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Hazard

Employees were exposed to the hazard of being struck by falling paper rolls that were improperly secured in the cargo hold of a ship.

Process

An on-board crane is used to load rolls of paper into the hold of a ship.

Activity at time of incident:

Two employees helping to load paper rolls in the hold of a ship were taking a break in the hold when a stack of paper rolls about 26 feet high toppled and fell on them.

Incident Description

Setting:

Longshoremen are loading paper rolls into a ship's hold, using an on-board crane equipped with a pan attached to the spreader bar. The hold was approximately 34 feet deep. The paper rolls are about 40 inches high and 40 inches in diameter, and weigh about 1,400 pounds each. The crane operator picks up approximately 16 rolls of paper at a time on a pan with a spreader bar from the dock and then lowers the load into the center of the ship's hold. A forklift operator working in the hold then stacks the rolls in rows along the front and sides of the hold. Each stack consists of seven or eight rolls and is about 26 feet high. Two other employees, "helpers," also work in the hold, placing cardboard on the deck where the paper rolls are to be stacked.

The employees first load the front of the hold, and then begin to stack the rolls along the starboard side of the vessel, forward to aft. After two rows of paper rolls have been stacked on the starboard side, the ship has a noticeable list to the starboard side. At the direction of a crew member, the employees then place two rows of paper rolls on the port side to alleviate the list.

Incident:

At the time of the incident, the forklift operator was stacking rolls on the starboard side at the aft end, while the helpers took a break near a pile of cardboard in the center aft end. The loaded forklift caused the ship to list and a stack of paper rolls on the port side fell toward the starboard side. The rolls struck both helpers, killing one employee and injuring the other.

Relevant Factors:

Planning for cargo placement to preserve the stability of the vessel should be accomplished prior to loading. Their efforts to steady the ship was not effective.

Powered industrial trucks (PITs) were not maintained in safe working order. Deficiencies included inoperable brakes, inoperable horn, and broken front windshields.

Applicable Standards and Control Measures
  • 29 CFR 1918.83(a): Stowed cargo; tiering and breaking down. "When necessary to protect personnel working in a hold, the employer shall secure or block stowed cargo that is likely to shift or roll."

This hazard could have been prevented by ensuring that the paper rolls were adequately secured to prevent shifting. Additionally, this accident may have been prevented if the employer had undertaken further efforts to reduce the ship's list by redistributing the load in the hold.

  • 29 CFR 1918.98(b)(1): Qualifications of machinery operators and supervisory training - Supervisory accident prevention proficiency. "Immediate supervisors of cargo-handling operations of more than five (5) persons shall satisfactorily complete a course in accident prevention."

This accident may have been prevented if a supervisor properly trained in hazard recognition, accident prevention and vessel stability had been present to ensure that the cargo was properly distributed and secured and that employees worked in a safe location away from the potential path of falling cargo.

Other Standards and/or Control Measures
  • 29 CFR 1918.24(a): Fixed and portable ladders. "There shall be at least one safe and accessible ladder for each gang working in a single hatch. An effective means of gaining a handhold shall be provided at or near the head of each vertical fixed ladder. No more than two ladders are required in any hatch regardless of the number of gangs present."

A ladder should be available for the employees to use while working in the hold.

  • 29 CFR 1918.65(f)(1): Mechanically powered vehicles used aboard vessels - Maintenance. "Mechanically powered vehicles shall be maintained in safe working order. Safety devices shall not be removed or made inoperative except where permitted in this section."
  • 29 CFR 1918.65(f)(2): Mechanically powered vehicles used aboard vessels - Maintenance. "Braking systems or other mechanisms used for braking shall be operable and in safe condition."

PITs in use must be maintained in safe working order, e.g., with operable brakes and horns.

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