Crush incident on board ro-ro cargo vessel Clipper Pennant with loss of 1 life

Accident Investigation Report 16/2024

Read our marine accident investigation report, which includes what happened, subsequent actions taken and recommendations:

MAIB investigation report 16-2024: Clipper Pennant

Summary

At 1353 on 20 July 2021, the bosun of the roll-on/roll-off cargo vessel Clipper Pennant was fatally crushed while working on the vessel’s vehicle deck. Clipper Pennant was alongside in Liverpool, England, loading a cargo of semi-trailers. A tractor unit driver pushed a semi-trailer into a corner space, marshalled by the vessel’s bosun in their assigned role as banksman. The accident was not seen by the driver, who disconnected the tractor unit and drove away. Shortly afterwards, two crew members found the bosun trapped between the rear of the semi-trailer and the vessel’s structure.

Safety issues

The banksman was fatally crushed while standing in an unsafe area in the path of an approaching semi-trailer.
The driver of the tractor unit pushing the semi-trailer did not monitor the banksman’s position because they were relying on other visual cues to manoeuvre the semi-trailer and had assumed the banksman would keep out of the path of the advancing semi-trailer.
The bosun did not act as expected and instead stood on an unprotected walkway that had been painted inside the vehicle lane.
The loading operation was unsupervised because the bosun had become involved in marshalling, and the crew did not continuously monitor one another’s positions on the vehicle deck.
Neither the port nor the vessel’s manager had developed a safe system for loading high-risk stowage spaces.
The accident reflected routine and widespread divergence from safe working practices on vehicle decks in the ferry industry because the local procedures and guidelines did not reflect how people worked, and there was no common standard.
The vessel’s managers had an insufficiently robust approach to organisational learning and continuous improvement.
There were shortcomings in the standards of tractor unit driving at the port, resulting in a tacit acceptance of some unsafe practices that had become ‘normal’.
There was no national occupational driving standard for tractor unit drivers.

Statement from the Chief Inspector of Marine Accidents

Recommendations

The MAIB made nine recommendations, including:

Three safety recommendations to industry bodies to develop a jointly agreed and consolidated industry Code of Practice for vehicle deck safety on roll-on/roll-off vessels (2024/148 and 2024/149) and to develop a national occupational driving standard for tractor unit drivers (2024/150);
A recommendation to the Maritime and Coastguard Agency and Health and Safety Executive (2024/151 and 2024/152) to, subsequently, amend their relevant codes and guidelines to reflect industry best practice and to consider the consolidated industry Code of Practice for vehicle deck safety on roll-on/roll-off vessels developed in accordance with recommendation 2024/148;
Recommendations to CLdN RoRo Limited (formerly Seatruck Ferries Limited) to improve its organisational safety culture and ensure effective supervision of vehicle deck cargo loading operations (2024/153 and 2024/154); and
Recommendations to P&O Ferries Limited (2024/155 and 2024/156) to review how it achieves assurance that its ports adhere to its vehicle deck safety procedures and that a jointly agreed safe system of work is in place on chartered vessels

A safety bulletin, advising operators of vessels with roll-on/roll-off vehicle decks to review cargo handling procedures and identify the hazards associated with stowage areas that have limited means of escape and take appropriate action, was published on 4 November 2021.

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