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TRANSPORT ACCIDENT INVESTIGATION COMMISSION ACT 1990 The principal purpose of the Transport Accident Investigation Commission shall be to determine the circumstances and causes of accidents and incidents, with a view to avoiding similar occurrences in the future, rather than to ascribe blame to any person. ENGINEER'S HASTE PROVED FATAL A n electro-hydraulic watertight door on the 63m passenger ship Oceanic Discoverer which closed at twice the allowable speed trapped the chief engineer. The Transport Accident Investigation Commission said he had possibly tried to pass through the door before it was fully open. For some reason the door began closing and eight minutes passed before the crew could free him. He was resuscitated but never regained consciousness and died later in hospital. The accident occurred on February 19, 2009 while the crew was conducting a fire and emergency drill while the Oceanic Discoverer was berthed in Napier. Part of the drill included closing and testing the two electro-hydraulic watertight doors on the ship. At 1002 the ship's master sounded the emergency signal and the crew assembled at their designated muster stations. Following the muster, one crew team started to run out fire hoses as part of a fire drill. At 1003 the chief engineer started the general service pump for the hoses. Three minutes later the master announced over the public address system that he was about to close the watertight doors and that personnel should stand clear. He operated the master switch on the bridge and the doors closed. The garbage room hose began hammering and the chief engineer, the second engineer and the first mate entered the room to investigate. When the second engineer walked through the watertight door into the engineroom, their conversation was interrupted by the watertight door alarm. The first mate returned to C deck to close up the fire drill, leaving the chief engineer at the bottom of the stairway next to the entrance to the engineroom. The first mate told the master via radio they had completed the fire segment of the drill. The door was opened for about nine seconds when the second engineer went through it, and the chief engineer followed less than 20 seconds later. A short time later, the second engineer turned around and saw he was trapped. He tried to open the door by operating the handle but it was hitting the chief engineer's right shoulder. Crew on both sides of the door tried frantically to release the door, but it took seven minutes before the lower hydraulic ram was removed so the door could be pushed aside to free the chief engineer. He was taken by ambulance to Napier Hospital, where he died on March 9. The doors were normally set in "local control" mode so they would not automatically close after someone had walked through. At the time of the accident they were in "remote close" mode, meaning they would automatically close when the user released the opening handle. The TAIC found that the crew routinely used the door to access the engineroom. They usually opened the door about 42cm, wide enough to pass through, reached through the gap, gripped the open-close lever on the other side of the door, held it down before passing through and used the lever to close the door behind them. The crew was not taught to open the door fully before passing through. 72 Professional Skipper March/April 2012 Watertight door viewed from the engine room side Watertight door viewed from the garbage room side "The operator contended that the chief engineer would have also used this method, but no-one knows whether he did so at the time of the accident," the Commission said. Once the door had closed on the chief engineer's body he could not have used the handle, as his shoulder obstructed its arc of movement. The door was reassembled after the accident. The Commission was not able to determine how long the doors had operated at double the recommended speed. It also found the audible alarm on the engineroom side did not operate. The spring on the door operating lever had been replaced by a non-standard bungee cord and the mechanical lock for keeping the door in the closed position was not latching correctly. Regular maintenance required by the manufacturer required the door cover to be removed, but when the Commission's staff watched the crew rectifying numerous faults it was obvious the cover had not been removed for a long time. "In summary, the condition of the watertight doors on board the Oceanic Discoverer did not comply with the various rules and regulations that they were required to." The Commission noted five safety lessons following its inquiry: • Always fully open a watertight door before passing through the doorway when the door is in the remote-close mode • The faster the door closes, the greater the risk. Under no circumstances should watertight doors be set to close faster than the maximum allowable speed • Ship operators should adopt specific procedures for operating watertight doors in both local control and remote close modes. The procedures should be compatible with the doors' purpose and design and the frequency with which they are used • Legislation governing the design and use of watertight doors should be flexible enough to achieve appropriate procedures for the use of any watertight door in any mode, and • Poorly maintained doors are dangerous. Shipboard planned maintenance systems should be designed and followed to ensure watertight doors are maintained in accordance with the manufacturers' instructions and with good standard marine engineering practice. Following the Commission's inquiry, the manufacturer of the watertight door, IMS AS, said it had designed the control handle so persons passing through the doorway could hold both handles in the open position without being able to set the power closing mechanism in operation accidentally.