Cause & Consequence
Support vessel eg Supply, Standby
Lifting, crane, rigging, deck operations
The rack was not of a type that the Installation deck crew were familiar with, and this may have contributed to the incident.
The rack had been made ready for shipment the previous day when the internal retaining bar had been secured with tie wraps and an additional fabric ratchet strop had been used to secure the cylinders in the rack. These prevented any bottles falling to the deck of the vessel, which could have been potentially serious for the vessel deck crew, although the strap was probably a bit too low.
The rack had then been given a visual check and lifted with no incident from a landing area where bottles had been loaded, to the roof to await backload.
On the day of the back-load, the material controller had carried out the Banks-man’s checks and visually checked the door was closed, attached a Banks-man’s label and sent the load down to the boat. With hindsight, a physically check of the door security was not done as it was believed that the door was secure.
1. Banks-man’s checks should include not only visual, but a physical check of security of any opening doors or panels, not only on gas bottle racks, but any back-loaded cargo.
CHECK THE DOORS!
2. The internal retaining bar and application of an additional fabric ratchet strop clearly prevented the bottles falling when the door opening and it is recommended that bottles racks are not moved without these additional precautions being used.
3. Ratchet straps should be fitted in a position which takes into account the likely centre of gravity of the bottles.
4. Suppliers of bottle racks of similar design should be contacted to make them aware of the need to provide clear indication and instruction as to how doors should be locked.