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Report of investigation

into the electrocution of

a fitter during welding repair

on board Hong Kong registered vessel

Suntec on 23 January 2010

15 November 2010

Purpose of Investigation

This incident is investigated, and published in accordance with the IMO Resolution MSC

255(84), the Code of the International Standards and Recommended Practices for a Safety

Investigation into a Marine Casualty or Marine Incident (Casualty Investigation Code)

adopted on 16 May 2008.

The purpose of this investigation conducted by the Marine Accident Investigation and

Shipping Security Policy Branch (MAISSPB) of Marine Department is to determine the

circumstances and the causes of the incident with the aim of improving the safety of life at

sea and avoiding similar incident in future.

The conclusions drawn in this report aim to identify the different factors contributing to the

incident. They are not intended to apportion blame or liability towards any particular

organization or individual except so far as necessary to achieve the said purpose.

The MAISSPB has no involvement in any prosecution or disciplinary action that may be

taken by the Marine Department resulting from this incident.

Table of Contents Page

1. Summary 1

2. Description of the vessel 2

3. Sources of evidence 4

4. Outline of events 5

5. Analysis of evidence 8

6. Conclusions 15

7. Recommendations 16

8. Submissions 17

1. Summary

1.1 At 1748 on 22 January 2010, the Hong Kong registered general cargo vessel Suntec

departed the port of Huangpu, China after loading 19 300 tonnes of river sand to be discharged at the port of Keelung, Taiwan.

1.2 On the morning of 23 January 2010, the deck fitter was assigned to carry out electric arc welding repair on the bulwark on the main deck at the port side near No.5 cargo hold.

1.3 At about 1440, while the fitter was carrying out the welding repair, seawater suddenly rushed up the deck through the opening between the deck and the bulwark plate and dampened his body. He screamed after suffering from electric shock and fell unconscious on the deck.

1.4 The crew on board tried in vain to resuscitate him. He was later airlifted by rescue helicopter to a hospital in Hong Kong, China, for treatment, but was subsequently certified dead on 23 January 2010.

1.5 The investigation revealed that the main contributory factors to the accident were as follows:­

ò Before commencement of the work, the risks of electric shock and electrocution to the deck fitter was not fully assessed by the Master of the vessel; and

ò no assistant was assigned to watch and alert the deck fitter of seawater rushing up the deck during the welding operations.

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2. Description of the vessel 2.1 Particulars of M.V. Suntec

Port of Registry : Hong Kong, China

IMO No. : 7825227

Call sign : VRXY2

Type : Bulk/Lumber

Year Built : 5 April 1979

Gross Tonnage : 15 278 tonnes

Net Tonnage : 8 689 tonnes

Length Overall : 163.34 metres

Breadth : 24.80 metres

Moulded Depth : 13.40 metres

Main Engine : 1 x Sumitomo Sulzer 6RND68

Engine Power : 17 821 kW

Speed : 14 knots

Class : Lloyd’s Register of Shipping

Owner : Protec Maritime Limited

Management Company : Shanghai Adani Shipping Co., Ltd

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Fig 1: M.V. Suntec at berth

Fig. 2: Port side main deck

Fig. 3: Port side main deck near

No. 5 cargo hold

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3. Sources of evidence

3.1 Report and other information provided by the management company of the vessel

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4. Outline of events

9.08 metres and 9.15 m etres respectively.

(all times are local)

4.1 At about 1600 on 22 January 2010, the Hong Kong registered general cargo ship Suntec finished loading 19 300 tonnes of river sand at the port of Huangpu, China and started to prepare for sailing. The forward and aft drafts of the vessel were

4.2 The pilot embarked at 1715 and the vessel departed at 1748. At about 2300, the pilot disembarked and the Master of the vessel continued the voyage to the port of Keelung, Taiwan for discharging the cargo. It was drizzling with light breeze and small wavelets at sea.

4.3 On the morning of 23 January 2010, the Chief Officer assigned the deck fitter to carry out electric arc welding repair on the bulwark on the port side main deck near No.5 cargo hold (Fig.4), with two seamen assisting him.

Fig. 4: The position of the bulwark being repaired by the fitter at the time of the accident

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4.4 The weather was overcast, with force 6 wind and sea waves of 2.5 to 3.0 metres in height. The vessel was moving against the winds. Seawater was occasionally rushing up the deck near No.1 and 2 cargo holds.

4.5 The repair work went smoothly in the morning. At about 1330 in the afternoon, the deck fitter returned from lunch break and carried on with the welding repair. The two seamen helped by cutting some steel plates at a place about 10 metres away from the deck fitter.

4.6 Before the accident, the weather was cloudy, with slight breeze and moderate waves at sea. The vessel was moving against the winds and almost no seawater was seen rushing up the deck.

4.7 At about 1440, while the deck fitter was welding on the bulwark, seawater suddenly rushed up the deck through the opening between the deck and the bulwark plate and dampened his body. He screamed after suffering from electric shock and fell unconscious on the deck.

4.8 The Bosun working near the deck fitter immediately ran to the welding machine to cut off the electrical power supply. He then asked the seamen to help carry the deck fitter into the corridor inside the crew accommodation for rescue.

4.9 At the time of the accident, the vessel was passing the Strait of Taiwan at the position 22° 19.5’N 115° 47.4’E about 35 miles from Shanwei, China.

4.10 Seeing that an accident had happened, the duty Second Officer on the bridge immediately informed the Master, who was in his cabin, of the accident. The Master arrived at the corridor in the accommodation and found some crew members trying to resuscitate the deck fitter. The Chief Officer was also there in charge of the rescue operation.

4.11 The deck fitter’s eyes and mouth were seen to have opened for a short moment during the rescue, but his condition kept deteriorating.

4.12 At about 1500, the Master reported the accident to the company and sought assistance from the Hong Kong Maritime Rescue Coordination Centre (HKMRCC) and the Shanwei Rescue Centre (Shanwei RCC). The Master also ordered the vessel to head for the port of Shanwei, China.

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4.15 At 1745, t he vessel continued i ts voyage to K eelung, Taiwan.

4.13 At 1510, the HKMRCC received the message from the Master of the vessel. At 1730, the deck fitter was airlifted from the vessel by a rescue helicopter deployed by the Government Flying Services of Hong Kong, China.

4.14 At 1740, the Master informed the company, the HKMRCC and the Shanwei RCC of the successful transfer of the deck fitter from the vessel towards Hong Kong, China.

4.16 At 1815, the rescue helicopter delivered the deck fitter to the Pamela Youde Nethersole Eastern Hospital in Hong Kong, China, where he was certified dead at 1825 on 23 January 2010.

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5. Analysis of evidence

Certification, training and experience of the deck fitter (the deceased)

The weather and sea c onditions

The workplace and the repair work

5.1 The welding repair work on the bulwark, which is close to the ship’s side, involved cropping and renewal of corroded steel plating of the bulwark. The workplace was on the port side main deck near No. 5 cargo hold, in the aft part of the main deck and in front of the crew accommodation (Fig. 3).

5.2 On the morning of 23 January 2010, the weather was overcast, with force 6 wind and sea waves of 2.5 to 3.0 metres in height. In the afternoon, the weather became cloudy, with slight breeze and moderate waves at sea. Visibility was about 10 nautical miles.

5.3 While the vessel was sailing against the winds, seawater had been occasionally rushing up the forward deck near No.1 and 2 cargo holds in the morning. In the afternoon, the weather and sea conditions improved slightly and there was no seawater rushing up the deck.

5.4 The deck fitter joined Suntec in the port of Fuzhou, China on 23 August 2009. The vessel was the second ship under Suntec’s management company that engaged his service. He had previously joined another vessel managed by the same company on 3 February 2008 and worked as deck fitter until signing off from the vessel on 28 September 2008.

5.5 He held a permit issued by the Mainland authorities certifying his competence in carrying out electric arc welding and gas cutting work on board ships. The permit was issued on 13 July 2007 and valid until 13 July 2013. Two endorsements by the authorities, respectively in the month of July in 2009 and 2011, are required in order to maintain its validity. The first endorsement was made and the permit was stamped. Therefore, the deck fitter was competent and certificated to carry out electric arc welding on board Suntec.

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Familiarization training

The welding m achine

5.6 The fitter joined Suntec on 23 August 2009. He had been working on board the ship for five months before the accident happened on 23 January 2010. He had completed the familiarisation training on board.

5.7 The fitter used an alternating current welding machine for the repair work. The return cable of the welding machine was connected to the ship’s hull near the location of the machine.

5.8 The instructions for hot work provided in the Safety Management System (SMS) manual of the company stipulates that ship structures should not be used as the earth return for the welding machine. The Code of Safe Working Practices for Merchant Seamen also stipulates that a “go-and-return” system utilizing two cables from the welding set shall be adopted and the welding return cable should be firmly clamped to the workpiece.

5.9 Therefore, it is evident that the arrangement of the return cable for the welding machine did not follow the company’s instructions or the requirement of the Code.

Fig. 5 The welding machine used by the deck fitter for repairing the bulwark on deck

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Procedures for hot work in the SMS manual

5.10 The SMS manual of the company provides the instructions for hot work on board vessels managed by the company. It requires that: ­

i) hot work permits should be issued by the department heads and approved by

the Master of the vessel before commencement of hot work

The Master of the vessel approved the hot work permit issued by the Chief Officer at 0800 on 23 January 2010. All the safety precautions stipulated in the hot work permit were confirmed satisfactory. Under the section on “items of special concern” in the standardized form of the hot work permit are the following words: “Beware of fire hazards, electric shock and waves rushing up the deck”. The Master only put down in this section a remark concerning fire precautions. It is therefore evident that the risk of electric shock to the deck fitter due to waves rushing up the deck at the workplace had not been taken into consideration when the hot work permit was issued and approved.

ii) one watchman must be provided to assist the welder during welding

operations

There was no mention in the instructions about the duties of the watchman, but it is understood that the duty should include fire watch during welding. In this incident, none of the two seamen who were assigned to assist the deck fitter was keeping a fire watch at the time of the accident. Instead, they were helping the fitter by cutting some steel plates in the vicinity.

iii) if there are no effective measures protecting personnel against electric shock,

no electric arc welding operations should be carried out on deck in case

waves rush up the deck

The Code of Safe Working Practices for Merchant Seamen stipulates that an assistant should be in continuous attendance during welding operations. He should be alert to the risk of accidental shock to the welder, and be ready to cut off power instantly, raise the alarm and provide artificial respiration without delay. In this incident, no assistant was assigned to alert the deck fitter of the risk of accidental shock arising from seawater rushing up the deck at the workplace during the welding operations.

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Hot work permit

Assessment of risk of electric shock

The cause of water rushing u p the deck at the workplace

Use of personal protection equipment for welding w ork

5.11 During the work, the crew did not strictly follow the safety precautions stipulated in the hot work permit approved by the Master of the vessel at 0800 on 23 January 2010 in that:

i) there was no fire-fighting supervisor keeping the fire watch when the deck fitter was welding on the bulwark. The two seamen were helping the fitter by cutting some steel plates.

ii) communication between the fire-fighting supervisor and the bridge was not effective. The fire-fighting supervisor at the scene was not informed by the bridge when the duty Second Officer changed the ship’s course.

5.12 The deck fitter wore proper dry clothing, boots, and gloves and had face visor on during welding. Therefore, the personal protection equipment for the deck fitter was adequate under normal working conditions.

5.13 According to the investigation by the ship management company, the probable cause of seawater suddenly rushing up the deck at the workplace was a deviation of the ship’s course to starboard by the duty Second Officer, who intended to avoid a close quarters situation with a small fishing vessel. Subsequent to the change of the ship’s heading, the vessel had its port side turned against the winds and seawater rushed up its portside deck.

5.14 On the morning of 23 January 2010, seawater was occasionally rushing up the main deck. Although the welding operations took place in the aft part of the main deck, under the prevalent weather and sea conditions, the risk of electric shock to the deck fitter was extremely high when welding operations were being performed at positions close to the ship’s side.

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Fatigue at work

Safety aw areness

Monitoring an d supervision of repair work

5.15 Also, when the deck fitter was welding with a face visor on, he could not at the same time watch for seawater rushing up the deck at the workplace. Therefore, there should be an assistant to keep watch in case seawater should rush up the deck. Besides, special arrangements should be considered for the electrical power supply to the welding machine to be cut off as soon as possible before seawater rushes up the deck. It is therefore advisable that, under such circumstances, non-urgent repair work should be postponed.

5.16 It is therefore evident that the Master of the vessel did not assess the risk of electric shock to the deck fitter when granting approval for the relevant hot work permit.

5.17 The two seamen who assisted the deck fitter during the welding repair could not substitute the Chief Officer’s role as supervisor of the work. Since at the time of the accident there was no watchman for fire and waves rushing up the deck, it is evident that the Chief Officer was not monitoring and supervising the repair work.

5.18 The duty Second Officer on the bridge knew about the repair work on the deck. However, when he changed the ship’s course, he was not aware that the action could cause seawater to rush up the deck. Neither did he alert the fire-fighting supervisor at the workplace before taking the action.

5.19 The deck fitter, who had good experience in welding repair work on board ships, was not aware of the risks of electric shock and/or electrocution while carrying out electric arc welding operations at or near the ship’s side as there is always the possibility of seawater rushing up the deck in poor weather and rough sea.

5.20 The fitter worked eight hours a day and did not work overtime on the previous days. He should not have suffered from fatigue at work before the accident.

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Safety m anagement system

Autopsy

Electrocution

Effect of drugs and alcohols

5.21 The autopsy report revealed no evidence of the fitter being affected by drugs and alcohol prior to the accident.

5.22 The fitter wore proper personal protective clothing and the workplace was dry prior to the accident. The welding position was not such that would normally cause his body to come into contact with the ship structure during welding.

5.23 The return cable of the welding machine was not connected to the workpiece. A long return path of electric current through the ship’s hull during welding would have had a higher electrical resistance, but the lack of such was not the main cause of this accident.

5.24 The most probable cause of the accident was the large quantity of seawater suddenly rushing up the deck at the workplace where the fitter was performing electric arc welding repair on the bulwark. His body became wet immediately and he was electrocuted.

5.25 The autopsy report issued by the Department of Health of Hong Kong, China indicated that the direct cause of the fitter’s death was electrocution.

5.26 The Master did not observe the company’s instructions for hot work. When he gave his approval for the relevant hot work permit, he had not assessed the risk of electric shock that would cause danger to the fitter when he was carrying out electric arc welding on the deck.

5.27 The crew did not strictly follow the safety precautions stipulated in the relevant hot work permit. They might not have received adequate training or fully understood the company’s instructions for the hot work and the purpose of the permit-to-work system.

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5.28 The deck fitter and the two seamen had been working on the main deck without supervision by the Chief Officer. Even though the safety precautions stipulated in the hot work permit were not followed during the work, there was no intervention by the Chief Officer.

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6.6 The investigation a lso r evealed t he following safety factors:­

6. Conclusions

6.1 At 1748 on 22 January 2010, the Hong Kong registered general cargo vessel Suntec departed the port of Huangpu, China after loading 19 300 tonnes of river sand to be discharged at the port of Keelung, Taiwan.

6.2 On the morning of 23 January 2010, the deck fitter was assigned to carry out electric arc welding repair on the bulwark on the main deck at the port side near No.5 cargo hold.

6.3 At about 1440, while the fitter was carrying out the welding repair, seawater suddenly rushed up the deck through the opening between the deck and the bulwark plate and dampened his body. He screamed after suffering from electric shock and fell unconscious on the deck.

6.4 The crew on board tried in vain to resuscitate him. He was later airlifted by rescue helicopter to a hospital in Hong Kong, China, for treatment, but was subsequently certified dead on 23 January 2010.

6.5 The investigation revealed that the main contributory factors to the accident were as follows:­

ò Before commencement of the work, the risks of electric shock and electrocution to the deck fitter was not fully assessed by the Master of the vessel; and

ò no assistant was assigned to watch and alert the deck fitter of seawater rushing up the deck during the welding operations.

ò the Master of the vessel did not strictly follow the company’s instructions when approving the relevant hot work permit;

ò the Chief Officer and the crew did not strictly follow the safety precautions during the hot work;

ò the Chief Officer did not supervise the repair work properly;

ò the return cable of the welding machine was not connected to the workpiece; and

ò the officers and crew did not receive adequate training or fully understand the company’s instructions for hot work and the purpose of the permit.

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7.2 The ship m anagement company of Suntec is required t o:­

7. Recommendations

7.1 A copy of the report should be sent to the ship management company of Suntec

informing it of the findings of the investigation into this accident.

ò issue a circular letter to all vessels under its management to ensure that the company’s instructions for hot work are strictly followed by the crew on board at all times;

ò provide all personnel on board its vessels with training on the permit-to-work system; and

ò ensure that the senior officers on board properly monitor and supervise all work activities carried out on board.

7.3 A Merchant Shipping Information Note (MSIN) should be issued to promulgate the lessons learnt from this accident.

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8. Submissions

8.1 In the event that the conduct of any person or organization is commented in an accident investigation report, it is the policy of the Marine Department to send a copy of the draft report or parts thereof to that person or organization for its comment.

8.2 The draft reports were sent to the ship management company, the Master, the Chief Officer and the Second Officer of Suntec for comment. There was no submission received.

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