1  What the type of casualty

事故类型

Very serious marine casualty: Fall from ladder while hold cleaning

非常严重的海事事故：洗舱时从梯子上坠落

2  What happened

事故经过

A bulk carrier was at anchor to carry out hold cleaning operations. The chief officer ordered two seamen to clean No.1 Cargo Hold and issued a permit to work for the activity in accordance with the ship's SMS.

The activity included the cleaning of the hold bulkhead corners by hand, which required the use of a portable aluminium ladder for working at height. One of the seamen ascended the ladder and carried out his task at a height of 4 metres above the cargo hold's tank top.

On completion of his task, the seaman, who was wearing a safety harness and lanyard, unclipped the lanyard. He then lost his balance, fell 2 metres onto the sloped side bulkhead, and then rolled a further 2 metres to the tank top.

The seaman was taken to the ship's hospital and later transferred to a hospital ashore, where he subsequently died of his injuries.

一艘散货船在锚地进行洗舱作业。大副命令两名水手对1号货舱进行洗舱，并根据船舶SMS要求为该作业签署了工作许可。

这项作业包括手动清理货舱舱壁的角落，这项高空作业需要使用便携式铝质梯。其中一名海员登上梯子，在离货舱底部4米高的地方执行任务。

在完成任务后，这位戴着安全带和吊绳的水手解开了吊绳。随后，他失去了平衡，跌落2米后摔到了倾斜的舱壁上，又滚落2米至货舱底部。

这名水手被送到船上的医务室，之后被转移到岸上的医院，后来因伤势过重而死亡。

3  Why did it happen

事故分析

There were several trip hazards where the seaman had been standing.

原因一：这名水手所站的地方有几处被绊倒的危险。

The bulkhead against which the portable ladder was positioned was uneven.

原因二：便携式梯子依靠的舱壁是不平整的。

After unclipping the lanyard, there were no means to prevent the seaman from falling when he lost his balance.

原因三：在解开吊绳后，无法防止水手在失去平衡后坠落。

There was nothing in place to arrest the seaman's fall.

原因四：没有在适当的地方设置任何设施防止海员坠落。

The perception of the ship's crew was that personal care and vigilance were sufficient to avoid falling from the ladder once the lanyard had been unclipped.

原因五：船员们认为：只要个人足够小心和谨慎，就可以避免在吊绳被解开后从梯子上坠落（存在侥幸心理）。

The activity was not supervised.

原因六：该作业没有在监督下完成。

The risk of falling in the cargo hold was neither specifically discussed in the ship's SMS nor identified in the ship's risk assessments.

原因七：在货舱中坠落的风险既没有在船舶的安全管理体系中详细论述，也没有在船舶的风险评估中加以确认。

4  What can we learn

事故警示

 01  

An activity that poses a reasonable risk of falling a distance liable to cause personal injury should be properly planned and supervised.

对于存在跌落一段距离可能造成人身伤害的合理风险的作业，应做好计划并设置适当的监督。

 02  

When identifying the safety controls required to reduce a risk of falling, the hierarchical principle of "avoid, prevent and minimize" should be applied.

在确定降低坠落风险所需的安全控制措施时，应采用"避免、预防和减少"的等级制度。

 03  

If a risk of falling cannot be avoided, measures are required to minimize the distance and consequences of the fall, such as the use of a fall arrestor and/or safety net or air bag.

如果坠落风险不能避免，则需要采取措施尽量降低坠落的距离和减轻事故造成的后果，例如使用防坠器或安全网或安全气囊。

 04  

Seafarers should recognize the dangers of unclipping prematurely and not disconnect their safety devices until such time as they are in a safe position to do so.

海员应意识到过早解开安全带的危险性，在处于安全位置之前，不要解开安全装置。

5  Who may benefit

本文对谁有用

Seafarers, shipowners and operators

海员，船东和船舶经营人

（TIPS：如有异议，请以英文版本为准，欢迎私信哦。）

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