Report slams “weak” safety culture on MSN Explorer after crewman Alfred Ismaili is crushed to death in King’s Lynn
- Credit: Archant
A cargo ship on which a crewman was crushed by a hold cover had a 'weak safety culture', according to an official report into his death.
Albanian seafarer Alfred Ismaili, 36, died on board the MSN Explorer when it was docked in King's Lynn on February 1. He left a wife and three young children.
Today the Marine Accident Investigation Branch blames the tragedy on 'procedural inadequacies and a lapse of supervision' aboard the 81m Liberian-registered timber ship.
'The investigation identified that the vessel's safety management system was immature and the safety culture on board the vessel was weak,' its findings say. 'Risk assessments had not been conducted for routine tasks and a safe system of work had not been developed for opening and closing the forecastle stowage space hatch cover.'
Mr Ismaili was also more than twice the drink drive limit when the accident occurred, the report said.
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The crew of the Explorer, which was berthed at Lynn's Alexandra Dock, had finished unloading a cargo of timber from Sweden when the accident happened.
Mr Ismaili, who was the ship's cook, arrived on deck at 11.20am to tell his shipmates lunch was ready.
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The MAIB said a discussion took place and the crew decided to finish stowing loading slings in the Explorer's front storage hold before eating.
Locking pins had been removed from the hatch cover before a crane had been attached to lower it.
As Mr Ismaili climbed up the inside of an open hatch cover to retrieve a sling it collapsed, trapping him against deck combing.
Crew members tried to lift the hatch cover but it was too heavy. It was raised by a dockside crane.
Mr Ismaili was lifted unconscious into the deck. Paramedics arrived at 11.40am but were unable to revive him and he was pronounced dead at the scene.
A post mortem examination identified the cause of death as blunt force injury to the chest.
The MAIB said toxicology tests revealed Mr Ismaili had a blood alcohol level of 75mg/100ml - more than twice the legal drink drive limit.
Its analysis of the accident identifies four contributing factors - a sense of urgency, alcohol consumption, an immature safety management system and weak safety culture.
'Alfred was the ship's cook and he had prepared lunch, which was ready to eat and probably getting cold,' it says. 'This could have caused him and the crew to rush and try to do several tasks simultaneously.'
The report says Mr Ismaili's blood alcohol level was 50pc higher than the 50mg/100ml limit in seafarers fitness for duty regulations. It adds this could have affected his judgement.
The 1,800-tonne MSN Explorer was registered in Liberia, owned by Explorer Ships and managed by Sky Mare Navigation - both registered in Athens. Mr Ismaili joined the crew of six on November 23, 2017. His able seaman's salary was $1,300 a month.
His contract of employment said his next of kin should receive $102,308 and each dependant child $20,462 in the event of his death.
But while his employers have paid for his body to be flown home and his funeral costs, his wife and three young children have not received compensation.
In April, shipping minister Nus Ghani said compensation should be paid 'without delay'.
Sky Mare said it was awaiting the conclusion of the MAIB investigation.
Mr Ismaili's family have threatened legal action. They say they have been told they must go to Athens and sign an agreement waiving any future claim for compensation.
Sky Mare was recommended to take 'appropriate action' to improve the level of safety culture on board the Explorer and its other vessels.
The MAIB said it should also take appropriate action to remove the need for crew to climb onto the hatch cover and coaming.
'Alfred was allowed to enter the danger zone because he and the other crewmen did not realise the risk and because the operation was not being adequately supervised,' it said.
Sky Mare has written to the masters of all its vessels highlighting the circumstances of the accident.
It has carried out a risk assessment and drawn up a written procedure for opening and closing the hatch cover.
It has also delivered training to the Explorer's crew and launched a safety campaign.
An internal investigation by the company concluded the accident was caused by an 'improper attempt to save time and avoid discomfort' along with 'improper performance'.