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Report of investigation

into the incident on

man overboard from

river-trade cargo vessel

“Yue Feng 901” at

Western Anchorage No.1

In Hong Kong

on 11 March 2009

Purpose of Investigation

This incident is investigated, and published in accordance with the IMO Code for the

Investigation of Marine Casualties and Incidents promulgated under IMO Assembly

Resolution A.849(20). The purpose of this investigation conducted by the Marine Accident

Investigation and Shipping Security Policy Branch (MAISSPB) of Marine Department 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.

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Table of Contents Page

Summary 1

Description of the Vessel 2

Sources of Evidence 3

Outline of Events 4

Analysis of Evidence 7

Conclusions 11

Recommendations 12

Submission 13

1.4 The investigation revealed the main contributory factors to the accident were:

1. Summary

1.1 An accident happened on board the Chinese registered river-trade cargo vessel Yue

Feng 901 at Western Anchorage No.1 in Hong Kong on 11 March 2009.

1.2 The accident happened when Yue Feng 901 was manoeuvring in the anchorage after

finish cargo loading. There was moderate breeze and small waves at sea.

1.3 At the time of the accident, the Chief Engineer was rigging the tarpaulin tent for

covering the cargo hold. He was standing on the tarpaulin at the starboard side on the

roof deck. The tarpaulin was suddenly blown up by wind and flipped causing him lost

balance and fell over the side of the deckhouse into the water. He was rescued and sent

to the hospital. He was certified dead later in the hospital.

the Chief Engineer rigged the tarpaulin tent when the vessel was manoeuvring,

which was an unsafe condition;

the Chief Engineer while working aloft and near to the ship side did not use safety

harness and lifeline and wearing lifejacket;

the Chief Engineer might have lowered his alertness on the hazards involved in the

operation of the rigging the tarpaulin tent.

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Bridge deck

Aft deckhouse

2. Description of the Vessel

2.1 Particulars of Yue Feng 901

Port of Registry : Guangzhou, China

Registration No. : 090102001245

Type of Vessel : Container Cargo Ship

Year of Built : 2000

Built At : Guangzhou Zhujiang Shipyard, China

Owner of Vessel : Guangdong Province Pearl River Navigation Company Limited

Length : 49.90 metres

Breadth : 13.00 metres

Depth : 4.00 metres

Gross Tonnage : 972

Net Tonnage : 544

Engine Power : 440 kW

No. of Crew : 7

2.2 Yue Feng 901 is a steel hull, single-hold without hatch, container cargo ship operating

in the Pearl River Delta area (called river-trade ship). A tarpaulin tent is designed for

covering the cargo hold (see Fig.1). The vessel is designed with the fore and aft

deckhouses. The wheelhouse is located on top of the forward deckhouse where remote

control of main propulsion engine is provided. The crew accommodations are

distributed in the fore and aft deckhouses. The engine room is located in the aft part of

the vessel.

Tent tarpaulin covered the cargo hold

Fig. 1: River-Trade Cargo Vessel Yue Feng 901

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3. Sources of Evidence

a) Statements provided by the crew of Yue Feng 901;

b) The weather report provided by the Hong Kong Observatory;

c) The autopsy report of the deceased provided by the Department of Health of

Hong Kong.

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4. Outline of Events

4.1 Yue Feng 901 (the Vessel) departed from the port of Gao Ming in Guangdong, China

and arrived in Hong Kong in the morning on 10 March 2009. She was anchored in the

Yau Ma Tei Anchorage waiting for the loading instructions from the shipping

company.

4.1 The Vessel left the Yai Ma Tei Anchorage in the morning on 11 March 2009 and at

about 0900, the Vessel was alongside a dumb steel lighter Hoi Lung No. 2008, which

moored to the starboard side of an ocean-going ship anchored at the Western

Anchorage No.1. Steel sheet rolls were discharged from the ocean-going ship to the

Vessel by using the derrick crane of the dumb steel lighter.

4.2 At about 1300, the Vessel fully loaded with sixty-three (63) rolls of steel sheet (see

Fig.2) departed from the dumb steel lighter to let another river trade cargo ship come

alongside for loading. Before that, the Petty officer of the Vessel had gone onboard the

ocean-going ship to process the cargo documents.

Fig. 2: Steel Sheet Rolls Loaded in Cargo Hold of “Yue Feng 901”

4.3 While the Vessel was manoeuvring in the area waiting for the Petty Officer, the Chief

Engineer went to the roof deck of the aft deckhouse trying to cover the cargo hold by

rigging the tarpaulin tent which was stowed on the roof deck.

4.4 The Chief Engineer started the electric motor-driven winch located on the roof deck to

haul the gantline tight. After that, he operated another winch to slide the tarpaulin tent

out from its stowage position towards forward of the Vessel to cover the cargo hold.

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4.5 While the Chief Engineer was rigging the tarpaulin tent, the Chief Officer, who was

working in the forward of the Vessel, shouted to stop the rigging operation of the

tarpaulin tent immediately as it was unsafe to do so while the Vessel was cruising. A

motorman ran up quickly to the roof deck and stopped the winch.

4.6 After the Petty Officer finished his paper work, the Vessel returned to fetch him. The

Vessel moored alongside the other river trade cargo ship that had been secured

alongside the dumb steel lighter.

4.7 After the Petty Officer returned onboard, the Vessel prepared to depart to an area in the

anchorage where it would be safe for covering the cargo hold by rigging the tarpaulin

tent.

4.8 At the time of the accident, there was moderate breeze and small waves at sea in the

anchorage. Wind was blowing towards port side of the ocean-going ship. At about

1345 when the Vessel had just departed, she lost shelter and exposed to wind on the

down side of the tied-up vessels. The Chief Officer saw the tarpaulin tent was

suddenly blown up and flipped. The Chief Engineer, who was standing on the

tarpaulin at the starboard side on the roof deck, lost balance and fell over the side of

the deckhouse into the water (see Fig. 3 & 4).

4.9 The crewmembers onboard the Vessel immediately threw three lifebuoys onto the

water trying to save the Chief Engineer. The Chief Officer jumped into water to tow

the Chief Engineer to the shipside. The crewmembers threw a rope to the Chief Officer

for him to fasten Chief Engineer’s body. Finally, the Chief Engineer was lifted up to

the main deck of the Vessel.

4.10 The Chief Engineer was unconscious when he was taken to the hospital by a fireboat

of the Fire Services Department. He was certified dead later in the hospital.

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Tarpaulin

Roof deck of aft deckhouse

The Chief Engineer

Gantline

Fig. 3: The Deceased Stood on the Tarpaulin at the Time of Accident

“Yue Feng 901”

Aft deckhouse

Falling

Path

The deceased

Fig. 4: The Deceased Fell Overboard at the Time of Accident

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5. Analysis of Evidence

Working experience & training

5.1 The Chief Engineer held Certificate of Competency issued by the Guangdong

Maritime Safety Administration of China for working onboard river-trade cargo

vessels.

5.2 The Chief Engineer had more than four years experience working as a Chief Engineer

onboard river-trade cargo ships. He worked on the Vessel for two years and therefore

he was considered competent to operate the winch system for the tarpaulin tent of the

Vessel.

Fatigue

5.3 The Vessel arrived Hong Kong in the morning on 10 March 2009 and started loading

of cargo in the morning on 11 March 2009. Normally, there was no engine room watch

at night for this type of vessel. Therefore, the Chief Engineer should have sufficient

rest while the Vessel was anchored in the Yau Ma Tei Anchorage waiting for the

loading instructions from the company. The Chief Engineer started working at about

0800 on 11 March 2009 until the time of accident at about 1345, he should not be

suffered from fatigue of work.

Environment

5.4 At the time of accident it was moderate breeze and small waves at sea in the Western

Anchorage. The Vessel could be swaying slightly by waves. Also, the partly rigged up

tarpaulin tent could be blown up easily by the wind.

Aft deckhouse

5.5 The aft deckhouse is about 2.4 meters in height above the main deck. Cabins for the

Chief Engineer, Motormen and sailors are located in the aft deckhouse. There is a steel

vertical ladder fitted to provide access to the roof deck of the aft deckhouse.

5.6 Steel I-beams are fitted on the roof deck for carrying containers. There are two

winches at the back of the roof deck for rigging the tarpaulin tent. One winch is used

for hauling the gantline wire rope and the other winch is for controlling the wire ropes

to open or close tarpaulin tent. The winch control panel is located at the port side on

the roof deck. A vertical steel frame fabricated by round steel pipes is installed for

preventing the containers hitting the winches and equipment at the back of the roof

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deck. There is no side railings provided on the roof deck of the aft deckhouse. (see Fig.

5)

Gantline Vertical steel frame

Control panel Winches for for winchesrigging up

gantline and pulling tent

tarpaulin Steel frames to accommodate

container

Fig. 5: The Rooftop of Aft Deckhouse

Tarpaulin tent

5.7 The tarpaulin tent, 33 meters long and 8 meters wide, is bulky and heavy. When it is

stowed on the roof deck, it could not be easily blown up by the wind.

5.8 When the tarpaulin is partly rigged on the gantline without proper securing, the surface

area would make the tarpaulin prone to be moved by the strong wind.

Man overboard accident

5.9 The Chief Engineer had attempted to close the cargo hold by rigging the tarpaulin tent

earlier but the operation was stopped by the Chief Officer.

5.10 Immediately after the Vessel departed, the Chief Engineer was in a hurry again to go

up to the roof deck trying to rig the tarpaulin tent even though the vessel was still

manoeuvring in the Anchorage.

5.11 At the time of the accident, the Chief Engineer was standing at a position less than one

meter from the starboard side of the roof deck. There were no guard railings on the

roof deck and therefore he was in an unsafe position with high risk of falling from

height (see Fig. 6).

5.12 The tarpaulin tent was partly rigged up by the Chief Engineer earlier. Whilst

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Safe working practices

attempting to rig the tent again, he stood on the tarpaulin. The tarpaulin was blown up

by a strong wind. He lost his balance and fell into the water.

The deceased

Tarpaulin

No guard railings on

starboard side of roof deck

Fig. 6: The Deceased Stood near the Open Edge

Human elements in the accident

5.13 It is likely that when a person is very familiar with a certain job, he would try to finish

the work in a hurry without sufficient awareness of the possible risks associated with

it. The Chief Engineer had done the operations of rigging the tarpaulin tent many times

and it would be probable that he was overconfident. In this case, the Chief Engineer

was trying to finish the tarpaulin tent quickly without realizing the risk involved while

the vessel was underway in a situation that there could be strong wind.

5.14 The Code of Practice on Using Protective Clothing and Equipment for Works on Local

Vessels issued by Hong Kong Marine Department in January 2007 stipulates that all

persons working at height (aloft), outboard, below decks or in any other area where

there is a risk of falling more than two metres, should wear a safety harness attached to

a lifeline as far as reasonably practicable.

5.15 Working aloft is risky. Personnel working at a height may not guard themselves

against falling when they give full attention to the job. Therefore, it is not advisable to

work aloft on board vessel when underway. As far as practicable, working aloft should

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be done when the vessel is anchored or berth alongside. However, if the work has to be

done due to urgency, suitable safety measures such as wearing a safety harness

attached to a lifeline should be taken.

5.16 The Chief Engineer was working aloft on the roof deck and near to the shipside,

however, he did not use safety harness and lifeline and without wearing lifejacket.

Personal communication equipment

5.17 There was no portable personal communication equipment for the crew onboard. At

the time of the accident, the Chief Officer was in the Wheelhouse and the Chief

Enginer was working at the aft deckhouse. Without proper equipment,

communication between them would be difficult.

5.18 Provision of proper communication equipment such as walkie-talkie could improve

the safety at work during opening / closing of the tarpaulin tent onboard the Vessel.

Autopsy report

5.19 The autopsy report of the deceased provided by the Department of Health indicated

that the cause of the death was due to drowning.

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6. Conclusions

6.1 An accident happened on board the Chinese registered river-trade cargo vessel Yue

Feng 901 at Western Anchorage No.1 in Hong Kong on 11 March 2009.

6.2 Yue Feng 901 was manoeuvring in the Anchorage after finish cargo loading. There

was moderate breeze and small waves at sea.

6.3 At the time of the accident, the Chief Engineer was rigging the tarpaulin tent for

covering the cargo hold. He was standing on the tarpaulin at the starboard side on the

roof deck. The tarpaulin was suddenly blown up by wind and flipped causing him lost

balance and fell over the side of the deckhouse into the water. He was rescued and sent

to the hospital. He was certified dead later in the hospital.

6.3 The investigation revealed the main contributory factors to the accident:

the Chief Engineer rigged the tarpaulin tent while the vessel was manoeuvring,

which was an safe condition;

the Chief Engineer while working aloft and near to the ship side did not use

safety harness and lifeline and wearing lifejacket;

the Chief Engineer might have lowered his alertness on the hazards involved in

the operation of the tarpaulin tent.

6.4 The other safety factors to the accident were:

there was no safety instructions onboard the Vessel for the operation of the

tarpaulin tent;

there was no personal communication equipment onboard the Vessel for use in

rigging the tarpaulin tent.

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7. Recommendations

7.1 A copy of this report should be sent to the owner and Master of Yue Feng 901 advising

them the findings of the accident. They are required to:

provide safety instructions and personal communication equipment for the crew in

the operation of the tarpaulin tent;

instruct the crew members to use personal safety equipment when working aloft

and / or near the ship’s sides.

7.2 A copy of this report should be sent to Guangdong Maritime Safety Administration for

their information.

7.3 A Marine Department Notice should be issued to promulgate the lessons learnt from

this fatal accident.

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8. Submissions

8.1 In the event that the conduct of any person or organization is criticized in an accident

investigation report, it is the policy of the Marine Department that a copy of the

relevant parts of the report is given to that person or organization so that he can have

an opportunity to rebut the criticism or offer evidence not previously available to the

investigating officer.

8.2 The final draft of the report was sent to the owner and Master of Yue Feng 901 for

comment. There was no comment received from them at the end of the consultation.

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