INVESTIGATION

CASE 8
Maintenance Blindness
Narrative
Three crew members on board a
190m long bulk carrier were injured
during berthing operations in a
UK port when the accommodation
ladder they were rigging collapsed.
Figure 1: Similar arrangement of accommodation ladder
Once the bulk carrier was moored
alongside, the three crewmen
were sent to rig its starboard
accommodation ladder. The
accommodation ladder was in its
stowed position and needed to be
un-stowed, lowered to the quayside
and rigged ready for use.
The top of the accommodation
ladder was hinged onto a turntable, which in
turn was mounted on a platform attached to
the ship’s deck (Figure 1). The access platform
at the bottom of the ladder was fitted with a
set of collapsible handrails on either side.
The crew initially released the ladder’s stowage
securing arrangements and lowered it from
its vertical stowage position to a horizontal
position outboard and parallel to the hull
of the ship, over the quayside. The bottom
platform of the ladder was then lowered to
a position just above the quayside. With the
free end of the ladder still suspended from
its winch wires, the three crew members
started to descend the ladder in order to rig
the handrails. As they did so, the turntable at
the top of the ladder fell away from the ship
and onto the quayside below. All three crew
members fell off the ladder and were injured
when they landed on the quayside. They were
all taken to hospital for treatment and made
full recoveries from their injuries.
The turntable at the top of the accommodation
ladder was secured to the platform with a
bolted central pivot pin, and was supported by
two sets of roller bearings.
Upon investigation it was found that the
failure of the accommodation ladder was due
to the corrosion of the central pivot pin, which
had caused the turntable to detach from its
support platform (see Figures 2 and 3). In
addition, the turntable’s roller bearings were
completely rusted and had seized solid. The
surrounding metal structure of the platform
was also wasted due to corrosion.
According to the ship’s maintenance
management system, the ladder, turntable and
support platform should have been inspected
and greased on a monthly basis. It was evident
from the post-accident inspection, that the
greasing point in the centre of the turntable
had not been used for some time. It was also
evident that the roller bearings could not be
inspected or greased without unbolting the
turntable from the platform, and dismantling
it. There was no record of this task ever having
been done.
16
MAIB Safety Digest 1/2017