01What the type of casualty 事故类型

Very serious marine casualty: Crew member falling overboard onto wharf below 

非常严重的水上交通事故：船员从船上坠落至码头

02What happened事故经过

On a 123 m long, 5,300 GT chemical/oil tanker, an able seaman was fatally injured while throwing rubbish from the ship's second deck into a rubbish container on the wharf 8 m below. The able seaman was in the area reserved for life-raft stowage and launching, protected only by two chains strung across the opening in the handrails. He lost his balance, and as the chains were insufficient to restrain him, he fell over the side onto the wharf below.

在一艘123米长，5300总吨的化学品/油轮上，一名水手在二层甲板将垃圾扔到码头上的垃圾箱里时受了重伤，从二层甲板到码头的垂直高度为8米。这名水手位于救生筏储存和释放区域，该区域的栏杆仅靠横跨扶手开口的两条铁链保护。由于铁链不足以保护他，导致他失去平衡，从船上摔到了下面的码头上。

03Why did it happen事故原因

● The risks associated with the task had not been sufficiently well assessed and preventative measures to guard against a fall from height were not implemented.

（1）与该任务相关的风险没有得到充分的评估，也没有采取预防措施以防止人员从高处坠落。

● The chains in place protecting a gap in the handrails were insufficient to provide protection if leant or fallen against. The gap was more than two metres longer than it should have been. This had escaped notice since the ship was built.

（2）栏杆之间设置的铁链不足以在人员倾斜或跌落时起到保护作用。这个间隙比它应有的长度长了两米多。自该船建造以来，这一缺陷一直没有被发现。

04What can we learn事故启示

● All shipboard activities should be considered from a risk management perspective.

（1）所有船上活动都应从风险管理的角度考虑。

● All work near the ship's side needs to be assessed in regard to the dangers of falling from height. This accident highlights how flexible barriers such as chains may be insufficient to prevent or arrest a fall.

（2）所有靠近船舷的工作都需要评估从高处坠落的风险，这起事故突显了诸如铁链等活动的栅栏可能不足以防止或阻止人员跌落。

● The risks involved in seemingly routine tasks can be perceived to be lower when the tasks are undertaken with a degree of autonomy, freedom of choice and are thought to be within one's own control. A positive illusion of control is established where the risk is underestimated and a person is therefore more willing to accept the risk and exposure to hazards.

（3）如果一个人在执行任务时具有一定的自主权，且他认为这个任务在自己的掌握范围以内时，那么看似常规的任务所涉及的风险就会被低估。在风险被低估的情况下，就会让人产生一种积极的控制错觉，因此一个人更容易接受风险并将自己暴露在危险中。

05Who may benefit此文对谁有用

All seafarers, shipowners and operators, surveyors.

所有海员，船东和经营者，验船师。

（TIPS：如有异议，请以英文版本为准，欢迎私信哦。）

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