SAFETY ALERT

Fugro Company:
Location/Site:
Date and Time:
Consequences:

Incident Potential
Incident
Description

Maridive Survey
Onboard MV Flying Enterprise, No 5 Berth Abu Qir Port, Alexandria, Egypt
10th October 2005. 22.35hrs (GMT+2)
(e.g. damage to environment, reputation, equipment schedule and cost)

Loss of life,

Cost impact including vessel scheduling,

Reputation

High

Medium

Low

At 22:35hrs (GMT+2) on Monday, 10th October 2005, the analogue geophysical survey
vessel, returned to the port of Abu Qir in Alexandria, Egypt to change-out an underpowered
deck mounted generator. At the time of the incident the vessel was moored starboard side to
alongside Berth No. 5.
At the time of the incident, the vessel was engaged in lifting operations which involved using
a mobile crane (positioned on the quay-side) to remove the deck mounted generator and
load a replacement.
To carry out this operation an experienced mobilisation team from Maridive Survey, who
were used to working together, were sent to the vessel. (It should be noted that all team
members directly involved in the lift had received formal training in rigging and lifting)
This was considered a routine operation as the vessel had been mobilised on many
previous occasions by the same team.
The underpowered generator was located on the port side of the aft deck, however it was
normal practice to go along side starboard side to as the vessel had been equipped with a
bulwark mounted USBL pole on the port side of the vessel. This equipment is easily
damaged and a decision was made to keep this equipment clear of lifting operations. This
decision resulted in the crane operator having to extend the crane boom to remove the
generator and place the new generator in the same position. The horizontal distance
between the centre of the crane pedestal and the intended location was 14m.
Following the successful transfer of the underpowered unit from the vessel to the quayside
the replacement generator was connected to the crane and the second lift commenced.
Two tag lines were fitted to the load prior to the start of the lift. The two housings were
slightly different in dimensions, however the weights were considerably different:
-

Underpowered generator weight: 3.6 Tonnes

Replacement generator weight (via calibrated load cell): 4.9 Tonnes

At the required boom length of 18m the Safe Working Load (SWL) of the crane being used
was calculated as being between 2.35T and 2.85T (Tonnes). The weight of the replacement
generator has been confirmed, (following the accident using a load cell), as being
4.9T(Tonnes). During the first and second lift the SWL of the crane was exceeded.
Whilst attempting to position the replacement generator in the area which had been
occupied by the faulty unit, the crane was required to jib-out and as a result of the
combined boom extension and excessive load the crane outriggers lifted on the quayside.

The severity of this tilting moment was such that the crane was compromised in terms of
stability. It has been established through the investigation that there are two possible
causes for this, either
-

The crane rocked on its outriggers nearest the vessel causing the boom and
the load to drop to deck. Or:
The automatic braking system failed to stop the load descending possible due
to inadequate maintenance

(Note: Only a visual inspection has been possible due to restricted access being granted by
the crane owners. Abu Qir is a Naval port and subsequently the civil authorities have no
jurisdiction. As the vessel was part of a commercial operation, the Military authorities do not
wish to become involved).
The load unexpectedly moved downwards and across the aft deck simultaneously at
considerable speed towards the portside gunwales. Due to the speed and weight of the load
the two tagline operators were unable to control this sudden movement.
At the time of the premature descent of the load, the operation supervisor (Deceased) who
had been in ready to position the load, was unable to avoid being struck. A witness has
reported that the victim was unable to clear the area following a collision with the guard rail.
Following the initial impact there are reports that the generator was raised from the deck
(either by the crane operator hoisting the load or due to the rocking motion of the crane)
before again striking the victim and surrounding vessel infrastructure. The casualty was
removed from the area and all operations immediately suspended. The generator was left in
situ on the deck and the scene secured prior to the arrival of the investigation team.
The casualty was immediately transferred by car to the Abu Qir hospital in Alexandria but
was pronounced dead on arrival from his injuries.
Although the lift was performed at night the vessel lighting on the aft deck (and the lighting
within the port) is very effective and no effects of dazzling or glare were reported by any
personnel involved. The view from the operators cab of the crane was verified after dark the
following day and deemed adequate.
At the time of the incident the vessel was securely moored alongside the quay and sea
conditions were calm with no significant wind effect. The tidal range in the area is less than
0.6m.
See photographs and sketch attached

Injuries / Medical
treatment required:
Findings:

Fatal crushing injuries to right leg and torso.

The overall root cause of the incident was established as a failure to adhere to specific areas
of the HSE Management System, in particular:
- Vessel mobilisation procedure
- Management of Change procedure
- Risk Assessment
- Supply Chain Management
Additional causes include:
The mobile crane was working with a load over and above its safe
working limits.
The Fugro Golden Rules of Safety - Lifting and Mechanical
Handling were not followed.
No Lift Plan
No documented Tool Box talk
No identification / verification of the load weight
Lack of basic safety awareness

Lessons Learnt:

Recommendations
and corrective
action:

1. The company HSEMS procedures should be followed at all times.(In this incident
the failure to implement the Management of Change Procedure)
2. The importance of efficient and effective supply chain management for safety critical
suppliers
3. Follow company procedures and the Fugro Golden Rules of Safety
Short Term
1. Implement a specific company lifting procedure
2. Review and up-date the lifting Risk Assessment
3. Implement a Lift Plan template
4. Implement a lifting check-list for all lifting operations
5. Ensure that the Management of Change process is used
6. Follow company Procedures, guidelines and the Fugro Golden Rules of Safety
7. Ensure that tool box talks are carried out and documented
8. Provide a dedicated mobilisation supervisor to manage all mobilisations
9. Clarify the roles and responsibilities at mobilisations (Mobilisation team/Party Chief)
Medium Term
10. Identify through audit specialist lifting companies and establish an approved
vendors list for safety critical suppliers.
11. Enhance the Supply Chain Management process to include all safety critical
suppliers
12. Produce and roll-out a Lifting and mechanical handling safety campaign on vessels
and in the office
13. Produce and circulate a Fugro Safety Alert
14. Produce a power point presentation for circulation to other Fugro Opcos
15. Provide lifting and rigging refresher training for all personnel involved in this activity
Long Term
16. Consider appointing a specialist lifting advisor to oversee all lifting activities, audits
and provide an inspection and test service for all lifting appliances/equipment
17. Consider appointing an additional HSE specialist to provide assistance to the
Q/HSE Manager

Alert Issued by:

Safety Alert Reference No.

LIFTING FATALITY 10th October 2005 - PHOTOGRAPHS

Photo 1: Accident Scene Pan 1 :

Position
of Casualty

Photo 3: Accident Scene Pan 3 :

Photo 2: Accident Scene Pan 2 :

Position
of
Banksman

Photo 4: Crane Drivers View :

Schematic of scenario