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TAIC Report – Fatality On Factory Trawler


All machinery should work safely, even if staff do not comply with rules for safe operation.

Safety for machinery operators depends on everyone knowing how a piece of machinery works; understanding how people work with it; and identifying and thinking about the hazards of using it.

So says the Transport Accident Investigation Commission (TAIC) on the release of its Final Report on a fatal accident on the fish processing line of the NZ-registered deep-sea factory trawler San Granit

The accident occurred in the very early hours of 14 November 2018 while it was trawling about 102 km east of Banks Peninsula.

Chief investigator of Accidents, Aaron Holman, says a factory deckhand found a colleague trapped in still-working machinery - a large tub where boxes of fish accumulated for storage.

“There were no signs of life when they managed to extract the freezerman from the machinery,” said Mr Holman.

“We don’t know why the worker entered the safety-guarded area around the accumulator – it may have been to clear a jammed box of fish – but we do know there were issues with the crew’s understanding of the risks, and the quality of their safety training.

“The factory deck crew didn’t fully understand the risks of operating the accumulator, and the vessel’s owner relied too much on all of the crew always operating the machinery correctly. That, and the training of factory staff likely resulted in confusion about which emergency stop buttons stopped which pieces of machinery.”

“The vessel’s owner Sanford Limited has already done well in re-engineering the machinery to make it harder to operate it incorrectly and risk getting trapped.

“What remains a concern is the chance of crew accessing running machinery after pressing the wrong emergency stop, so the Commission has recommended that Sanford train the crew on configuration of emergency stops.

“If you can’t totally get rid of a hazard, then do a task analysis to figure out the safest practicable ways of working, and to inform the right training for future safety.”

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