Botched gearbox maintenance has been blamed for a ladder collapse that killed an Evergreen crewman in the US.
Chin-Fu Huang, 41, from Taiwan, fell from the 6,046-teu UK-flagged containership Ever Elite (built 2002) on 10 September 2009 as it entered San Francisco Bay.
He drowned after the lower section of the accommodation ladder he was standing on broke free and fell into the water, the UK’s Marine Accident Investigation Branch (MAIB) said.
It was the third fatality on board Evergreen’s 11 UK-flagged ships reported to MAIB within eight months.
And six accommodation ladder hoist failures on other owners’ ships have been reported to the MAIB in the last five years, two of which resulted in the loss of life.
When Huang was on the ladder, a colleague heard “a loud bang followed by a whirring sound as the ladder fell rapidly towards the sea,” MAIB said.
The man was spotted about half a metre below the surface of the sea by a tug crew between 10 and 15 minutes after entering the water, but there were no signs of life.
The local coroner determined the cause of death to be drowning with blunt force injuries.
Huang had suffered injuries to his head, neck, chest, back, abdomen and legs, resulting in a broken right femur, fractured ribs, multiple bruising and abrasions. These injuries were not considered to be fatal.
The report found that the ladder was set free when the hoist winch gearbox failed.
“The gearbox had been incorrectly re-assembled by the ship’s crew following maintenance,” it added.
Factors leading to this error included:
- the lack of technical information held
- an ineffective management system of onboard maintenance
- the low-level maintenance and testing requirements adopted for the hoist winch because it had not been considered to be lifting gear as defined in national regulation.
It also said rigging the ladder when underway was unnecessarily hazardous, and a safe system of work had not been developed.
Huang fell into the water and drowned because he was not wearing a fall arrest device and a lifejacket, which should have been required for working over the side.
Other, unrelated, safety shortfalls were identified during the investigation, MAIB added.
MAIB has asked Evergreen to strengthen its safety culture and improve the maintenance management systems on board its vessels.
Marine Accident Investigation Branch — Report on the investigation of the uncontrolled descent of an accommodation ladder from the container ship Ever Elite in San Francisco Bay on 10 September 2009 resulting in one fatality. Report No 8/2010. Published 14 July 2010.