Report of Investigation into

the fatal accident of

a slinger on board Kam Ying

at Kwun Tong Typhoon Shelter

on 9 April 2011

13-7-2012

Purpose of Investigation

This incident is investigated, and published by the Marine Accident

Investigation and Shipping Security Policy Branch (MAISSPB) of Marine

Department pursuant to Merchant Shipping (Local Vessels) Ordinance Chapter

548 Section 40, 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 Vessels 2

3 Sources of Evidence 4

4 Outline of Events 5

5 Analysis of Evidence 11

6 Conclusions 16

7 Recommendations 17

8 Submissions 18

1

1. Summary

1.1 On 9 April 2011 at 1600, a fatal accident happened on board the Hong

Kong licensed Dumb Steel Lighter Kam Ying at Kwun Tong Typhoon

Shelter, Hong Kong.

1.2 Kam Ying was alongside the Chinese registered river trade vessel Bo

Hai Yun 118. Kam Ying unloaded the waste papers bales on board

using her derrick crane to Bo Hai Yun 118.

1.3 After a slinger engaged cargo slings on a waste paper bale in the eighth

bay at the second tier, he walked aside and waited for the next

unloading operation. While the bale was transferring towards Bo Hai

Yun 118, fifteen bales at the fifth, sixth and seventh tiers of the eleventh

bay collapsed and crushed the slinger.

1.4 The slinger was sent to the hospital for treatment and was certified dead

on 10 April 2011.

1.5 The investigation revealed the main contributory factor of the accident

was that there was no proper cargo planning and risk assessment. The

bales were transferred in a way leaving the bales at the eleventh bay

stacking like a wall without securing. The bales collapsed due to

rolling motion of the dumb steel lighter caused by movement of the

cargo, wind and wave motion.

2

2. Description of the Vessels

2.1 Particulars of Kam Ying

Certificate of issuing authority: Hong Kong Marine Department

Certificate of Ownership No. : B22078Y

Type of Vessel : Dumb Steel Lighter Class II B

Year of Built : 1981

Owner : Hand G-Well (International Holdings)

Ltd.

Length : 34.75 metres

Breadth : 13.94 metres

Gross Tonnage: 760.47

Net Tonnage: 532.33

Engine Power: N.A.

Fig 1 Kam Ying

3

2.2 Particulars of Bo Hai Yun 118

Port of registry: Hui Zhou, China

Registration No.: 090410000217

Type of Vessel: Container

Year of Built: 1993

Built at: Panyu Lingshan Shipyard

Owner : Zhou Hui Guang

Length : 45.85 metres

Breadth : 11.85 metres

Depth: 3.3 metres

Gross Tonnage: 737.00

Net Tonnage: 412.00

Engine Power: 434 kW

No. of Crew: 4

Fig 2 Bo Hai Yun 118

4

3. Sources of Evidence

a) The Master of Bo Hai Yun 118

b) The works supervisor of Kam Ying

c) The crane operator of Kam Ying

d) The signaller of Kam Ying

e) Autopsy report by the Department of Health

5

4. Outline of Events

4.1 On 8 April 2011, Bo Hai Yun 118 (the Vessel) departed Boluo, China at

about 1500. She arrived and anchored at Kwun Tong Typhoon Shelter,

Hong Kong at about 0500 on 9 April 2011.

4.2 At about 0830, the Vessel berthed her starboard side at the port side of

Kam Ying (the DSL), by that time the DSL had been moored with her

starboard alongside the pier (Fig 3).

4.3 At about 0830, the DSL started unloading waste paper bales on board

and transferred the bales to the Vessel. The cargo plan of the DSL

before unloading was as shown in Fig 4. Four workers participated in

the cargo handling on board the DSL, they were a works supervisor, a

signaller, a slinger and a crane operator (Fig. 3).

4.4 From 0830 to 1600, about 300 paper bales from the fourth to tenth bays

on board the DSL were unloaded to the Vessel using the derrick of the

DSL.

4.5 At about 1600, the slinger engaged a cargo sling on a bale at the second

tier, fifth row, eighth bay and then stepped aside. The signaller, who

stood on the port main deck, gave a hand signal to the crane operator to

lift the bale.

4.6 When the crane operator used the derrick crane to transfer the bale to

the third bay of the Vessel, he observed that many bales at the eleventh

bay on board the DSL were collapsing. He immediately stopped the

derrick crane.

4.7 The signaller went to the cargo hold and found the slinger lying on the

bale of first tier, fifth row, eighth bay. The slinger was conscious with

blood on his face.

6

4.8 The slinger was sent to the hospital for treatment and was certified dead

later in the hospital.

3rd

Bay

2nd

Tier

Wheelhouse

No.4 bale from

starboard side

Accommodation

1st

Bay

8th

Bay

11th

Bay

4 tier

4 tier

3 tier

3 tier

2 tier

1 tier

1 tier

1 tier

1 tier

1 tier

7 tier

Accommodation

DSL “KAM YING”

BO HAI YUN 118

Signaller

Slinger (the deceased)

Crane

operator

A

B

A

B

4

4

4

6

6

6

6

6

7

6

6

Nos. of tiers at

about 0830am

Nos. of tiers at time

of accident (1600)

Kerry D.G. Warehouse (Kowloon Bay) Limited

Kowloon

Godown

Boarding Access

Works supervisor

Fig 3 Berthing Plan of the Vessels

11th row 1st row

.

Fig 4 – Section A-A the cargo plan before cargo operation

7

First row eleventh row

8

Fig. 5 Section B-B at the time of accident

9

Fig 6 Bales toppled at the eleventh bay of the DSL

10

Wind

Vessel rolling due to wind and wave motion

wave

Fig 7 DSL rolling due to external forces and movement of cargo

DSL rolling due to movement of cargo

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5. Analysis of Evidence

Working experience & training

5.1 The Master has worked as master on board the Vessel for two years.

He held a Certificate of Competency issued by Huizhou Maritime

Safety Administration, China as a River Trade Vessel Master. He had

completed the mandatory basic safety training of the shipboard cargo

handling and works supervisor safety training in 2010. His training

certificates were valid at the time of the accident.

5.2 The works supervisor of the DSL held a valid basic safety training

certificate of shipboard cargo handling and certificate of training of

shipboard works supervisor. He was certificated to work as a works

supervisor on board the DSL.

5.3 The crane operator of the DSL held a valid basic safety training

certificate of shipboard cargo handling and certificate of training of

shipboard crane operator. He was certificated to work as a crane

operator on board the DSL.

5.4 The signaller of the DSL held a valid basic safety training certificate of

shipboard cargo handling.

5.5 The slinger (the deceased) held a valid basic safety training certificate

of shipboard cargo handling.

Working hours

5.6 All four workers attended the DSL at 0800 on 9 April 2011 and the

cargo operations started at 0830. There was no evidence to show that

the workers had suffered from fatigue.

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The environment

5.7 At the time of the accident, the wind speed was 20 kilometres per hour.

There was moderate breeze, small waves could have generated at sea.

Personal protection equipment

5.8 The slinger (the deceased) worn safety helmet and reflective vest

during cargo operation at the time of the accident.

The autopsy report

5.9 According to the autopsy report issued by the Department of Health,

the direct cause of death was due to retroperitoneal hematoma, pelvic

fracture and vertebral fracture. The injuries were consistent with

crushing by heavy object.

Maintenance of the derrick

5.10 The annual examination of the derrick, its lifting appliances and lifting

gears on board the DSL were examined by a competent examiner on 7

November 2010. The certificates of test and examination were valid at

the time of the accident.

5.11 The weight of a waste paper bale was about one tonne. The safety

working loads of the derrick, lifting appliances and lifting gears are

much higher than one tonne. There was no evidence to show that the

derrick, appliances and lifting gears were overloaded.

Stacked cargo safety practice

5.12 Person in charge of works should conduct risk assessment for each type

of cargo operations. He should also continually review the risk

assessment from fresh risks arising from changes in operational

environment or modes of operation.

5.13 Before unloading, the cargo plan of the DSL is shown in Fig. 4. The

bales were then unloaded to the Vessel and before the accident, the

cargo plan of the DSL is shown in Fig. 5. The bales had been unloaded

in such a way that the bales in front of the eleventh bay (i.e. sixth to

tenth bays) were unloaded to remain only one tier of bales while

leaving the bales in the eleventh bay stacked up to seven tiers high. It

is apparent that the cargoes were unloaded in a convenient manner

without proper cargo planning and risk assessment.

5.14 Shipboard Cargo Handling Safety Guide issued by the Marine

Department stated that effective measures should be taken at all times

to prevent the collapse of stacked cargo. In this accident, the works

supervisor should have assured the stacked waste paper bales being

firmly secured at all times during cargo operation. When the stacked

cargoes became unstable, they should be rearranged and properly

secured before continuing the cargo operation. However, in this

accident, the paper bales were unloaded in a way leaving a single row

of bales of seven tiers stacking like a wall. The wall-like stack of paper

bales possessed high risk of collapse.

Contravention of Merchant Shipping (Local Vessels) Ordinance

and Regulation

5.15 In is apparent that the Person in Charge of the DSL did not conduct any

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risk assessment nor take measures to secure unstable cargoes. As a

result, a single row of bales of seven tiers collapsed. Therefore, he

might contravene the following Ordinance and Regulation:

Merchant Shipping (Local Vessels) Ordinance Cap. 548, section

45(1) stipulates that “ A person in charge of works shall not carry

out, or cause to be carried out, any works in a condition or

manner that does not provide adequately against unnecessary risk

of accident or bodily injury”

Merchant Shipping (Local Vessels) (Works) Regulation, Cap

548I, section 64 stipulates that “ Where stacking, unstacking,

stowing or unstowing of cargo or handling in connection with

such cannot be safely carried out unaided, reasonable measures

to guard against accident shall be taken by shoring or otherwise”.

Possible cause of the accident

5.16 The dimension of a paper bale was about 2.13 metres (length), 1.06

metres (breath) and 1.06 metres (height). When the paper bales were

stacked at a height of seven tiers, it was about 7.42 metres. The base of

the bales was not flat and would become unstable when being stacked

high. Therefore highly stacked bales were vulnerable to collapse

5.17 Fifteen bales stowed at the eleventh bay on board the DSL collapsed

while a paper bale was being transferred from the DSL to the Vessel,

therefore it was believed that the collapse was caused by movement of

the bale. When the bale was transferred from the DSL towards the

Vessel, the centre of gravity of the DSL would shift towards the port

side thus caused the DSL to roll (Fig7). Therefore the bales collapsed

due to rolling of the DSL.

14

15

5.18 The DSL may also be moved by wind and wave motion. At the time of

accident, the wind speed was about 20km/hour and small waves might

have been generated. The degree of movement of the DSL, while

transferring cargo overboard, could be multiplied by effect of wind and

wave motion (Fig.7).

Safety awareness

5.19 Works supervisor involving in cargo operation of stacked cargo should

take effective measures at all times to prevent collapse of stacked

cargo. It is evident that in this case, the person in charge of the DSL

was not aware of the risk and did not take any measures to secure the

stacked bales firmly.

5.20 It is evident that there was no proper cargo planning and risk

assessment of cargo operations and the bales were unloaded

indiscriminately without assessing the hazard of unsecured stacked

bales.

16

6. Conclusion

6.1 At about 1600 on 9 April 2011, a fatal industrial accident happened on

board the local dumb steel lighter Kam Ying at Kwun Tong Typhoon

Shelter, Hong Kong.

6.2 Waste paper bales stacking on board Kam Ying were transferring to the

river trade vessel Bo Hai Yun 118 using the derrick of Kam Ying.

6.3 While a paper bale was transferring from Kam Ying to Bo Hai Yun 118,

some top paper bales stacked at the eleventh bay toppled and crushed

onto a slinger staying at first tier, eighth bay on board Kam Ying.

6.4 The investigation revealed the main contributory factor of the accident

was that there was no proper cargo planning and risk assessment. The

bales were transferred in such a manner that the left bales at the

eleventh bay stacking like a wall without securing. The bales collapsed

due to rolling of DSL caused by movement of the DSL, wind and wave

motions.

6.5 Another contributory factor was that there was a lack of safety

awareness of the person in charge and workers of Kam Ying in handling

of stacked cargo.

17

7. Recommendations

7.1 A copy of the report should be sent to owners and person in charge of

Kam Yin advising them the findings of the accident.

7.2 The owners and person in charge of Kam Ying are required to:

Take proper risk assessment involved in the operations of stacked

cargoes and preventive measures to minimize the potential risks;

and

Secure stacked cargoes properly in a stable condition at all times.

7.3 A Marine Department Notice should be issued to promulgate the

lessons learnt from the accident.

18

8. Submission

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

commented in an accident investigation report, it is the policy of the

Marine Department to send a copy of the draft report to that person or

organization for their comments.

8.2 The final report was sent to the owners and person in charge of Kam

Ying for their comments. There was no comment received from them

at the end of the consultation period.