Bulk carrier, ETG Aquarius, Stevedore fatality during coal loading operations, Lyttelton Port, 25 April 2022
Occurrence Date
Report Publication Date
What happened
On 27 April 2022, the Minister of Transport directed the Transport Accident Investigation Commission to open two inquiries under section 13(2) of the Transport Accident Investigation Commission Act 1990. The inquiries were in response to two fatal stevedoring accidents that occurred at two New Zealand ports.

Separate investigations were conducted into each accident. There were common systemic safety issues identified in the two accidents and the Commission has therefore published the two inquiries in a single report. These systemic issues are relevant to the wider stevedoring industry.

The first accident occurred on 19 April 2022 at the Port of Auckland. A stevedore, working onboard the container vessel Capitaine Tasman, moved underneath a suspended 40-foot container and suffered crush injuries as a result of the container being lowered onto them. The stevedore was employed by Wallace Investments Limited (WIL), an independent stevedoring company operating at the Port of Auckland.

The second accident occurred at Lyttelton Port on 25 April 2022. A stevedore, involved in the process of loading coal onto the bulk carrier ETG Aquarius, was discovered, deceased, on the deck of the vessel, buried under a quantity of coal. The stevedore was employed by the Lyttelton Port Company Limited (LPC).

Why it happened
The Commission found that both WIL and LPC were in the process of improving their respective safety systems. However, at the time of the accidents there were deficiencies common to both organisations. The risks associated with work activity were primarily managed with administrative risk controls, yet robust safety assurance processes to ensure that these controls remained effective were lacking. As a result, neither LPC nor WIL adequately understood how the day-to-day behaviour of their employees was negating the effectiveness of already vulnerable control measures.

While both organisations were attempting to improve their safety management systems, a lack of cohesiveness within the stevedoring community meant there was little ability to benchmark comprehensively with others in the industry. With no best practice guidelines, no minimum training requirements and few safety-related information-sharing platforms, leadership from within the sector was found lacking.

Historically, stevedoring has a poor safety record (International Labour Office, 2018), yet it is not regulated with the degree of rigour afforded to other high-risk industries. From a regulatory perspective, neither organisation received a satisfactory level of proactive oversight of their stevedoring operations. Most regulatory interactions were limited to LPC and WIL reporting notifiable events under the Health and Safety at Work Act 2015, and to any subsequent follow-up by Maritime New Zealand (MNZ) and WorkSafe New Zealand (WorkSafe) as a result of those notifications. Reactionary reporting and associated regulatory sanctions provide little insight into the health of an organisation’s safety system or assurance of future safety performance. Nor do they encourage information sharing within the industry to encourage safety growth across the sector.

The Commission has made five safety recommendations as a result of these two inquiries.
What we can learn

Those who work in high-risk industries are not necessarily exposed to adverse events on a regular basis. This can lead to a desensitisation to risk, which itself becomes a hazard.

When risk is not fully understood or appreciated, a variety of factors can lead to employees taking shortcuts or drifting away from rules. Passive safety messages and reminding people to follow procedures are not effective means by which to change risk perceptions or modify behaviours.

The way in which tasks are designed and procedures are written is often incongruent with how day-to-day work activity is conducted. A critical component of any safety system is the ability to identify, understand and resolve the reasons for the disparity.

Where administrative risk controls are necessary to manage hazards associated with high-risk activity, appropriate supervision and a culture of strong safety leadership is required to ensure their effectiveness.

Industry collaboration and benchmarking is one of the most effective ways to improve safety standards and support continuous improvement.

Reactive interventions are not a substitute for proactive regulatory oversight of high-risk industries, particularly those with a poor safety record.

Who may benefit
Regulatory bodies, port organisations, stevedoring organisations, stevedores, vessel operators, anyone designing safety standards, and anyone working in a high-risk industry may benefit from this report and the Commission’s recommendations.

For Information on MO-2022-203: Fatal accident at Port of Auckland, 19 April 2022, please refer to Appendix A of the attached Investigation Report
Lyttelton Port (-43.608916,172.731332) [may be approximate]