Investigation Report
Crush incident in lift shaft on container vessel Ever Excel with loss of 1 life
Crush incident in lift shaft on container vessel Ever Excel with loss of 1 life
- MAIB
- Investigation Report
- Unknown
- Line of FireMachinery and Equipment
- Crushing and pinch pointsLeadership and safety cultureRisk management
- Inspection and maintenance
- Competence and trainingOperating and work proceduresPermit to workRisk assessment
- Marine industry
- Vessel
Summary
Investigation synopsis of a fatal passenger-lift accident aboard Ever Excel in Kaohsiung, Taiwan. The chief engineer was trapped after controls were reset and the lift resumed automatic operation. Findings address circumvented safety barriers, unassessed inspection risks, ineffective communication and weaknesses in implementing permits, safe working systems and organisational safety culture.
Classifications: Crushing and pinch points; crush hazards; pinch points.
Classifications: Leadership and safety culture; safety culture; safety leadership.
Classifications: Risk management; risk evaluation.
Classifications: Inspection and maintenance; asset inspection; equipment maintenance.
Classifications: Competence and training; competency assurance; safety training.
Classifications: Operating and work procedures.
Classifications: Permit to work; PTW; work permit.
Classifications: Risk assessment; hazard assessment.
Classifications: Marine industry; shipping industry; maritime sector.
Classifications: Vessel; aboard ship; onboard vessel.
Themes: line of fire, machinery and equipment.