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CASUALTY INVESTIGATION REPORT

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					                                                                                     PARIMAL BHATTACHARY
Death - M/V ¨IBRA LNG¨                             _____                              Accidents Investigator




 CASUALTY INVESTIGATION


                                    REPORT



                         S.S. “IBRA LNG”




                                          Panama Maritime Authority
                                   Directorate General of Merchant Marine
                         Investigation of Wrecks and Maritime Accidents Department
                                         Panama, Republic of Panama




                                               Page 1 of 63
                                                                                     PARIMAL BHATTACHARY
Death - M/V ¨IBRA LNG¨                             _____                              Accidents Investigator




                                                INDEX

 SL. NO.                                    CONTENTS                                        PAGE NO.

 1.             SUMMARY                                                                          5

 2.             FORWARD                                                                          6

 3.             DESCRIPTION OF VESSEL                                                            6

      3.1       GENERAL DATA                                                                    7-8

      3.2       MANNING                                                                          9

 4.             INCIDENT VOYAGE                                                                  9

      4.1       SEQUENCE OF EVENTS                                                             10-13

      4.2       DEATH CERTIFICATE                                                                14

      4.3       OFFICIAL LOG BOOK ENTRY                                                        15-17

 5.             ACTION TAKEN BY CREW                                                             18

 6.             ACTION TAKEN BY COAST GUARD                                                      19

      6.1       POST MORTEM REPORT                                                               19

      6.1.1     INJURIES                                                                       20-21

      6.1.2     OPINION AS TO CAUSE OF DEATH                                                     22

      6.2       DETAILS OF CASUALTY                                                              22

 7.             INVESTIGATION                                                                    23

      7.1       INVESTIGATION INITIATION                                                         24

      7.2       ELEVATOR DETAILS                                                               24-25

      7.3       LAY OUT OF ELEVATOR                                                            26-28

      7.4       PERIODIC MAINTENANCE                                                           29-31


                                          Panama Maritime Authority
                                   Directorate General of Merchant Marine
                         Investigation of Wrecks and Maritime Accidents Department
                                         Panama, Republic of Panama




                                               Page 2 of 63
                                                                                     PARIMAL BHATTACHARY
Death - M/V ¨IBRA LNG¨                             _____                              Accidents Investigator




 8.             FLEET NOTICE                                                                     32

       8.1      SAFETY SYSTEM OF CAGE AND DOOR                                                 32-33

       8.2      SAFETY IN ELEVATOR HOIST WAY                                                     33

       8.3      SAFETY IN MACHINE ROOM                                                         34-35

       8.4      SAFETY DURING MAINTENANCE                                                        35

       8.5      PREPARATION FOR MAINTENANCE/INSPECTION PROCEDU                                 35-36

       8.6      POINTS TO CONSIDER DURING MAINTENANCE                                          37-38

       8.7      CONFIRMATION OF WORK COMPLETION                                                  39

 9.             COMPANY’S PROCEDURE                                                              39

       9.1      FAMILARISATION                                                                   39

       9.2      IBRA LNG ELEVATOR                                                                40

       9.3      MAINTENANCE AS PLANNED                                                           40

 10.            INCIDENT INVESTIGATION                                                         40-43

       10.1     DATA GATHERING                                                                   43

       10.1.1   PEOPLE                                                                         43-53

       10.1.2   ENVIRONMENT                                                                      54

       10.1.3   THE EQUIPMENT                                                                  54-55

       10.1.4   PROCEDURE                                                                        55

       10.1.5   THE ORGANISATIONAL FACTOR                                                        56

 11.            APPARENT CAUSE ANALYSIS                                                        57-60

 12.            CONCLUSION                                                                     60-61

 13.            RECAPITULATION                                                                 61-62



                                          Panama Maritime Authority
                                   Directorate General of Merchant Marine
                         Investigation of Wrecks and Maritime Accidents Department
                                         Panama, Republic of Panama




                                               Page 3 of 63
                                                                                     PARIMAL BHATTACHARY
Death - M/V ¨IBRA LNG¨                              _____                             Accidents Investigator




 14.            RECOMMENDATION                                                                 63-65

 15.            OUTCOME OF THE INCIDENT                                                          65




                                  LIST OF APPENDIX



SL. NO.        APPENDIX NO.                                         PARTICULARS


  01.      APPENDIX – 1                     :    AUTHORIZATION LETTER FROM PMA.


  02.      APPENDIX – 2                     :    D.G. SHIPPING’S LETTER TO PMA.


  03.      APPENDIX – 3                     :    SHIP’S CERTIFICATES.


  04.      APPENDIX – 4                     :    SHIP’S PARTICULARS & CREW LIST.


  05.      APPENDIX – 5                     :    CHART SHOWING DIVERSION POINT.


  06.      APPENDIX – 6                     :    MASTER’S FORMAL CASUALTY REPORT.


  07.      APPENDIX – 7                     :    CALCULATION   SHOWING     HOW                         THE
                                                 ELEVATOR SETTLED AT UPPER DECK.


  08.      APPENDIX – 8                     :    LIST OF ABBREVIATIONS.




             PHOTOGRAPHS                :       IN CD.
                                          Panama Maritime Authority
                                   Directorate General of Merchant Marine
                         Investigation of Wrecks and Maritime Accidents Department
                                         Panama, Republic of Panama




                                                 Page 4 of 63
1. SUMMARY

  LNG vessel SS “IBRA LNG” was on her way from Singapore to Qalat LNG
  Terminal in Oman. The vessel had sailed on her ballast voyage from Singapore on
  29th January 2007. On 03.02.07 approx at 1425 hrs L.T. ( S.M.T. on board ), some
  shouting was heard from the Elevator shaft and was found that the Electrician, Mr.
  Ioan Cumpat, was trapped in inverted position at the side of the elevator at level
  between “A” and “B” decks of the accommodation levels on the vessel. The vessel
  was at position 070 58.9 N and 0760 43.2 E in the Arabian Sea and the speed of
  the vessel was reported 15 Knots at that time.

  Ship’s crew then made an attempt to rescue him from the trapped condition and
  though initially he was found to be in a conscious state although he had an open
  wound and a fractured leg. But approx around 1450 hrs L.T. he lost his
  consciousness before he could be freed from his trapped position. Vessel then
  altered course towards Trivandrum Port in order to receive medical assistance. At
  1520 hrs L.T. vessel course was altered towards Cochin as per the advice of the
  Owners. He was ultimately made free and was taken to the ship’s hospital at 1530
  hrs L.T. and was rendered cardiac compression and artificial respiration. The
  vessel was in touch with the local Indian Coast Guard for medical advice. The
  electrician was under constant watch by the ship’s crew and whatever medical
  advice was received from shore was duly administered by the ship’s staff
  continuously. At 1615 hrs L.T. it was felt that no revival of the casualty was
  possible. At 1650 hrs L.T., Mr. Ioan Cumpat did not show any vital signs and his
  breathing stopped, eyes were dilated and there was no pulse beat in his body.
  Finally, as per the instruction of the local Indian Coast Guard, the vessel anchored
  at 1755 hrs L.T., in position 080 21’ N and 0760 57’ E. By this time Mr. Ioan Cumpat
  had expired. At 1830 hrs L.T. Mr. Ioan Cumpet’s body was lowered into a Fishing
  boat Olympia as per instruction of the local Coast Guard. At 1940 hrs L.T. the
  Coast Guard confirmed that Mr. Ioan Cumpat was dead when they received the
  body in their custody.




                                    Page 5 of 63
     It is reported that the Electrician was carrying out routine maintenance of the
     Elevator and while doing so, he accidentally fell in an awkward position which
     resulted in his eventual death.
2.   FORWARD

     On being informed about the casualty on board SS “IBRA LNG”, the Panama
     Maritime Authority, Casualty Department was in contact with Director General of
     Shipping, Bombay, India, and the Shipping Company, M/s Oman Ship
     Management Co. Ltd., who apprised them about the casualty.

     The Panama Maritime Authority, Casualty Investigation Branch, appointed
     Mr. P. K. Bhattacharyya of Henderson Int’l (India) Pvt. Ltd., Kolkata, India as
     Principal Investigator on 28.02.07 to carry out casualty investigation in the matter
     of death on board SS “IBRA LNG”, IMO No. 9326689, of Mr. Ioan Cumpet, who
     was employed as an Electrician on board the vessel.

     The principal investigator met with the Master, Chief Engineer and the, DPA on
     05th – 06th March 2007 on board the vessel and inquired about the events prior to
     the Accident on 03rd February 2007 and also the subsequent events till the body of
     Mr. Ioan Cumpat was discharged from the vessel and handed over to the local
     Indian Coast Guard.



3.   DESCRIPTION OF VESSEL

     SS “IBRA LNG” is an 147000 m3 LNG carrier powered by 36510 PS MCR Steam
     Turbine running at 87.7 rpm. The vessel was built at SAMSUNG HEAVY
     INDUSTRIES, Korea on August 2006. The vessel is provided with 4 no. cargo
     tanks of membrane type.

     The vessel is fitted with one set of electric motor driven counter weight type
     personnel elevator in the accommodation area which moves from Engine Room
     floor upto below navigator bridge deck within an enclosed steel trunk.




                                       Page 6 of 63
3.1 GENERAL DATA

NAME               :   S.S. IBRA LNG
CALL SIGN          :   3EGE9
TYPE OF SHIP       :   SEGREGATED BALLAST LNG CARRIER
STEM               :   BULBOUS BOW & RAKED STEM
STERN              :   TRANSOM
CLASSIFICATION     :   AMERICAN BUREAU OF SHIPPING
                       AIE, LIQUEFIED GAS CARRIER, SHIP TYPE 2G
                       (MEMBRANE TANK, MAXIMUM PRESSURE 25Kpag
                       AND MINIMUM TEMPERATURE - 1630 C, SPECIFIC
                       GRAVITY             500         kg/m3          ),
                       SH-DLA, SHCM, SFA (40), AMS, ACCU, UWILD,
                       PMS INCLUDING CMS.
PORT OF REGISTRY   :   PANAMA.
OFFICIAL NUMBER    :   34534 – TJ.
IMO NUMBER         :   9326689.
BUILT PLACE        :   SAMSUNG       HEAVY   IND.,   GEOGJ     SHIPYARD,
                       SOUTH KOREA.
KEEL LAID DATE     :   23RD MAY 2005.
LAUNCHING DATE     :   10TH SEPTEMBER 2005.
DELIVERY DATE      :   10TH AUGUST 2006.
OWNER              :   SNC CORENTIN.




                           Page 7 of 63
OWNER ADDRESS          :   HONGKONG BANK BLDG., 6TH FLOOR, SAMUEL
                           LEWIS       AVENUE,   PANAMA,   REPUBLIC    OF
                           PANAMA.
MANAGEMENT             :   OMAN       SHIPPING   MANAGEMENT       COMPANY
                           S.A.O.C., OMAN
MANAGEMENT ADDRESS :       P.O. BOX 104, ALHARTHY COMPLEX, P.C. 118,
                           SULTANATE OF OMAN.
ENGINE                 :   STEAM TURBINE, MCR: 36510 PS @ 87.7 RP.
SIDE THRUSTER          :   ELECTRO-HYDRAULIC, 2000Kw, CONTROLLABLE
                           PITCH.



LENGTH OVERALL         :   285.103 M
MOULDED BREATH         :   43.40 M
MOULDED DEPTH          :   26.00 M
SUMMER DRAUGHT (MAX) :     12.100 M
SUMMER DEADWEIGHT      :   81057 M
LIGHT SHIP             :   29787
KEEL TO TOP THE MAST   :   50.000 M/ 54.995 (MAST LOWERED/ RAISED)
GROSS TONNAGE          :   96671
NET TONNAGE            :   29001
SUEZ GROSS             :   99,956.26
SUEZ NET               :   85,759.37
WINDAGE AREA           :   LATERAL - 6700M2, FRONT- 1369 M2 (BALLAST OR
LOADED)
CARGO CAPACITY         :   145,951 M3 - 98.5% @ (-165) DEG CENT
CARGO TANK - SAFETY    :   25 KPA
VALVE
INTER BARRIER - SAFETY :   3 KPA
VALVE
INSULATION - SAFETY    :   3.6 KPA




                               Page 8 of 63
VALVE
DESIGN SPEED                 :   19.0 KNOTS AT MCR WITH 21% SEA MARGIN
FUEL COMSUMPTION             :   156.4 METRIC TONNES PER DAY AT NCR


3.2 MANNING
        Ship’s Minimum Safe Manning Certificate dated: 30th March 2006 ( valid )
        required 14 persons. The vessel has crew members in excess of minimum
        manning requirement. There were 31 crew members on board. The vessel has
        mixed crew consisting of British, German, Croatian, Lithuanian, Indians and
        Filipinos. All the crew members have valid Panamanian Seaman’s documents.
        All Officers have Panamanian endorsement on their certificates, as required by
        Panama Flag State.


4. INCIDENT VOYAGE

    The vessel SS “IBRA LNG”, under the command of Capt. Robert Grant Valentine
    with valid Master’s Licence, sailed from Singapore on a ballast voyage on 29th
    January 2007 toward Qalhat, Oman. The sailing draft of the vessel was 8.8 m ford
    and 9.3 m aft. On 03rd February 2007, while the vessel was proceeding at an
    average speed of 15 knots some noise was heard from the elevator shaft
    approximately around 1425 hrs L.T.. The vessel’s position at that time was 070
    58.9’ N & 0760 43.2 E, maintaining 3060 (T) course. Condition of the sea was
    smooth and wind moderate to fresh. Wind direction and, sea and swell were all
    North Easterly. On inquiry of the ship’s staff, it was found that the Electrician, Mr.
    Ioan Cumpat, was trapped in on inverted position at the aft side of the Elevator
    cage, his right knee was firmly stuck between upper guide rail of ‘A’ Deck door and
    upper guide rail of the lift car. It was reported that Mr. Ioan Cumpat was carrying
    out routine maintenance on the elevator. He was reported to be assisted by the
    wiper. It was further reported that when the routine maintenance was about to be
    completed, Mr. Ioan Cumpat       dismissed his assistant and for some unknown
    reason, he re-entered the lift shaft to gain access to the top of the Elevator cage.




                                       Page 9 of 63
   At 1425 hrs L.T., the Master was alerted first by the 2nd Officer and then by the
   Chief Officer that someone was trapped in the elevator. There was also a lot of
   commotion and shouting. It was then observed by the Master that Mr. Ioan Cumpat
   was trapped at the side of the elevator in an inverted position, being held by the left
   foot, which was preventing him from falling below. There was a drop of nearly 20 or
   25 M below. Mr. Ioan Cumpat was conscious at that time and he had visible open
   wounds. The vessel’s crew tried to administer first aid in that position. But the
   position was so awkward that it was virtually impossible to do so. The casualty had
   to be removed from the trapped position after gaining access through ‘B’ deck door
   to the ship’s hospital. It took nearly 1 hour and 5 minutes to shift him to the ship’s
   hospital after initial alarm was raised. The casualty fell unconscious at 1450 hrs
   L.T.. However, once the casualty was made free from his trapped position in the
   elevator shaft, he was given cardiac massage and artificial respiration by the ship’s
   staff and continued to do so till he was pronounced dead by the Master and his
   body was handed over to the local Indian Coast Guard.
4.1 SEQUENCE OF EVENTS

    03RD FEBRUARY 2007

    0745 Hrs         :   During the morning meeting it was decided that Elevator
                         routine maintenance is to be carried out in the afternoon.
                         Elevator was functioning normally during all this time.

    1300 Hrs         :   It was decided in the afternoon meeting to change oil of gear
                         box of the elevator and to carry out normal maintenance
                         schedule. Meanwhile each elevator door switch was marked
                         “Lift under Maintenance”.


    1300-1400        :   Electrician, together with wiper, started work in the elevator
    Hrs                  trunk.
    1400 Hrs         :   Wiper went to collect work materials.




                                      Page 10 of 63
1415 Hrs   :   Wiper took mat out of elevator to clean it to Upper Deck on
               electrician’s instructions. Electrician then went into the
               elevator and went down.


1425 Hrs   :   After this heard somebody screaming and a loud noise came
               from the elevator trunk.


1430 Hrs   :   Called Captain and informed him that someone is stuck in the
               elevator on a deck.


1435 Hrs   :   To investigate the shouting of Mr. Ioan Cumpat access to the
               elevator lift shaft was made through “B” deck door when it
               was found that he was trapped in an inverted position at the
               side of the elevator by the ladder, his leg was twisted and
               trapped thereby preventing him from falling. Casualty was
               conscious and coherent.




                           Page 11 of 63
1435-1530   :   Attempting to free the casualty
Hrs
1440 Hrs    :   Captain called O.S.M.C and informed them of the situation.


1440 Hrs    :   Altered course toward Trivandrum, South India.


1450 Hrs    :   Casualty became unconscious.


1515 Hrs    :   Transmitted Security Message on VHF Ch 16 for Medical
                Help.
1520 Hrs    :   Transmission of security message was repeated.


1522 Hrs    :   Coast Guard Vessel “Ankleshwar” instructed vessel to
                contact Cochin Port for medical assistance.


1526 Hrs    :   O.S.M.C. instruct vessel to proceed to Cochin, India.


1530 Hrs    :   Casualty was finally freed from the elevator and taken to the
                hospital in an unconscious state. He was found not breathing
                and with a very weak pulse. Commenced CPR. The pupils
                were dilated and there was no response to the torch light
                when directed towards his pupils. CPR was continued but no
                response by the casualty. Oxygen was also administered
                continuously until the Coast Guard boat had arrived.

1540 Hrs    :   Repeated the transmission of security message on VHF Ch
                16.

1545 Hrs    :   Repeated the transmission of security message on VHF Ch
                16.




                            Page 12 of 63
1615 Hrs   :   Altered course towards Kovalam point ( India South West
               Coast ).
1632 Hrs   :   Transmitted ship’s position to Indian Coast Guard, who
               instructed the vessel to head for Vilinjam light.


1650 Hrs   :   Indian Coast Guard vessel instructed the vessel to anchor
               approx 5 NMPs off Vilinjam coast. Casualty showed No vital
               signs & no response to CPR. However, CPR was still
               continued.
1715 Hrs   :   Coast Guard informed they were preparing for the Doctor and
               he would be underway very soon.


1735 Hrs   :   Exchanged relevant information with Coast Guard like
               Master’s Name, Crew nationality and casualty name etc..

1742 Hrs   :   Commenced walking back Stbd Anchor.


1755 Hrs   :   Stbd Anchor brought up in position 0800 21N 076-57E.


1755 Hrs   :   Casualty showed no vital signs. Casualty was declared dead
               by Master.


1806 Hrs   :   Coast Guard informed the vessel that they were underway.


1820 Hrs   :   Observed one fishing boat “Olympia” standing off port
               quarter.
1830 Hrs   :   Coast Guard boat approached from the port quarter. But
               could not come alongside SS IBRA LNG due to choppy seas.
               It was decided to lower the casualty from the stbd side (
               which was the lee side ).




                            Page 13 of 63
   1845 Hrs          :   Coast Guard Boat “C-34” approached own vessel from stbd
                         quarter. Casualty could not be disembarked by crane
                         because of the super structure of the Coast Guard Boat “C-
                         34” coming in the way.

   1852 Hrs          :   Coast Guard boat instructed the vessel to disembark the
                         casualty in the fishing boat “Olympia”.

   1855 Hrs          :   Fishing boat “Olympia” approaching vessel from stbd side.


   1858 Hrs          :   Casualty disembarked by crane into Fishing Boat “Olympia”


   1940 Hrs          :   Coast Guard informed vessel to await at anchor till further
                         notice whilst also confirming the casualty as deceased.



4.2 DEATH CERTIFICATE

    Death Certificate signed by the Master gives following details :

    (a)       Date of death        :   03RD FEBRUARY 2007.

    (b)       Place of death       :   080° 21’ N 076° 57’ E

    (c)       Name                 :   IOAN CUMPAT

    (d)       Sex                  :   MALE

    (e)       Date of Birth        :   17 MAY 1958

    (f)       Occupation           :   ELECTRICIAN

    (g)       Domicile at          :   ROMANIA

    (h)       Time of death        :   1755 Hrs L.T. / S.M.T.

    (i)       Passport No.         :   I 1669423




                                       Page 14 of 63
4.3 OFFICIAL LOG BOOK ENTRY
   Official Log Book Entry of the incident is reproduced below :




                                     Page 15 of 63
Page 16 of 63
Page 17 of 63
5.   ACTION TAKEN BY CREW

     When the crew learnt about Mr. Ioan Cumpat getting trapped in the elevator, they
     made an attempt to open the elevator door from ’B’ deck, which took nearly 4 to 5
     minutes to open. After opening the door, the crew learnt the position of Mr. Ioan
     Cumpat, who was trapped in an inverted position. Considering the risk involved in
     making an attempt to remove the casualty with the help of the elevator. Mr. Ioan
     Cumpat, was tied to a safety harness and heaved-up, and finally was brought to
     the ship’s hospital. He was continuously given cardiac massage and artificial
     respiration. As the condition of            Mr. Ioan Cumpat, with open wounds and
     multiple injuries, was considered critical, the Master informed the Owners and also
     the Indian Coast Guard requesting immediate medical attention. The vessel was
     diverted to off the South Indian Coast, as advised by the Owners and the Coast
     Guard. The position from where the vessel was diverted is shown in the chart
     below.




                                        Page 18 of 63
      As the vessel was moving towards the position instructed by the Coast Guard, the
      casualty finally died. The time of his death was 1755 hrs L.T., the vessel’s position
      at that time was 080 21’ N, 0760 57’ E. The death certificate issued by the Master
      recorded the time as 1755 hrs. L.T. / S.M.T.. At 1858 hrs L.T., the mortal remains
      of Mr. Ioan Cumpat was finally handed over to the Indian Coast Guard.



6.    ACTION TAKEN BY COAST GUARD

      After taking the dead body in the custody of the Coast Guard, the Deputy
      Commandant,             Mr. Deepak Singh, filed a First Information Report ( F.I.R. )
      with Vizhinjam Police Station for the necessary action. Subsequently, the body of
      Mr. Ioan Cumpat was sent for post-mortem and the findings of the post-mortem
      report had been handed over to the vessel.



6.1   POST MORTEM REPORT


       P.M. No. 284/07                                                               Date
       : 04.02.07


       I, Dr. C. S. Sreedevi, Asst. Professor of Forensic Medicine, certify as hereunder:-


       Dead body of a male by name IONA CUMPAT, aged about 49 years, was sent
       by Sub Inspector of Police, Vizhinjam Police Station, with a requisition dated 04th
       February 2007 through the H.C. No.7633, for conducting postmortem
       examination and report.


       The body was in-charge-of the H.C. No.7633, who identified it as that of the
       deceased in Crime No. 52/07 of Vizhinjim Police Station. The post-mortem




                                        Page 19 of 63
    commenced at 2.30 p.m. L.T. on 04th February 2007 and was concluded at 3.30
    p.m. L.T. / I.S.T. The following findings were observed.




    Body was that of a well built and nourished fair skinned adult male of height 170
    cm and weight 94 kg. Eyes were closed. Conjunctivae congested. Pupils dilated.
    Blood stained fluid present at nostrils. Other external body orifices were normal.
    Finger nails were blue. Old scar 25 x 2 cms, vertical, on the abdomen in the
    middle. 5 cm below the lower end of breast bone.


    Corneae clear. Rigor mortis fully established and retained all over the body. Post-
    mortem staining at the back and sides of body, not fixed. No sign of
    decomposition          ( Body was kept in the cold chamber ).



6.1.1 INJURIES (ANTEMORTEM) :

     1. Contusion of scalp 9 x 5 x 0.5 cms on the left side of head just above the
       ear.

     2. Abrasion 1.8 x 0.2 cms on right side of chin 6 cm outer to midline. Brain
         showed subdural and subarachnoid haemorrhage. Sulci were narrowed and
         gyri flattened.

     3. Lacerated wound 5.5 x 4 cms enterining into the abdominal cavity of the
         perineum just behind the scrotum. Fracture separation of pubic symphasis.
         The soft tissues around were seen infiltrated with blood.

     4. Multiple small abrasions over an area 22 x 2 to 7 cms on the front aspect of
         right arm 7 cms below the shoulder tip with fracture of humerus underneath.

     5. Abrasion 9 x 1.5 to 3 cms on the back of right forearm 13 cms above wrist.




                                      Page 20 of 63
6. Abrasion 1 x 0.3 cms on the back of the right wrist.

7. Abrasion 1 x 0.3 cms on the outer aspect of right forearm 4 cms above
   wrist.

8. Abraded contusion 7 x 4.5 x 1 cms on the inner aspect of the right arm 7
   cms above elbow with an abrasion ( 6 x 4 cms ).


9. Multiple small abrasions over an area of 4 x 3.5 cms on the back of right
   elbow.

10. Abraded contusion 18 x 7 x 2 cms involving the inguinal area and adjacent
   part of front of thigh.

11. Abrasion 6 x 4 cms on the inner aspect of right thigh 20 cms above knee.

12. Abrasion 8 x 4 cms on the back and inner aspect of right knee and adjacent
   part of thigh.

13. Lacerated wound 5 x 1 x 0.4 cms on the front of right knee with multiple
   small abrasions over an area 30 x 7 cms around and adjacent parts of front
   of thigh and leg.

14. Multiple abrasions over an area 30 x 13 cms on the inner aspect of left thigh
   and knee.

15. Abrasion 7 x 0.5 cms on the front aspect of left thigh 32 cms above knee.

16. Abrasion 4 x 2 cms on the left groin.

17. Multiple abrasions over an area 30 x 3 to 8 cms on the left side of front of
   chest its upper outer and just below the front fola of armpit.

18. Abrasion 29 x 6 to 12 cms on the right armpit and adjacent part of left side
   of chest.




                               Page 21 of 63
        Air passage contained blood stained fluid. Lungs were congested and
        oedematous. Liver was fatty. Stomach was full with starchy food materials and
        other unidentifiable food materials having no unusual smell, mucosa normal.
        Urinary bladder was empty.

        All other internal organs were pale, otherwise appeared normal.

        Sample of blood was preserved and sent for chemical analysis




6.1.2    OPINION AS TO CAUSE OF DEATH:

         Death was due to injuries sustained to head and pelvis.



6.2     DETAILS OF CASUALTY

        Name                                  :   Mr. Ioan Cumpat.


        Rank                                  :   Electrician.


        Date of Birth                         :   17th May 1958.


        Manning Agency                        :   AZA LEA MARITIME B.V.


        Years in Rank                         :   More than 20 years.


        Date of Joining vessel                :   23rd January 2007.




                                       Page 22 of 63
    Hours worked on previous day              :   8 hours.


    Hours    worked   on   the   day     of :     5.5 hours.
    accident
    Nature of work                            :   In charge of maintenance & operation
                                                  of all electrical installations on board
                                                  including personnel elevator.


    Passport No.                              :   I 1669423




7. INVESTIGATION

   The investigation was carried out on board the vessel on 5th & 6th March 2007 at
   whilst she lay safely anchored at Fujairah Anchorage, Fujairah Port, U.A.E.. It was
   carried out as per American Bureau of Shipping incident investigation methodology
   MARCAT guidelines and also as MINICAM guide. The objective of the
   investigation is to conduct RCA of the loss of human life on board and to determine
   whether the loss was related to safety environment or human element. However, in
   this particular event, which resulted in the death of an officer on board, RCA was
   not possible as nobody was witness to the incident. Therefore, the analysis is
   based on ACA technique as the various available data related to the incident were
   viewed after more than a month of the actual date of occurrence.




                                       Page 23 of 63
7.1 INVESTIGATION INITIATION

      The vessel SS “IBRA LNG” is fitted with one set of electric motor driven counter
      weight type personal elevator capable of moving in an enclosed steel trunk from
      engine room floor below Navigation deck.


      As the incident of death occurred during the discharge of routine maintenance
      work of the Elevator, it is essential to take a closer look at the design specification
      of the Elevator and its maintenance requirement.



7.2   ELEVATOR DETAILS

        TYPE OF ELEVATOR                CREW ELEVATOR


        CAPACITY                        500 KG (6 PERSONS)


        SPEED                           45M/MIN


        DRIVE                           VVVF


        TYPE OF CONTROL                 2 BC (SELECTIVE COLLECTIVE CONTROL
                                        SYSTEM)
        TRAVELLING HEIGHT               33900


        CAR INTERNAL SIZE               950 (W) X 1300 (D) X 2100 (H)


        NO. OF SERVICE                  9 STOPS (MAIN, 4TH, 3RD, 2ND, UPP, A, B. C. D
                                        DK)
        CLEARANCE OF DOOR               800(W) X 1200(H)


        DOOR OPERATION                  1 SPEED CENTER OPENING DOOR (ISCO)




                                         Page 24 of 63
LANDING DOOR (E/R)     GAS     TIGHT          SWING     DOOR     WITH    A-60
                       INSULATION
LANDING DOOR (ACCOM)   1 SPEED CENTER OPENING DOOR WITH A-0
                       INSULATION

TRACTION MACHINE       TM 400


DIA OF MAIN SHEAVE     O 570


MAIN ROPE              O 12 X 4 (1:1 ROPING)




CAR RAIL               13K RAIL


CWT RAIL               8K RAIL


MOTOR CAPACITY         5.5 KW


POWER SUPPLY           MAIN       3 PH          440 V       60 HZ
                       LIGHT           1 PH      220 V          60 HZ


PAINTING COLOUR        CAR INSIDE & DOOR STAINLESS HAIRLINE
                       FINISH CAR CEILING STAINLESS HAIRLINE
                       FINISH LANDING DOOR                 MAIN - 2ND DK
                       MUNSELL          NO.     2.5   Y   9/2    UPP-D    DK
                       STAINLESS AIRLINE ELECTRIC EQUIPMENT
                       MUNSELL NO. 7.5 BG 7/2.
FLOORING               LUCKSTRONG ( TYPE : RS-90028 )


RULES & REGULATIONS    AMERICAN BUREAU OF SHIPPING (ABS)




                       Page 25 of 63
7.3   LAYOUT OF ELEVATOR




                           Page 26 of 63
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7.4   PERIODIC MAINTENANCE

      Mr. Ioan Cumpat, being the person entrusted with the responsibility of
      maintaining all electrical items under the able guidance of the Chief Engineer, he
      had to follow a proper maintenance guideline as stipulated in the manufacturer’s
      manual. The manual and also company guidelines stipulates a routine
      maintenance programme, which he undertook to carryout in that fateful day. The
      relevant program is detailed below :




                                      Page 29 of 63
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8.   FLEET NOTICE

      The Owners M/s Oman Ship Management Co. Ltd., Oman, by their Fleet Notice
      OSMC–06–01 dated : 27th March 2006, which was subsequently updated on 17th
      February 2007, specifies that basic safety measures should be taken during
      maintenance & inspection of Elevators as per “Marine Elevator” handling
      guidelines. The guidelines are given below :


      Marine elevators tend to be regarded as ‘simple and convenient machines’ by
      those who use them, but they are actually a combination of several dozen different
      pieces of equipment and devices. Mishandling and wrongful maintenance /
      inspection of any one of these components can lead to not only damage to the
      equipment itself, but also accidents causing injury or death.


      All crew members are expected to understand some of the basic structures and
      operations, and to be able to take appropriate responses during an emergency.
      In general, rope-type elevators are used for marine elevators.


      Elevator performs as a type of “well bucket”, with a “cage” to contain the
      passengers / load on one side of the pulley, and a counterweight on the other side
      to raise or lower the cage with the minimum of power.



     8.1 SAFETY SYSTEM OF THE CAGE AND DOOR

           The part of the elevator which holds people or cargo is called a “cage”. The
           size of the cage decides its capacity, or the maximum number of persons it
           can hold, with one person calculated as 65 kg.


           Generally, an elevator is equipped with the following safety systems ( though
           they may vary by manufacturer or type ) :




                                        Page 32 of 63
      a. Gate switch : a type of safety switch that becomes operable once the door of
         the cage is completely shut.


      b. Door switch : a type of safety switches that becomes operable once the
         hoistway door on each floor is completely shut.


      c. Emergency switch : the switch used to stop the elevator when there is an
         emergency in the cage.


      d. Safety edge of door : a device to open the door automatically when
         passenger(s) or cargo get caught in the door of the cage.


      e. Emergency bell and telephone : used to communicate with the outside in the
         case of an emergency.


      f. Emergency light : a lighting apparatus which receives electricity from a battery
         and illuminates in the event of a blackout.


      g. Safety switch : blackout / operating switch used for maintenance, provided on
         cage top.


      h. Door locking device : once the hoistway door closes, this device prevents the
         door being manually opened.


8.2     SAFETY IN ELEVATOR HOISTWAY

         Safety to be implemented in Elevator Hoistway involving :

          1. Termination switch

          2. Overrun limit switch

          3. Buffer




                                        Page 33 of 63
8.3 SAFETY IN MACHINE ROOM

   Safety system to be implemented in Machine Room involving the following :

  a. Electromagnetic brake : also known as an “eddy-current braking”, this type of
     brake utilizes the braking torque between the electric current and magnetic
     field generated when the magnet and metal plates on both ends of the poles
     are in motion; that is, the brake moves with the friction from the
     electromagnetic power. When the overrun limit switch or emergency switch is
     activated, the cage is brought to a sudden stop, and the brake keeps the cage
     in that position. In general, the brake works as follows:


  1 The buttons in the cage operating panel or on the floor are pressed to operate
     the elevator.


  2. Electricity is supplied to the motor.


  3. Auxiliary contact on the main relay of the control panel turns ON.


  4. Electricity is supplied to the coil attached to the top of the brake device, and
     the core is activated.


  5. The link mechanism sets the brake shoe apart from the brake drum, and the
     brake opens.


     In this way, the elevator starts to move. When the cage arrives at its
     destination, electricity is supplied to the motor, the coil is cut-off, and the
     spring located at the bottom of the brake device thrusts the brake shoe
     toward the brake drum. The friction at the brake lining stops the elevator
     cage.




                                   Page 34 of 63
      b. Speed regulator : also known as the governor, this device utilizes centrifugal
         force to adjust the spinning body so that a constant rotary speed can be
         maintained regardless of the shift in the load applied to the revolving
         machine. The speed regulator is activated not only when the overrun limit
         switch or other safety system is turned on, but also when the speed of the
         elevator exceeds the rated speed. At the first motion, the speed regulator cuts
         off the electric circuit to the motor when the speed reduction is below 130%,
         and activates the electromagnetic brake to stop the cage. If the cage does not
         stop and speed reduction approaches 140%, then the speed regulator grabs
         the speed regulator rope to bring the cage to an emergency halt.



8.4 SAFETY DURING MAINTENANCE

         In order to maintain the safe operational status of the elevator, planned
         maintenance and regular inspections are important, as is true of all engines
         and equipment. When conducting routine maintenance and inspection work,
         “Under   inspection/   Do   not    use”      announcements       must   be   clearly
         communicated to all other personnel, not just the maintenance workers. Close
         communication between the maintenance workers must be kept, and relevant
         equipment and devices be appropriately used at all times.




8.5     PREPARATION             FOR        MAINTENANCE                /     INSPECTION
       PROCEDURES


         a. Before commencing these procedures, obtain all necessary permissions
            from the Captain and the Chief Engineer.


         b. Always hold a meeting, and confirm the following before starting work:




                                      Page 35 of 63
 1. Who will take part in the work and what is the role of each worker ( Note
     : work should always be conducted by two or more workers ).


 2. What should be worn, and what equipment is needed to carry out the
     work        ( work clothes, safety shoes, helmet, torch, transceiver, etc. )


 3. Means of communication during the work ( in-cage telephone,
     transceiver, etc. )


 4. Special / general tools required for the work.


c. Clearly and comprehensively announce that the elevator is “Under
   inspection - Do not use”


d. Put up a sign “Under inspection / Do not use” in front of the hoistway door
   on each floor, and cover the “cage call button” with vinyl, duct, or other
   suitable tape. To prevent the button from being accidentally pressed, a
   plastic / wooden cover hung over the button on each floor can be effective.


e. Make sure that the emergency alarm and telephone are operational.


f. Personnel other than maintenance / inspection workers must not perform
   any of the maintenance / inspection procedures.


g. Ensure that there is sufficient light in the work area.




                              Page 36 of 63
8.6 POINTS TO CONSIDER DURING MAINTENANCE

  a. Perform the inspection procedures according to the checklist, and make notes
     on any necessary information required.


  b. Activate the emergency stop switch in the cage top operating panel so that
     the cage cannot move, and make sure that all openings are closed.


  c. Elevator machine room :


     1. When conducting inspection/ adjustment of moving parts such as the hoist
        or the deflector sheave, make sure that the power supply is turned off.


     2. When checking the controller (insulation, resistance measurements, etc.),
        make sure it is turned off.


     3. Use the telephone in the elevator machine room to communicate with the
        worker in the cage ( if vessel has a telephone equipped ). When
        communicating with other parts of the vessel use the transceiver, and
        keep in close contact with each other throughout the maintenance/
        inspection procedures.


     4. Take extra care not to spill oil / grease on the pulley of the hoist, defector
        sheave, or wire rope. The presence of oil / grease can cause slippage of
        the wire rope, which is extremely dangerous.


  d. Top of the cage and hoistway :


     1. Turn on the inspection light on the cage top, and ensure that there is
        adequate lighting.




                                  Page 37 of 63
   2. Always keep the area tidy, and make sure that there is enough space to
      put up a scaffold.


   3. Once on the cage, turn the AUTO-MANUAL switch in the cage top
      operating station to MANUAL.


   4. While these procedures are being carried out, keep the emergency switch
      in the cage top operating station active.


   5. When moving the cage, or opening / closing the door manually, contact
      the other workers to ensure that the surrounding area is secure ( beware
      of the counterweight or projections in the hoistway ). When operating,
      release the emergency stop and make sure that the worker knows what
      buttons to press.


   6. After finishing these procedures, contact the other workers to ensure that
      the surrounding area is secure, and turn the AUTO-MANUAL switch in the
      cage top operating station back to AUTO.


e. Bottom of the hoist way :


   1. Turn off the control panel main switch in the elevator machine room.


   2. When conducting counterweight - clearance measurements, bring the
      cage to the top floor, press the emergency stop button in the cage, and
      put up an “Under inspection / Do not use” sign.


   3. Use the release key to open the lowermost door manually, and go down to
      the bottom of the hoistway keeping the door open with a wedge or rope.


   4. If the pit of the hoistway is stained with oil, wipe it clean to avoid slippage.




                                 Page 38 of 63
     8.7 CONFIRMATION OF WORK COMPLETION

       a. Check the number of tools ( to ensure none have been left behind ).

       b. Test elevator operation, and make sure that there are no abnormities.

       c. Report to the captain and chief engineer that the procedures have been
           completed, and let the personnel on the bridge know that the inspection is
           finished. Make an in-vessel announcement, and then remove all plates
           around the elevator doors on each floor and tapes covering the buttons.



9.   COMPANY’S PROCEDURE

      M/s Oman Shipping Co. maintains a familiarization programme for every officer
      joining the vessel, as a standard procedure.



9.1 FAMILIARIZATION

      As per the company’s familiarization programme and the ISM requirement, the
      Electrician was required to familiarize himself as to the working of the Elevator and
      its maintenance aspect. It was reported that having worked on a sister ship of the
      company, Mr. Ioan Cumpat had adequate knowledge about the elevator
      maintenance and its working principle.


      However, he still had to carry out the familiarization of all electrical hardwares as
      per the company procedure towards requirement of the ISM. It appears that Mr.
      Ioan Cumpat had complied with the familiarization programme immediately after
      joining the vessel.




                                        Page 39 of 63
9.2 “IBRA LNG” ELEVATOR

    The Elevator, as fitted in the vessel, is a modern Elevator built by Hyundai It has
    all the safety systems incorporated in it such as gate switch, door switch,
    emergency switch, safety edge of door ( a device do open the door automatically
    when passengers or cargo get caught in the door of the case ), emergency bell
    and telephone, emergency light etc. The elevator is also provided with safety
    switch which is the operating switch used for maintenance. The switch is
    provided on cage top. There is door locking device which prevents the door from
    being manually opened once the hoistway door closes.



9.3 MAINTENANCE AS PLANNED

    It was decided to carry out a normal routine maintenance of the passenger lift.
    Accordingly a safety meeting was held on 3rd February 2007, in the morning.
    During the safety meeting the Electrician was advised to take the ‘wiper’ along
    with him during his maintenance work.

    The work was started soon after the afternoon safety meeting. The normal
    maintenance routine was then reportedly carried out as per the manufacturer’s
    instructions after taking all necessary safety precautions. However, during the
    course of his normal maintenance work, the Electrician, Mr. Ioan Cumpat,
    expired at 1755 hrs L.T. on 03rd February 2007 at the Elevator trunk ( the
    sequence of events have been very elaborately narrated elsewhere in this Report
    ). During the course of investigation, the place where the accident took place was
    identified by the principal investigator.



10 INCIDENT INVESTIGATION

   Once identified the place where Mr. Ioan Cumpat got trapped in the elevator, the
   incident site was examined for a quick overview. Whatever data were available at
   the time of our visit were duly examined and various witnesses were interrogated




                                      Page 40 of 63
    in order to ascertain the veracity of the written statements of the witnesses which
    were made earlier .The findings were noted as below :

•    Position of the Casualty was identified as being trapped in the inverted position
     inside the elevator trunk.

•    Ship’s position: 08 58.9 N Latitude, 076 43.2 E Longitude.


•    Routine maintenance was being carried out on Elevator cage.


•    Tools used to carry out the maintenance were normal electrician tools.


•    Safety devices in use were the normal safety gears that include safety boots and
     boiler suit. There was no sign of helmet whereas the safety harness was found
     outside the elevator trunk.


•    The top of the elevator cage was provided with a safety guard above the
     emergency escape. Escape ladder was also provided all the way from Floor
     Deck to Navigational Bridge Deck. Electrician had a walkie talkie with him at the
     time of the incident.


•    As far as safety was concerned, the elevator cage was equipped with an
     emergency switch ( and was reportedly found not activated ) inside the cage. The
     control box on top of cage had the following :


     1. Auto / Inspection Selector switch which was left on Auto.


     2. Door Open / Close Switch which was left in the Open Position.


     3. Door Switch ( No indication ).


     4. Emergency Stop that was not activated.




                                     Page 41 of 63
          •   A Remote Control that has 2 buttons ( Up / Down ) and an Emergency
              stop, which was not activated.


          •   The elevator is also equipped with an emergency stop at the Elevator
              Switchboard in the Elevator Machinery Room. This stop was not activated
              in order to be able to move the cage using the Remote Control on the top
              of the Elevator Cage.

          •   Warning signs were posted at all levels ( Elevator Under Maintenance ).


          •   There was no apparent damage to the equipment. However, the door at
              ‘A’ deck did not open using the Emergency Opening Key at the time of the
              rescue operation and had to be opened from inside the trunk. It was
              noticed that the bulkhead openings doors at all decks were provided with
              3 sides frame instead of 4 sides frame, although means of fixing the fourth
              side were provided.


          •   The area was kept at very good housekeeping. No signs of oil leaks.


          •   The weather at the time of the incident was fair with slight sea and low
              swell. Air temp +30C. Vessel moving easily at 14.75 knots.


          •   Lighting level was adequate as the trunk is equipped with fluorescent
              lights all throughout.


          •   No unusual noise was detected.


During the investigation, as many relevant facts as possible were collected. Many
photographs for both the general area and specific items were taken. Some
photographs were taken by the ship’s staff earlier which were carefully studied and
analyzed in order to help revealing any conditions or observations that might be missed




                                       Page 42 of 63
out. Sketches of the specific location and the position of the casualty as seen by the
ship’s crew were also made.


The photographs and sketches had a major role in understanding the incident and the
event leading upto it.


10.1 DATA GATHERING

       The collection of data contributing factors were divided into the following main
       areas :

       1. People
       2. Environment
       3. Equipment
       4. Procedure
       5. Organization


10.1.1 PEOPLE

        People who might have information about the incident were identified and the
        following statements were obtained from them :


   MASTER’S STATEMENT

   “03rd February 2007, shortly after 1425 hrs L.T., I was alerted to the fact that
   someone was trapped in the lift, initially by 2nd Officer, then the Chief Officer. On
   leaving my cabin and proceeding to bridge, I heard much commotion and shouting
   from lower in the accommodation.

   When I was informed of the situation and went to the scene, I was able to see Mr.
   loan Cumpat in inverted position. At this time he was quite conscious and coherent
   although his position was very awkward and he had obviously suffered severe
   trauma, with open wounds and a fractured leg.




                                      Page 43 of 63
I alerted OSMC ( Owners ) of the situation requesting their assistance in arranging
medical rescue assistance etc. and initially altered course towards Trivandrum Port.
Meanwhile attempts to release Mr. Ioan Cumpat were made by the crew, his
situation was extremely dangerous being supported by his trapped leg and foot in an
inverted position trapped between the Lift Cage, Trunk Ladder and angle Iron
brackets, there being a 12 - 15 meter drop beneath him.

Around 1450 hrs L.T., before he could be freed, he slipped into unconscious state,
ship’s crew secured line around casualty. Pan Pan message was transmitted with
little response. This was repeated several times.

1526 hrs L.T., vessel was instructed by Company to make full speed to Cochin, for
assistance, vessel’s course was adjusted accordingly.

1530 hrs L.T., he was finally freed and taken to ship’s hospital where cardiac
compression and artificial respiration with oxygen were administered by ship’s crew,
his pulse very rapid and very weak, his breathing stopped.

At 1538 hrs L.T., Radio Medical advice was sought via 32# Netherlands Coastguard,
who on being told our situation advised that what we had done was the most
appropriate action, and to continue until help could be received. But, however, that
we were probably not going to revive the casualty.

1615 hrs L.T., on gaining contact with local Coast Guard vessel was advised to
make for Kovalam point where Coast Guard would meet vessel with medical
assistance. Course was adjusted accordingly.

1650 hrs L.T., we were requested to anchor 5 miles off Vilinjam light. At this time
Mr. Ioan Cumpat was showing no vital signs, he was neither breathing nor was there
any pulse, his eyes were dilated and no response to light, attempts to resuscitate Mr.
Ioan Cumpat continued throughout.




                                    Page 44 of 63
Throughout there was frequent communications between Vessel, OSMC Casualty
Room and Coast Guard, both by telephone and VHF.

   Vessel as requested anchored safely off Vilinjam at 1755 hrs local time, in
   position 080 21’ N 0760 57’ E. At this time it was apparent that Mr. Ioan Cumpat
   was in fact dead, however, crew continued attempts to revive Mr. Ioan Cumpat
   until finally the Indian Coast Guard arrived.




   1830 hrs L.T., Coast Guard were unable to board vessel due to sea state hence
   it was decided to land Mr. Ioan Cumpat’s to the Coast Guard boat using the
   crane, this was also not easy due to superstructure of the Coast Guard boat, so
   on coast Guard instruction, we landed body to fishing boat “Olympia”, which was
   standing-off nearby.

   At 1940 hrs L.T. Coast Guard confirmed that Mr. Ioan Cumpat was dead upon
   his being received to their custody. Vessel was instructed to remain anchored
   until further notice/ formalities completed.


   It appears that whilst completing routine maintenance on vessel’s Elevator Mr.
   Ioan Cumpat accidentally fell resulting in his becoming trapped until further
   precarious position, leading to his tragic death.


   I believe that my crew did everything possible in the circumstance, and commend
   them for their efforts”.




                                     Page 45 of 63
CHIEF OFFICER’S STATEMENT

  “Around 1425 hrs L.T. I heard the shouting from the elevator. I advised the
  Bridge and all the crew over the VHF public system.. I rushed to the ‘A’ deck and
  with Chief and First Engineer was decided to open the ‘B’ deck elevator door.


  All crew were mustered and Medical team was instructed to prepare first aid
  equipment.


  After few minutes we access the top of the elevator and we found Mr. Ioan
  Cumpat                ( ship’s electrician ) trapped at side of elevator in inverted
  position.


  His leg was twisted and trapped between elevator and casing preventing him
  from failing.


  Bridge (Captain) was updated with situation.


  After we insured him from failing, elevator was manually operated from the E/R
  and Electrician leg was freed obstruction.


  After several attempts from the outside, we manage to open the Upper Deck
  elevator doors from inside of elevator trunk, Electrician was .lowered to upper
  Deck and taken out from the elevator trunk space.


  Electrician was found unconscious with stopped breathing and pulse very rapid
  and very weak.


  We rushed to the hospital and artificial respiration was given together with
  cardiac massage. Above attempts continued until Indian Coast Guard arrived
  without signs of life from injured person.




                                   Page 46 of 63
  At 1755 hrs L.T. the casualty was declared dead by the Captain.


  I solemnly pledge that the above statement is true and in the best of my
  knowledge.




  Ch / Off SS IBRA LNG                                                    Dated: 3rd
  February 2007
                                                                  Nenad Martinovic”
STATEMENT OF 1ST OFFICER

  “I received a call from the Chief Officer at 1430 hrs saying that there is somebody
  stuck up in the elevator and needed to be given First Aid. I rushed to the ‘B’ deck
  to find the Electrician hanging in an inverted position hanging by his foot/leg
  outside the elevator cage (in the maintenance area). Rescue work was in full
  swing to remove the casualty from the elevator area and bring him to the hospital
  on the stretcher. Meanwhile, I got the First Aid equipment ready. Casualty Mr.
  Ioan Cumpat (Electrician) was tied a safety harness to heave him up. The door of
  the elevator on the upper deck was opened by emergency key and he was finally
  taken out and brought to the hospital on the stretcher. He was found to have
  external as well as internal bleeding. He was immediately given artificial
  respiration followed by oxygen resuscitation via the resuscitator. His pulse was
  very weak and he was showing no vital signs. Artificial respiration continued till
  the Coastal Guard vessel arrived but the casualty still did not show any sign of
  improvement.
  1755 hrs the casualty was declared dead by the Captain.
  I solemnly pledge that the above statement is true and to the best of my
  knowledge.




                                  Page 47 of 63
                                                                -sd/-
                                                                (Gaurav
                                                                Choudhary)
                                                                1st Officer
                                                                SS IBRA LNG
                                                                03 February 2007”


STATEMENT OF CHIEF ENGINEER

  “Work carried out on ship’s elevator was part of routine maintenance prepared and
  discussed at morning meeting and in Engine Room just before work.


  Before    work    starts     warning    signals   posted   “ELEVATOR        UNDER
  MAINTENANCE” at all deck elevator doors. All preparation works carried out.


  Elevator was functioning normally during all this time.


  Electrician and wiper was assigned for maintenance work.


  Just before accident happened, wiper took mat out of elevator cabin to clean it in
  upper deck on electrician instructions. Then Electrician went into the elevator
  cabin and went down. It seemed that the Electrician decided to further routine
  maintenance on top of the elevator cabin. At the time         accident happened,
  elevator was switched off.


  The electrician was experienced in his rank. His last contract spent on sister ship
  equipped with same elevator.


  At the time of accident I was in the Engine Room workshop and I was called
  immediately after the accident happened. I went to ‘B’ deck to do as much as
  possible help to release injured electrician Mr. Cunpat. After ‘B’ deck was opened




                                    Page 48 of 63
  to access and electrician released, I went down to the Engine Room to handle
  main engine to full speed (course altered towards Trivandrum).


                                                                             - sd/-
                                                             CH. ENG. HIGIN BASIC
                                                              At and on 04 Feb 2007”




STATEMENT OF 1 A/E ( Assistant Engineer ).


  “I heard a scream around the elevator trunk around 1425 hrs. I went to elevator
  entrance door on ‘A’ deck where I heard voice from electrician calling for help.
  After a few minutes we managed to access inside elevator trunk via door ‘B’
  deck. I noticed E/E was trapped in an inverted position at the side of elevator, by
  the ladder, his leg was twisted and trapped thereby preventing him from falling. I
  realize it to be risky to try to get him out at that position by moving the elevator.
  So we decided that one team will tie a safety harness of rope around him and
  other in engine room will manually operate the elevator. After a while he was
  finally taken out and brought to the hospital. He was found with external bleeding
  and inside hospital I realized also with internal bleeding. He was immediately
  given artificial respiration. Oxygen was also given continuously. Artificial
  respiration continued till the Coast Guard vessel arrived but the casualty never
  gave signs of life.


  1755 hrs L.T. the casualty was declared dead by the Captain.


  I solemnly pledge that the above statement is true & in best of my knowledge.


                                                                            sd/-




                                   Page 49 of 63
                                                                      1 A/E MARIO
MATISAS
                                                                        04th February 2007




  STATEMENT OF 2 A/E ( Assistant Engineer )

    “I Patel Afzal Hajimubarak, 2nd Assistant Engineer on SS IBRA LNG testify the following.

    On 3rd Feb’ 2007, at 1300 hrs, as usual we had a job meeting with the engine
    staff in the Engine Control Room. At 1310 hrs, I along with one of the oiler went
    to the forward heavy fuel oil transfer pump room to purge the suction filters of the
    transfer pumps and to start the forward fuel oil tank heating.

    At 1415 hrs I returned back to the Engine Room.

    At 1425 hrs I was informed by Third Assistant Engineer on the radio that
    electrician was stuck inside the elevator trunk so I along with Third engineer took
    the elevator door opening key from Engine Control room and went to the upper
    deck. As instructed by the Chief Officer there, we tried to open the elevator door
    of the upper deck but it was stuck. Then, as per First Engineer’s instructions, I
    went to the elevator machinery room to prepare for emergency manual operation
    of the elevator if in case required. We were standby there for any instructions
    from the rescue party to manually move the elevator cage.

    At 1500 hrs, I was instructed by the First Engineer to go to the Engine Control
    Room and take care of the operation as we were increasing the ship’s speed to
    full rpm. Since then I was in the Engine Control Room with the Chief Engineer till
    the arrival anchorage point.




                                     Page 50 of 63
  After arrival anchorage, as per First Engineer’s instructions, I along with Third
  Engineer & wiper opened the main floor (M/F) deck elevator door to clean the
  elevator trunk bottom. We found blood drops and some tools and one shoe in the
  elevator pit. We removed the tools & shoe and cleaned the blood. There were
  some blood drops on the tools which we washed and then secured the tools in
  workshop.

                                                               Date – 06th February
                                                                               2007
                                                                             -sd/-
                                                            Patel Afzal Hajimubarak
                                                                 ( Second Assistant
                                                                         Engineer )



STATEMENT OF 3 A/E ( Assistant Engineer ).


  “I, Kanwar Udyan Rathore, 3 A/E on SS IBRA LNG testify the following.


  On 3rd Feb’ 2007 at 1300 hrs, as usual we had job meeting in the Engine Control Room.


  At 1310 hrs., I went for testing E/R fire dampers and funnel flaps. After finishing
  this I started overhauling package Air Conditioner, F.W. booster P/P in workshop
  where I heard on radio that electrician stuck in the elevator, then I call on the
  radio to the 2 AE & we took the elevator key from ECR. We opened the B deck
  door with rescue team. Then we tried to open the upper deck door which was
  stuck and we could not open it. Then as per C/O instructions we went to elevator
  machinery room for manual emergency operation of elevator. Then as per
  instructions we lowered the elevator few centimeters manually. Then I went up to
  Upper deck. Then rescue team opened the upper deck door from inside & we
  tried to lower the electrician with the help of ropes. Electrician was recovered
  from upper deck and we sent him to the hospital. After that I came back to
  Engine Control Room for maneuvering/anchorage.




                                  Page 51 of 63
  After arrival anchorage as per 1st Engineer instruction, I along with 2nd Engineer
  & wiper opened the main floor deck elevator door to clean the elevator trunk
  bottom. We found blood drops and some tools and one shoe and cleaned the
  blood. There were some blood drops on the tools, which we washed and then
  returned the tools in workshop.


                                                           Date : 06th February 2007
                                                                      -sd/-
                                                             Kunwar Udyan Rathore
                                                            ( Third Assistant Engineer )




STATEMENT OF WIPER

  “During morning safety meeting in ECR, I received a job order from 1st Engineer
  to work together with electrician in his monthly maintenance routine of elevator.
  1300 hrs, after receiving an order from 1st Engineer, I & electrician posted a
  warning sign “ ELEVATOR MAINTENANCE” from ‘D’ deck down to main floor.
  After that, we proceeded to 4th deck where electrician turned off the power of
  elevator. He then opened the door of main deck for inspection. After a while he
  told me to clean the bottom of elevator trunk. 1345 hrs I called up electrician to
  look & see if I would still need to mop the bottom trunk or not. After seeing,
  electrician told me to secure my cleaning gear & so I did. Assuming that
  everything is finished, I went to ECR to get a cleaning foam and proceeded to
  upper deck when I saw that the elevator cage landed there. 1400 hrs I met
  electrician at upper deck & he asked me to clean the elevator mat. After that he
  went inside the elevator cage. I just saw that the elevator landed on 4th deck of
  the main floor (I don’t remember the exact deck No. it had landed). With the new




                                    Page 52 of 63
   job order from electrician, I went to “B” deck to take the vaccum & clean the mat
   on the upper deck. After cleaning I was not satisfied so I decided to go to A deck
   at the cleaning gear locker to take a mop and cleaned the mat once again. After
   a few minutes of cleaning, I decided to return the cleaning gear to their
   respective decks when I heard some body screaming inside the elevator. I knew
   it was electrician because he is the one working inside the elevator. I met oiler #
   1 & informed him that electrician was screaming for help. Then instructed me to
   inform 1st Engineer or anyone from the engine room what I did.


                                                                      -    sd/-
                                                                Fritz Andrew B. Rosel
                                                                  Wiper, IBRA LNG


Broad questions such as Who, What, When, Where, Why and How were asked to all
parties. All concerned were interrogated in order to elicit information related to the
incident.
All individuals were assured that the investigation / interviews were being conducted
to promote safety and not to apportion blame at any of them.

Everyone explained in his own words what happened and the action taken on
occurrence of the incident. They were asked if they knew of any near-miss history of
the Elevator.

During the interview / interrogation of all individuals been interviewed were observed
to be in physically & mentally sound condition. From the interviewers / interrogation
of the concerned person, it was found that the casualty was an experienced person
who had just signed off a sister ship with exactly the same elevator system. Looking
into the fact that he had been an electrician in the past twenty years, it could be said
that Mr. Ioan Cumpat was well experienced in the task and was fit for the job.


It was reported that the casualty was neither under stress nor under the influence of
alcohol.




                                    Page 53 of 63
10.1.2 ENVIRONMENT

        The Environmental Factor was not found to be applicable to the causes of the
        incident as the weather was fair and the air temperature was good. No signs of
        toxic or hazardous gases, dust or fumes presented in the site.


10.1.3 THE EQUIPMENT

        The electrician was carrying out routine maintenance on the equipment. The
        elevator was reported to be in good condition and nothing untowards noticed
        about its normal operation since the vessel was built. The only thing noticed
        was the distorted bottom guide underneath the right hand side of the bulkhead
        opening slide door ( looking from inside ). This may be due to a missing frame
        side, as mentioned earlier above. This could not have contributed to the
        accident as it would keep the sliding door in the open position, in which case
        the electrician could easily escape from the scene. The possibility of the
        accident was more likely with a closed door.


  Other important issues with the equipment were checked. There was no apparent
  equipment failure at the time of the incident.


  The purpose of the Electrician being on the top of the cage was purely for routine
  maintenance that involved the following :

   1.    Cage emergency stop switches test,

   2.    Cage telephone communication test,

   3.    Cage bell - call to the bridge test,

   4.    Wire rope visual inspection,

   5.    Elevator motor gear case oil check,

   6.    Greasing of electric motor bearings,




                                        Page 54 of 63
   7.     Landing door interlock switches inspection,

   8.     Safety devices and alarm test,

   9.     Electric motor insulation resistance test,

   10. Oil level in the lubricator of the cage,

   11. Oil level in the lubricator of the counter weight,

   12. Tightness of mounting bolts of the rail,

   13.     Trunk lighting inspection,

   14. Clearance between brake lining and brake drum,

   15. Clearance between counter weights and buffer springs.


  The work was carried out as per the checklist which points out the possible hazards
  and the safety countermeasures that should be adopted. The vessel has the
  COSWP and Company SMS Fleet Notice No: OSMC 06-01 which gives guidelines
  for handling marine elevator. Both documents were reported to be understood by the
  Electrician. However, no risk assessment was made as it was a routine work.


  The Electrician was in charge of both maintenance and operation of the elevator.
  Total running hours of the machine was reported to be 652 hours since the date of
  delivery of the vessel.


10.1.4 PROCEDURE

         The work procedures, as well as the scheduling of the work, were examined in
         order to ascertain whether they contributed to the incident or not. It was found
         that the work was planned in advance and the Wiper was assigned to assist.
         However, the Electrician dismissed the Wiper who was assigned to help and to
         be part of the team in case something went wrong. The Wiper was dismissed
         before the job was completed. This had changed the condition making the
         normal procedure unsafe. Although safety harness was provided, it was not




                                        Page 55 of 63
         being worn at the time of the incident. No safety helmet was found in or around
         the accident location. All emergency stops were not activated and interlock
         switches were put to Auto position.



10.1.5   THE ORGANISATIONAL FACTOR

         From the above it appears that the organizational factor as reflected in this
         incident clearly shows that the ship used all possible sources to enhance the
         safety during this task but was violated by the Electrician. From the
         interrogation of concerned higher management, it appears that the safety rules
         were communicated in a way that they were understandable by all crew
         members. The written procedures were provided such as the COSWP, on
         board OPM, SMS Fleet Notices and Safety campaigns. Safety procedures
         being enforced but unfortunately dismissing the Wiper resulted in a broken
         safety chain. Going into the elevator trunk with all the safety interlock /
         emergency stops not activated had resulted is a devastating incident.

         Although the Electrician was experienced and well trained, a risk assessment
         had to be carried out. This was not done due to unknown reason. There was, of
         course, no direct violation of the safety rules. The reason for not conducting risk
         assessment was because the task involved was of routine nature which does
         not appear to be convincing.


         However, the Chief Engineer being the Head of Engineering Department under
         whose guidance the Electrician works on any vessel, cannot escape his
         responsibility for not enforcing Risk Assessment of the task prior to undertaking
         the maintenance work in a potentially risk prone area. It appears that just
         because the Electrician was an experienced person, and just because the
         maintenance work was of routine nature, entire task was left on to the
         Electrician and his assistant. During the course of Lift Maintenance no feed
         back of work progress was obtained and no cross check was carried out by the
         Chief Engineer (as reflected in his statement).




                                        Page 56 of 63
            The Chief Engineer was expected to carry out a proactive analysis of the
            situation during safety meeting and decide on the maintenance strategy to be
            adopted by the Electrician and his assistant.


            It was reported that the Elevator did not have any previous history of any
            operational problem. Therefore, elevator maintenance work need not have
            been done at ‘A’ deck / UD level. The ideal position for maintenance should
            have been the lift’s Lowermost position, and the lift operation should have been
            done manually and not electrically. The Chief Engineer should have instructed
            the Electrician accordingly.



11.        APPARENT CAUSE ANALYSIS

           The following analysis had helped to classify the facts in the ICAM model for
           inclusion in the investigation report and for briefing the PMA on the investigation
           findings :

      1.    A series of mistakes were made by the casualty. This was initiated by
            dismissing the direct assistance from the job, followed by not putting the full
            PPE, entering the elevator trunk on self initiative and changing the safety
            switches settings, missing the facts that this might be very dangerous as
            proved later. These errors had an adverse effect associated with the person
            having a direct contact with the equipment. It is believed that these acts have
            led directly to the incident.

      2.    The location of the incident reportedly made the rescue operation very difficult
            as the casualty was in the inverted position with his knee trapped between two
            iron brackets, there being a drop of about 25 meters beneath him.

      3.    At first the sliding door reportedly did not open using the emergency key from
            ‘A’ deck. A crew member had to enter from the above deck and open the door




                                            Page 57 of 63
     by releasing the locking mechanism from the inside. The total time used to
     secure the casualty into the ship’s hospital was 1 hour 5 minutes. The casualty
     was reported to be bleeding and blood drops could be traced all the way down
     from ‘A’ deck to the bottom floor. It was believed that the casualty had suffered
     from broken leg, twisted ankle, broken arm, internal and external bleeding. The
     casualty confirmed to be deceased by the Indian Coast Guard doctor at 1940
     hrs L.T. The time when the incident first happened was about 1425 hrs L.T..


4.   Organizational factor presented as inadequate procedures were used i.e. No
     Risk Assessment made for this specific operation.


5.   Failures into Organizational Factor using the Organizational Factor Type (OFT)
     were not applicable as far as the hardware is concerned. However, when it
     came to training, it could be seen that making assumption about the Electrician
     knowledge and skills seemed to be over-confident as he dismissed the
     assistant provided for him. The Electrician failed to assess the sequences of
     that decision as well as being inside the elevator trunk with no safety measures
     to stop the elevator from moving.


6.   As far as organization is involved, it could be seen that the Electrician had
     missed the definition of the objectives of the Wiper being with him due to
     unclear accountability and the understanding of the wiper being not directly
     trained on that particular job. This led into wrong decision making.


7.   With regards to communication, a poor feed back could be noticed as neither
     Bridge nor ECR were informed of the dismissal of the Wiper prior to completion
     of work.


8.   Incompatible Goals were demonstrated by the presence of conflicts between
     safe work and production priorities. The Electrician went into the Elevator Trunk
     as a conscious person who was trying to produce a good result out of his job




                                    Page 58 of 63
     being the person looking after the Elevator. Seemingly, he did not consider the
     safety aspects and the hazards involved.


9.   Error Enforcing Condition did not apply in this incident as there was no
     apparent human limitation, external disturbance, social factors and personality
     factor which are not known. The Electrician had recently joined the ship (12
     days prior to the date of the incident).

10. Procedures should have been easily identified as they are clearly written,
     documented and controlled. The missing risk assessment could have resulted
     in a poor feedback on practicality.


11. Maintenance management was enforced as the job was pre-planned from early
     morning to take place in the afternoon. There had been enough time for
     everything to be set and for the safety measures to be considered.


12. Although the maintenance manual does not provide any safety instruction
     before undertaking any maintenance work, it does provide “Escape method in
     an emergency”. However, considering the place of work being Elevator shaft,
     the general risk perception is obvious and hence additional guidelines as to
     ‘safety preparation’ is considered not necessary and code of safe works
     practice is considered adequate.


13. Apart from the missing frame side, which believed not to have contributed to
     the incident, there is no apparent design failure on the Elevator cage. During
     the rescue operation and while carrying out the investigation, it was noticed that
     the bulkhead opening sliding door could not be opened using the emergency
     key. This had happened at ‘A’ deck and ‘B’ deck and UD.


14. Once the elevator started to move upwards ( will be explained later in this
     Report ), the Electrician was able to understand the hazardous conditions
     which could occur but he failed to control the recovery defense and could not




                                     Page 59 of 63
      get out of trouble without injury due to the fast moving cage and the restricted
      area inside the elevator trunk.


 15. The casualty tried to prevent escalation of the injury by applying a containment
      defense procedure using his left leg to prevent him from falling all the way down
      to the elevator floor ( 25 meters drop ).


 16. Due to the restricted area failure to open the bulkhead slide door as quickly as
      possible, the emergency team could not manage to evacuate the potential
      casualty from the danger zone at a relatively good time. Medical first aid
      although given but could not improve the condition of the casualty. The site was
      isolated since then.



12. CONCLUSION

 1.   Usual practice of wearing PPE was not adhered to. Necessary PPE were left
      outside the elevator trunk.

 2.   The Electrician appeared to be over-confident so much so that he entered the
      elevator trunk without assistance resulting in vital human error.

 3.   Deliberately caused break in safety procedure by dismissing safety team,
      although he was specifically instructed to the contrary during safety briefly in
      the afternoon of 3rd February 2007.

 4.   Emergency stops were not achieved and “Inspection” selector switch was
      changed into Auto position.

 5.   Vital time was lost as the lift door could not be opened in time.

 6.   Rescue operation became difficult due to space restriction.




                                        Page 60 of 63
  7.   Considering the awkward position of the casualty who was trapped in an
       “Inverted” position, appropriate decision making process was delayed for quick
       rescue operation.

  8.   The casualty had been unconscious for about 40 minutes before he was finally
       freed and shifted to ship’s hospital before first aid could be started.

  9.   The casualty was reported to be bleeding for nearly an hour before actual first
       aid could be commenced.



13. RECAPITULATION

  1.   Electrician at Deck ‘A’ opened the elevator trunk door using emergency keys,
       slides onto the top of the elevator car (cage) which is at Upper Deck ( UD ),
       Door closed automatically ( as designed ),

  2.   Electrician carried out routine maintenance that involved checking of all fittings
       and lubrication etc.,

  3.   He decided to go out through ‘A’ deck so took the elevator (using the remote
       box) to a position where he could reach and unlock the door locking
       mechanism, approximately 50 cms above floor of ‘A’ deck,

  4.   Changed over from Inspection to Auto (Maintenance control box), taking into
       account that there is a delay period for the system to re-set, so he can reach
       the door,

  5.   Re-set time complete ( around 40 seconds ) before he succeeded in opening
       the door and elevator moves towards the nearest deck. ‘A’ deck being the
       nearest             ( 1700 mm to travel up towards ‘A’ deck, where as it needed
       2050 mm to travel downwards to UD level ),

  6.   Initial movement caused the electrician to panic and therefore he turns towards
       the ladder for easy escape,




                                       Page 61 of 63
   7.    Right foot get trapped at the top of the elevator car corner ( 1 piece of safety
         boot found at the bottom of the corner ), ankle twisted,

   8.    Electrician kneeled on his right leg and tried to hold / grab the ladder,

   9.    Due to potentially high speed of elevator he was held in the empty space
         (between the ladder and the bulkhead brackets),

   10. Inertia of high speed caused him to fall into this empty space, breaking his leg
         due to weight and at the same time slamming the ladder with his left arm and
         breaking it,


   11. Elevator moving up fast and reached the correct position of ‘A’ deck level in
         very few seconds,

   12. Electrician knee got trapped between the moving and stationary brackets taking
         all the weight;

   13. Wounded Electrician screamed for help.

The entire incident is illustrated in a sketch below :




                                         Page 62 of 63
14. RECOMMENDATION

   The following corrective actions were identified in order to prevent recurrences of
   such incident. At first a proactive analysis is to be carried out to identify
   significant risks and safeguards to prevent and mitigate the associated
   consequences as to what could go wrong, what are the consequences and what
   could cause these consequences. Based on this analysis, a Management
   System has to be set-up in order to control risk so that maintenance, strategies,
   methods and procedures could be developed. Although not all causes can be
   completely eliminated, effort must be made to enhance the safety awareness of
   the crew and the fleet as a whole. The corrective actions recommended are
   specific, measurable, accountable, timely, effective and can be reviewed
   whenever required. The Principal Investigator is of the opinion that the following
   formulated recommendations, if implemented, will reduce the risk of recurrence
   of the incident and the consequences thereof.


    •   The job is to be planned well in advance to allow for all safety measures to
        be carried out,


    •   A risk assessment should form a part of the planned maintenance and must
        be obtained prior to carrying out maintenance,


    •   At least two persons should be involved when elevator maintenance is
        carried out,


    •   A good communication must be established between all parties involved at
        all time. A time interval can be agreed between the involved parties,


    •   All safety procedure must be strictly observed. Every person involved in the
        work must have clear understanding of their duties and associated risks.




                                   Page 63 of 63
•   Elevator trunk must be treated as a confined space, therefore, an entry
    permit must be obtained,


•   Elevator door at specific deck to be locked open during maintenance,


•   Instruction for emergency opening of elevator doors should be posted by
    each door,


•   Clear warning of both the presence and the nature of a potentially
    hazardous situation must be explained to all members involved,


•   Must ensure that the team members understand the nature and severity of
    the hazardous conditions presents at the worksite,


•   Under no circumstances an individual is to be allowed to enter the Elevator
    trunk with the emergency stops not activated,


•   An announcement must be made through the ship’s PA prior to carrying out
    any maintenance on elevator,


•   The controls in cage maintenance call box must be configured in such a
    manner that it would not be possible to activate them accidentally.


•   No “complete maintenance” announcement is to be carried out until a full
    head count is conducted,


•   Owners must obtain makers recommendation towards safety enhancement
    for prevention of accidental fall (when opening the doors using emergency
    keys).




                               Page 64 of 63
     •    Person involved in elevator maintenance must demonstrate the capability of
          doing such task to the Chief Engineer before conducting the first routine
          maintenance.

     •    Warning notices must be posted so that accidental use of all call buttons is
          prevented.

     •    Design of the Elevator should include a safety barrier around the cage.

     •    Company OPMs must include instructions on elevator maintenance.

     •    All maintenance on the elevator must be carried out at lowermost position
          unless the situation demands otherwise.



15. OUTCOMES OF THE INCIDENT


     1.    Loss of life of one of the ship’s officer,

     2.    This incident will not be forgotten by any of the crew members due to the
           psychological effect on the individuals,

     3.    Equipment is left isolated since the day of the incident,

     4.    Lessons learnt and more precautions will be adhered to when attending
           any maintenance in future.




P. K. Bhattacharyya
PRINCIPAL INVESTIGATOR,
HENDERSON INT’L (INDIA) PVT. LTD.,
KOLKATA, INDIA.




                                       Page 65 of 63

				
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Description: CASUALTY INVESTIGATION REPORT