What happened
On 23 November 2019, at approximately 16:40 local time, an able seaman (AB) fell from a grab suspended on one of the ship's cranes aboard the Zealand Rotterdam. The vessel was anchored in the roads of Mumbai, India, preparing for unloading. The AB had climbed onto the grab to release lashing lines while other crew members attached the crane hook. Suddenly, the lifting block made an unexpected swinging motion that struck the worker, causing him to fall backwards onto the main deck below. He sustained fatal injuries and died.
The investigation
The Dutch Safety Board (OVV) investigated the incident as the flag state authority. Due to the vessel's imminent transfer to a new owner and flag state, along with visa restrictions and the onset of the COVID-19 pandemic, OVV could not conduct its own on-board inspection or interview all crew members directly. Instead, the investigation relied on information provided by the ship manager, Q-Shipping, an internal company report, and an abbreviated initial report from Indian maritime authorities who boarded the vessel before its transfer.
The vessel was in its final voyage under Dutch management before being sold to a Turkish owner. Weeks prior to the accident, six new crew members of Turkish nationality had joined the ship to replace existing crew members. The investigation noted that communication between the experienced international crew and the new Turkish crew was limited, with hand signals often used due to language barriers.
Findings
The direct cause of the fatal fall was the sudden swinging movement of the crane's lifting block, which struck the AB while he was working at height on the grab. The investigation could not definitively determine whether this movement resulted from crane operation or vessel motion, but noted that such risks are inherent to shipboard work.
Key contributing factors included:
- Lack of Personal Protective Equipment (PPE): The victim and other crew members involved were not wearing mandatory safety helmets or fall protection gear, despite it being available and required by the Safety Management System (SMS).
- Procedural Failures: No toolbox meeting or Last Minute Risk Assessment (LMRA) was conducted before starting the high-risk task of attaching the grab. The work was performed under time pressure.
- Crewing and Language Issues: The ship manager replaced experienced crew with new, inexperienced personnel who lacked a common working language with the rest of the team, hindering effective communication and safety coordination.
- Supervision Gaps: The vessel rarely visited European ports, limiting the ability of both the ship manager’s Dutch office and the Dutch flag state inspectorate (ILT) to conduct regular inspections or maintain oversight of on-board practices.
Safety action
The Dutch Safety Board issued three recommendations to the ship manager, Q-Shipping: 1. Maintain a fully experienced crew even during final voyages; deploy new crew members as supernumeraries in a learning role rather than as replacements, and ensure a common working language for all crew. 2. Ensure sufficient time is allocated to follow SMS procedures and risk assessments, even under time pressure, and develop high-risk activity procedures based on occupational health strategies. 3. Implement effective supervision of vessels that do not regularly visit European ports, regardless of whether oversight is managed from Dutch or foreign offices.