What happened
On 2 October 2019, at approximately 09:45 local time, a fatal accident occurred aboard the Damsterdijk, a general cargo vessel operating under the management of Shipping Company Groningen (SCG). The ship was located in the port of Ipswich, United Kingdom, where it had arrived to discharge and load cargo. Following the completion of unloading operations, the vessel was required to move backward approximately 100 meters to create space for another ship, as requested by the harbour master.
The maneuver was commanded from the bridge by the captain, with the first officer assisting on the starboard wing. On the aft deck, three crew members were present: an able seaman (AB) in charge, a cook/AB, and a cadet. The AB was responsible for the aft spring line, while the cook/AB and the cadet handled the stern lines. During the operation, the starboard stern line became entangled in the vessel's controllable pitch propeller. As the ship moved backward, the line came under extreme tension and broke. The snapped line whipped back at high speed, striking the cook/AB in the left leg and torso. Despite initial consciousness, the victim lost awareness before medical assistance arrived and died later that day in hospital.
The investigation
The Dutch Safety Board (OVV) initiated its inquiry immediately following the incident, collecting evidence in Ipswich and interviewing crew members, SCG representatives, and port authorities. Investigators analyzed CCTV footage, reviewed ship-specific procedures, and examined the manning plan submitted to the Human Environment and Transport Inspectorate (ILT). The investigation utilized the TRIPOD analysis method to identify failures in safety provisions and underlying organizational factors. Key areas of focus included the communication protocols during mooring operations, the supervision structure on deck, and the feasibility of the crewing levels relative to the tasks required.
Findings
The OVV established that the direct cause of the death was the impact from the breaking stern line. Several underlying factors contributed to this outcome:
- Communication breakdown: The cook/AB did not have a walkie-talkie, unlike other crew members on deck and ashore. Additionally, the AB in charge was out of visual and auditory range due to engine noise and vessel structure, preventing timely warnings.
- Supervision conflicts: The AB in charge was tasked with both supervising the operation and actively handling lines. This dual role prevented him from maintaining a full overview of safety conditions or issuing immediate alerts when the line began to run out.
- Manning discrepancies: The manning plan approved by the ILT assumed a crew strength that did not match the actual number of personnel available for the specific procedure described in ship-specific protocols. An omission during the certification process meant the feasibility of the proposed manning was not properly assessed.
- Environmental factors: Mooring lines were left loose on deck rather than coiled, allowing them to enter the water more easily. The snap-back zone was not clearly marked or signaled.
- Fatigue and training: The AB had not taken sufficient rest hours prior to the incident. Furthermore, the cadet was performing new tasks without adequate specific supervision for this particular maneuver.
Safety action
The Dutch Safety Board issued recommendations to Shipping Company Groningen, the Minister of Infrastructure and Water Management, and the Royal Association of Netherlands Shipowners (KVNR). Key actions include ensuring crew numbers align with procedural requirements, guaranteeing regulatory rest hours, equipping all deck crew with communication devices, and implementing clear warning systems for snap-back zones. The Board also recommended that the ILT verify the feasibility of manning plans against actual operational procedures before issuing safe manning certificates. Additionally, SCG was advised to enhance safety culture through regular procedure reviews, incident simulations, and targeted training for trainees.