What happened
On the morning of 30 June 2018, in the port of St. Marc, Haiti, a fatal accident occurred aboard the Dutch cargo ship Beauforce. A crew member was trapped between a moving hatch crane and stacked hatches while stepping from the hold entrance amidships onto the deck. At the time, the hatch crane was being used to close the hatches of hold number 1.
The operation involved three crew members: one operating the crane and two assisting from the gangway. After switching on the crane, the operator asked via transceiver if the operating range was clear. Both assistants confirmed it was free. The operator then moved the crane toward the bow. However, the victim, who was expected to be in the port-side gangway, was actually still walking from the hold entrance amidships to that location. Because the victim was on the port side and completely hidden from the operator’s view on the starboard side, he became entrapped just in front of the hold entrance between holds 1 and 2.
The investigation
The Dutch Safety Board (OVV) conducted an extended investigation because this was the second fatal entrapment on the Beauforce in three years, following a similar incident in 2015. The Board analyzed the course of events, focusing on two main perspectives: the safe operation of the hatch crane and the safety of working within its range.
The investigation revealed that the hatch crane design limits the operator’s visibility to one side of the ship. In this case, the operator had no view of the port gangway where the victim was located. The Board also examined five other similar incidents involving hatch cranes between 2013 and 2020 to identify common safety shortcomings. These included fatalities on the Toucan Arrow (2013), Beauforce (2015), Lady Christina (2017), Karina C (2019), and Cimbris (2020).
Findings
The primary causal factor was a failure in communication and situational awareness. The operator received confirmation that the area was clear, but this information was inaccurate because the victim was still moving into the danger zone. The design of the hold entrance amidships acted as a risk-increasing factor by creating a blind spot for the crane operator.
The Board found that existing control measures were insufficient to prevent such entrapments. Specifically, there was a lack of clear agreements regarding which activities are allowed in the hatch crane’s danger zone and how to effectively alert crew members to direct dangers during operations.
Safety action
The Dutch Safety Board issued several recommendations to improve safety:
- Vertom Shipmanagement b.v. and the Royal Association of Netherlands Shipowners must ensure that no one crosses hatch crane rails while the crane is in use. If crossing is necessary, the crane must be stationary.
- They must define clear agreements about the exact location of the danger zone and which activities are permitted within it.
- The Board recommended investigating design changes to eliminate or reduce entrapment risks, including methods to alert crew members clearly when hatch crane operations pose a direct danger.