离泊操作中，拖缆伤人事故

01、事故类型

What the type of casualty

非常严重的海事事故：离泊操作中造成一名船员死亡

Very Serious Marine Casualty: Fatal accident of a crew member during an unmooring Operation

02、事故经过

What happened?   

一名在内河渡船上工作的甲板部人员，他在正解开船舶整晚系固在浮筒上的缆绳，这时被一根缠在螺旋桨上的缆绳拖着撞到舷墙，并甩出了船外。致使其遭受了严重面部创伤，且在落入水中时几近昏厥，随后就溺亡，尽管在救生衣的帮助下浮出了水面，并且在其落水几分钟内，其同事将其救到了工作艇上。

A deckhand was working on board a river ferry to release lines that were securing the vessel overnight to a mooring buoy. He was dragged violently against the vessel's bulwark and was carried overboard by a mooring rope which had become entangled in the vessel's propeller and was being wound in. He suffered severe facial injuries and was almost certainly unconscious when he entered the water. He subsequently drowned although his lifejacket brought him to the surface and he was recovered by his colleagues to a workboat within minutes.

03、事故原因

Why did it happen?

缆绳缠在船舶和浮筒之间的原因是：船舶向前移动地比平常更快更远，但是缆绳收回地比平常更慢，或者是缆绳缠在了悬挂在浮筒外侧的短索上。

The mooring rope could have become trapped between the vessel and the buoy because: the vessel came ahead further and faster than usual; the rope was being recovered more slowly than usual; or the rope became entangled with the wire pennants hanging from the buoy.

由于船舶的构造，导致船长到系泊甲板和浮筒的视野被阻挡，也没人能够及时向船长汇报当时的情况——应当监督甲板作业和与船长沟通的船副迟到，且暂时接替大副的高级船员在转达了船长解缆的指令后就去了厕所。船长在等待这名高级船员缆绳被收回的信号时而不知道他已经去了厕所。

The master's view and line of sight towards the mooring deck and buoy were impaired by the vessel's structure. At that time, there was no one available to guide the master: the mate who should have supervised the deck operation and communicated with the master was late for work; and a senior deckhand who was temporarily filling the post went to the toilet after he relayed the master's signal to cast off the mooring rope. The master was waiting a signal from the senior deckhand that the rope had been retrieved not knowing that he had gone to the toilet.

缆绳从舷墙上方而不是导缆孔处被收回，而且很可能落水船员站在了缆绳受力的内侧。渡船船员各自形成了自己特有的关于离泊的一套体系，而且甲板部船员有自己特有的回收缆绳技巧。目前没有关于缆绳是应当从舷墙上方还是应从导缆孔回收的导则。

The mooring rope was being recovered over the bulwark, not through the fairlead, and it is most likely that the deckhand was standing in a bight of the rope. The ferry crews had each developed their own systems for unmooring, and the deckhands had their own techniques for rope retrieval. There were no guidelines on whether ropes should be recovered by leading them over the bulwark or through fairleads.

船上使用的一系列工作实践明显显示出船员所被教授的所谓的最佳操作技巧并不一定是最好的。标准被削弱的原因可能是工作任务熟练程度和重复的工作性质。甲板船员似乎更遵循习惯或资深同事所沿袭的工作方式。

A number of the working practices used on board clearly demonstrated an erosion of the best practices the crew members had been taught. The probable cause of this erosion of standards is likely to have been task familiarity and the repetitive nature of the work. The deckhand is likely to have complied with the custom and practice followed by his senior

colleagues on board.

落水甲板船员穿着救生衣，但未系紧。救生衣没能支撑他的面部完全脱离水面。由于没有合适的救助工具以及工作艇的干舷及舷墙高度差太大，导致从水中救起这名船员极度困难。

The lifejacket worn by the deckhand, but unsecured, was not fully supporting his face from the water. Recovery of the deckhand from the water was extremely difficult due to unavailability of suitable equipment for the recovery, and the height of the workboat's freeboard and bulwark.

离泊操作是一项日常工作，但是并未纳入公司安全管理体系中。结果，离泊操作中旋转的螺旋桨造成明显的实际危险没有被识别。公司的管理者虽然做过风险评估和操作步骤的审查，他们过去也曾是渡船甲板船员和船长，这也可能妨碍了他们对体系工作做出客观评价的能力。

The unmooring operation was a routine task but it had not been captured by the company's safety management system. Consequently, the very real hazard posed by the rotating propeller blades during the task had not been formally recognized. A review of the risk assessments and operational procedures had been conducted by managers who had been deck crew and masters on the ferries in the past, which might have hampered their ability to carry out an impartial evaluation of the work systems.

04、事故启示

What can we learn? 

1.具体的离泊步骤应当包含在安全管理体系当中。离泊操作中可能存在的风险应当被识别。

Detailed procedures for unmooring should be included in the safety management system, and the possible hazards during unmooring operation should be identified.

2.一名谨慎的监督者在监控环境时，应能给船长和船员合适的指导建议，能够防止缆绳被卡住，提醒并警告甲板船员不要站在绳圈中。

A vigilant supervisor, monitoring the situation and giving appropriate guidance to the master and deckhands, could have prevented the rope from becoming jammed and have warned the deckhand about standing in a bight.

3.没有足够的监督，离泊程序必定不安全。在公司风险评估程序里也应对此进行认定。

Without adequate supervision, the unmooring process was inherently unsafe and should have been recognized as such through the company's risk assessment process.

4.沟通本可以通过使用手持无线电来改善。船长如果给替代大副一个无线电话，就可以消除他们角色的不明确性。

Communications would have been improved by the use of hand-held radios,and the master handing a radio to a nominated acting mate would have removed ambiguity as to their role.

5.邀请独立的海事专家帮助审查船舶风险评估和操作程序，以便识别出当前船上习惯做法和工作方式的风险是有益的。

There are benefits to having independent marine experts assist with the review of the vessel's risk assessments and operational procedures to identify the risks of the prevailing shipboard customs and work practices.

6.所有河道内的工作艇都有可能被请求协作水上救援，所以应携带适合救援任务的工具。

All workboats on the river could be called upon to assist in water rescue, and therefore should carry suitable equipment for this task.

7.在关键船员到达指定岗位前匆忙离港是危险的。

The dangers of rushing to get underway before critical crewmembers are stationed at their designated post.

8.在看不到系泊作业船员时，船舶操纵者操纵船舶是危险的。The dangers of a vessel operator mooring a vessel without a direct line of sight to the mooring crew.

9.在没有建立与系泊船员有效的积极的沟通方式时，船舶操纵者操纵船舶是危险的。

The dangers of vessel operators mooring a vessel without establishing an effective and positive means of communicating with the mooring crew.

05、本文对谁有用？

Who may benefit? 

船舶所有人，船舶运营人，船员。

Shipowners, operators and crews.

知识补给站

船舶缆绳使用时的注意事项：

1.使用前，大副（船头）或者二副（船尾）认真检查缆绳的完好程度，出现缆绳的某个部位过度磨损或者大量的断头，及时更换缆绳，来不及更换的使用过程中尽量不要让这根缆绳承受太大的拉力，防止突然断裂。

2.带缆人员必须熟悉自己将要操作的缆绳的种类、特点，有针对性的操作，比如人造纤维缆绳在断裂前不会发出声音，没有任何可以很直观的看到的征兆，如果你造作的是这种缆绳那么在缆绳受力时，一定好掌握好缆绳大承受的拉力，防止突然断裂。

3.带缆的水手及船副必须佩戴安全帽、手套、安全鞋、工作服。绝对不允许“穿拖鞋，大短裤，赤手去带缆”很多小船的个别船副及水手不注意对自身的保护，一旦出现意外，缆绳断裂，巨大的缆绳断裂力量作用在断裂的缆绳头部，速度很快，威胁到自身的生命安全。

4.水头（船头）及二副（船尾）在操作搅缆车的时候注意手法。实践证明：缆绳断裂主要是因为连续的冲击负荷。鉴于这个原因，要求操作搅缆车的人员，必须操作熟练，尽量减少给缆绳的冲击负荷，减少因为这个原因造成缆绳断裂。

5.带缆人员必须熟悉带揽操作过程中涉及到的手势及手语，比如：放、收、停、刹住等。

6.站位要求：带缆人员及舷外缆绳作业区的位置；所有人员都不可站在绳环内；所有人员不可站在缆绳的“反弹区”内。