07121 on 6 September 2011, the vessel arrived at the outer anchorage of

Samarinda, Indonesia and dropped anchor at the position 00˚16.17’S 117˚40.43’E.

4.3 At 2230 on 7 September 2011, loading of coal cargo to the vessel commenced at

the anchorage. A crane barge was moored alongside the vessel and used its crane to

transfer coal from feeder-barges, which moored alongside the crane barge, into the cargo

holds of the vessel.

4.4 It was drizzling in the morning on 10 September 2011. At about 0600, loading

of coal cargo into No.2, No.3 and No.5 cargo holds was completed. The Chief Officer

asked the duty seaman to call the Bosun, Deck Cadet and Deck Fitter to sweep the cargo

residues remained on the face plates of hatch coamings of the aforementioned cargo holds

and to close their hatch covers after cleaning. The Bosun, Deck Fitter and Deck Cadet

commenced the work about 10 minutes later.

4.5 The Chief Officer called the Bosun twice through walkie-talkie at around 0720

and 0725 asking him to check and close the access hatch covers of the above cargo holds.

The calls were all acknowledged by the Bosun.

4.6 After the No.5 cargo hold hatch covers were closed. The rain started to fall.

The Deck Cadet went back to the crew accommodation for taking his raincoat. About

one minute later, putting on his raincoat, the Deck Cadet came to help the Bosun to close

No.3 cargo hold hatch covers. Both of them climbed up on the top of the hatch covers

and stepped on the hatch covers’ runner wires so as to use their body weight to help the air

motor close the hatch covers. After the No.3 cargo hold hatch covers were closed, the

Bosun and the Deck Cadet came down from the hatch covers.

4.7 The Deck Cadet and Deck Fitter then disconnected the air motor and air hose from

No. 3 cargo hold and moved them for connecting to No.2 cargo hold. At about 0732,

while the Deck Cadet was connecting the air hose to the air motor mounted to No. 2 cargo

hold, the Deck Fitter saw the Bosun leaning unconsciously against the access hatch

coaming of No.2 cargo hold that is located on the cross deck between No.2 and No.3 cargo

holds. They did not hear any abnormal sound of falling object or screaming. The ship

1 All time is Central time of Indonesia (GMT + 8)

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was not rolling at the time.

4.8 The Deck Cadet and the Deck Fitter immediately helped the Bosun to rest on the

deck and reported the incident to the duty officer. The Chief Officer arrived at the scene

shortly and found that the Bosun had stopped breathing and had no heartbeat. First aids

and cardiopulmonary resuscitation were administered to the Bosun immediately.

4.9 At about 0738, the Master of Great Harvest asked the foreman and the agent (who

were on board the vessel at the time) to call for assistance from shore.

4.10 By 0745, the Bosun had been moved to a place under the shade of a hatch cover of

No. 2 cargo hold, which was still open.

4.11 At 0750, the Master asked the agent to arrange transportation to send the Bosun to

hospital for treatment and he reported the incident to the ship management company at

0805.

4.12 A speedboat arrived at shipside shortly after 0900. The Bosun was sent to shore

at 0948 for medical treatment after clearing the customs and port formalities.

4.13 At 1230 on 10 September 2011, the Bosun was certified dead on arrival at the

local hospital.

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5. Analysis

The weather condition

5.1 In the morning on 10 September 2011 at 0600 hours, it was drizzling and raining.

There was a light southerly breeze of Beaufort Scale 3. The vessel was not

rolling.

Autopsy report

5.2 The autopsy report issued by a forensic doctor in Samarinda on 29 September

2011 stated that the head of the Bosun was swollen, skin-tore injuries left by

blunting at his neck, chest, abdomen, waist, back, left upper limb and right lower

limb. The liver and kidney were ruptured and shifted, and his stomach was also

ruptured. In addition, ribs of the left and right chest were broken due to blunting.

The doctor concluded that the Bosun died from rupture of liver and kidney

resulting from hitting against his stomach by blunt object.

5.3 Local Police had conducted initial criminal investigation into the death of the

Bosun. Finally they found no evidence of criminal offences and therefore the case

was aborted and no further actions were taken.

Human factors

5.4 The Bosun had worked on board ship for over 10 years. He joined the vessel on

12 January 2011 and it was his fifth time with the vessel loading coal cargo in port

Samarinda, Indonesia. The Bosun was considered to be an experienced seafarer.

5.5 The medical certificate issued to the Bosun on 16 December 2010 indicated that

his physical condition was normal. The autopsy report showed no signs of

physical handicap or illnesses of the Bosun, and he was not affected by alcohol

and drugs.

5.6 During cargo operation in Samarinda, the Bosun worked during the day. There

was no evidence to show that he suffered from fatigue at work.

5.7 It was raining at the time of the incident. The Bosun wore boiler suit, safety

shoes and helmet.

Circumstances leading to the dead of the Bosun

5.8 There were no witnesses to the accident. The probable causes of the dead of the

Bosun is deduced from available information.

5.9 The autopsy report stated that “the Bosun died from rupture of liver and kidney

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resulting from hitting against his stomach by blunt object”. It is suspected that

the Bosun was first hurt seriously after impacting his front body on the hinge of

the No.2 cargo hold access hatch cover.

5.10 Photographs taken by the Master of the vessel after the accident showed that there

was a slip trail beside the coaming of the No. 2 cargo hold access hatch (Fig. 2).

It is arguable the slip trail was left by the Bosun’s shoe upon his slipping on deck.

Nonetheless, at the time of the accident, it was raining and the deck covered with

coal dust was slippery. It was probable that the Bosun was hurry to close and

lock the No.2 cargo hold access hatch cover. He stepped on the slippery coal

paste on deck while approaching the access hatch and fell forward. His abdomen

hit the hinge of the access hatch cover, which may be in the close position but not

locked. The blunt edges of the hinge could not pierce the skin of his abdomen

but ruptured his internal organs during impact.

5.11 He was probably still conscious after the first hit. The excruciating pain in his

abdomen prompted him to turn and slide down to seat on deck for taking a rest.

A crew member re-acted the probable scene of how the Bosun’s back could have

lain against the hinge of the hatch cover (Fig. 3) before sitting down on the deck

and leaning against the coaming. That posture helped explain why a butterfly

nut beside the hinge of the access hatch cover and the hinge, which should be

sticking with coal dust, appeared to be shiny (Fig. 4) as the coal dust could have

been wiped out by the clothing of the Bosun. It also matched the autopsy

report’s finding that “the head of the Bosun was swollen, and skin-tore injuries

left by blunting at his neck, back, left upper limb and right lower limb”.

5.12 There was no abnormal sound of falling object or screaming. It was also probable

that the Bosun fainted shortly after he sat down on deck.

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Fig. 2 - The slip trail beside No.2 cargo hold access hatch

Fig. 3 – A crew re-acting the probable scene of how the Bosun’s back could have lain against the hinge of the hatch cover

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Fig. 4 – The hinge and butterfly nuts of the No.2 cargo hold access hatch cover.

The wings of the butterfly nut appeared to be shinier

than the other nuts of the same hatch cover

The hinges of the hatch cover

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6. Conclusion

6.1 At 0712 on 6 September 2011, the Hong Kong registered bulk carrier vessel Great

Harvest arrived at the outer anchorage of Samarinda, Indonesia and anchored in

the position 00˚16.17’S 117˚40.43’E.

6.2 At 2230 on 7 September 2011, loading of coal cargo commenced. A crane barge

was used to transfer coal cargo from feeder-barges into the cargo holds of Great

Havest.

6.3 At about 0600 on 10 September 2011, the loading of coal cargo into No.2, 3 and 5

cargo holds was completed and the Bosun, Deck Fitter and Deck Cadet were

asked to close the hatch covers and the access hatch covers of these cargo holds.

At about 0732, while the Deck Cadet and the Deck Fitter were moving the air

motor and the air hose from No.3 cargo hold and connecting them to No.2 cargo

hold, the Deck Fitter saw the Bosun sitting unconsciously on deck with his back

leaning against the coaming of the access hatch of the No.2 cargo hold.

6.4 The incident was reported to the duty officer immediately. The crewmembers

arrived at the scene and the Bosun was applied with first aid and cardiopulmonary

resuscitation. Later, he was sent to the hospital at shore for treatment. The

Bosun was certified dead on arrival in the hospital at 1230 on 10 September 2011.

6.5 At the time of the accident, it was raining and the ship was not rolling.

6.6 The investigation into the accident revealed that the Bosun was most probably

stepped on the slippery coal paste on deck and fell. His abdomen accidentally

hit the hinge of the access hatch cover of No.2 cargo hold, and the hitting of the

hinge probably ruptured his liver and kidney consequently.

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7. Recommendations

7.1. A copy of the report of investigation into the accident should be sent to the owner

/ management company and the Master of Great Harvest informing them the

findings of the investigation.

7.2. The owner / management company of Great Harvest should issue safety circular

to inform all masters, officers and crew on board the company’s fleet to take extra

precautions when working on slippery deck surface on board ship.

7.3. A copy of the report should be provided to the Mercantile Marine Office and the

International Safety Management Section of the Shipping Division for their

reference and necessary actions, if required.

7.4. A Hong Kong Merchant Shipping Information Note for promulgating the findings

and lessons learnt of this accident investigation should be issued.

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8. Submission

8.1 In the event that the conduct of any person or organization is criticized in an

accident investigation report, it is the policy of the Marine Department that a copy

of the draft report, either partly of completely, is given to that person or

organization so that they can have an opportunity to rebut the criticism or offer

evidence not previously available to the investigating officer.

8.2 Copies of the draft report in entirely were sent to the management company and

the Master of Great Harvest for their comment. They have no comments on the

draft report.

8.3 No comment was received from the parties in paragraph 8.2