A "weak" safety culture has been criticised after a seafarer was crushed to death on a Greek cargoship in the UK in February.
The Maritime Accident Investigation Branch (MAIB) said Alfred Ismaili, 36, was killed on the 2,500-dwt SMN Explorer (built 1986) at King's Lynn when a stowage space hatch cover fell on him.
The weight of the crewman climbing up the inside of the open hatch cover after its locking pins had been removed caused it to topple forward and slam shut, it added.
"The accident was the result of procedural inadequacies and a lapse of supervision," MAIB said.
"The investigation identified that the vessel’s safety management system was immature and the safety culture on board the vessel was weak."
Risk assessments had not been conducted for routine tasks and a safe system of work had not been developed for opening and closing the hatch cover, MAIB said.
Ismaili climbed up the inside of the hatch cover, using the framing as hand and foot holds, and reached up to grab the lifting slings, the report said.
As he did so the hatch cover fell forward, trapping him between the hatch cover and the hatch coaming.
Colleagues tried desperately to manually lift the hatch cover to release Alfred, but it was too heavy and Ismaili was later declared dead at the scene.
A postmortem examination identified that his death was caused by a severe blunt force injury to the chest.
Seafarer had been drinking
Toxicology tests identified that Ismaili had a blood alcohol level of 75mg/100ml, 50% higher than the mandatory 50mg/100ml limit set for seafarers in the Manila amendments to STCW.
Given the time of the accident, it is likely that he had drunk alcohol on board that morning, MAIB found.
He could have experienced increased self-confidence and decreased inhibitions, as well as reduced attention span, judgment and control, MAIB said.
"All of this could have affected Alfred’s judgment and his decision to climb up the hatch cover framing after the locking pins had been removed."
MAIB added: "Priority was given to getting the job done, rather than developing and promoting safe working practices."
The vessel was owned by Explorer Ships and managed by Sky Mare Navigation (SMN).
MAIB found the anchor guillotine locking pins were a loose fit in the hatch cover and backstop locating holes, and had no means of being locked in place, and the rope lifting slings appeared to be in poor condition.
SMN asked an external consultant to investigate. It concluded the cause was an "improper attempt to save time and avoid discomfort" in conjunction with "improper performance."
Contributing factors were the lack of warning signs, inadequate supervision and inadequate communication.
Too much haste
MAIB said: "A sense of urgency might have had an impact on the way this operation was executed and on Alfred’s actions in particular.
"Alfred was the ship’s cook and he had prepared lunch, which was ready to eat and probably getting cold.
"This could have caused him and the crew to rush and try to do several tasks simultaneously."
SMN has since issued a fleet-wide letter to the masters of its managed vessels highlighting the circumstances of the accident.
It has also conducted a task-specific risk assessment and produced a written procedure/checklist for the opening and closing of the hatch cover.
In addition, it has placed warning signs on the stowage space hatch cover promoting the use of the locking pins, and provided a set of dedicated locking pins for the cover.
