Improvised work results in crew injury

A SERIOUS injury on board a bulk carrier drifting in Cook Strait highlights the need for effective safety management systems, proper planning of lifting operations, and vigilance around high-risk areas during deck work, New Zealand’s Transport Accident Investigation Commission says.

The Commission’s report shows the importance of effective risk assessment, visible supervision and disciplined implementation of safety management systems in shipboard operations.

On 20 March 2025, the 61,190 DWT bulk carrier Thor Nitnirund, owned by Thailand’s Thoresen & Co, was drifting in Cook Strait while awaiting a berth in Wellington.

Heavy weather in preceding days had washed two cargo lashing chains over the ship’s side. To recover them, the crew improvised a lifting system powered by a mooring winch.

They hauled one chain on board. As they were hauling the second chain, a web sling anchoring the lifting system failed. Components of the system struck an able seaman, who suffered serious head injuries and was later evacuated by helicopter.

Why it happened

Unsafe lifting equipment remained in service

The sling failed at less than half of its expected minimum breaking load because its webbing was damaged and in poor condition, TAIC found. The sling was not recorded in the ship’s lifting gear register. It was likely inherited from a previous operator without being maintained or inspected under the ship’s safety management system.

Non-routine work was not properly planned or controlled

The crew did not identify the consequences of a failure under load and underestimated the risks of the improvised lifting arrangement. The task was not properly planned, risk-assessed or supervised. The ship’s safety management system required risk assessments and toolbox meetings, but these were not applied effectively to this task, and audits by the operator did not identify the gap, the Commission found.

A toolbox meeting was held, but it was in the cargo office not the worksite, so the crew had less opportunity to visualise the operation, identify hazards and consider safer ways of doing the work.

Learning points

This accident reinforces several lessons for front-line workers, mid-managers and senior officers carrying out lifting operations or other non-routine tasks, TAIC says.

• Stay clear of danger zones: Never stand in the bight of a line or lifting system. If equipment fails, serious injury can happen fast. Identifying and monitoring this risk should be part of pre-task planning and supervision during the work.
• Plan the work: Plan, risk-assess and supervise lifting operations before work begins. Non-routine jobs can introduce hazards that are not immediately obvious, and crews may miss risks or use equipment and methods that are not suitable for the task.
• Hazard-control equipment: Know what equipment is covered by the safety management system, and ensure it’s inspected, maintained and documented. Equipment outside these controls can remain in service with hidden defects and fail when it is needed most.
• Make it real: Senior officers must actively implement the ship’s safety management system. Audits and compliance checks should test how procedures are applied on board, not just whether forms have been completed. Gaps between the system and day-to-day practice can leave serious risks unmanaged.

Safety actions

The Commission issued no new recommendations. The operator, Thoresen & Co (Bangkok) Limited, showed that it had taken action to address the safety issues identified in this inquiry.

This included stronger lifting gear inspection and maintenance procedures, unique identification of lifting equipment, colour-coding, inventory controls and standardised fleet-wide management processes. It also strengthened requirements for worksite toolbox meetings, task supervision, risk assessment procedures and auditing of onboard practices.