Corrective-Prevention Actions Follow Up 2013

Corrective/Preventive Action follow up (rolling document)
Contarct
or CO.
Equipment (if applicable)

Item
Time Of
Incident
Related to
Type
Number
Inj/LTI
Estimated/Actu
al Lost Days
Corrective Action
Date
Case Explanation
Root Cause
(As per preliminary
investigation findings)
Employee statement summary
Preliminary Investigation
By
Risk Value
Action
Owner-ship
Deadline
Status
(open/close
d)
SYNERGY NO.
Shift Manger
Item
CMO
reference
Date
Time Of
Incident

Type
F-03-02
Contractor CO.
Corrective Action
Related to
Number
Case Explanation
Root Cause
(As per preliminary investigation

findings)
Preliminary Investigation By
Risk Value
Action
New
Status Penalty
(open/clo Code (if
sed)
applica
ble)
Owner-ship
Deadline
OPS
January 8, 2013
Open
OPS
January 8, 2013
Open
SYNERGY NO
Supervisor responsibility
Involved Person : Nam e: El-Sayed M ohame d El-Abot y

ID : 14 51
D epa rtm ent: OPS
Po sit ion: QC Op era tor
Experien ce: One year a nd 2 mon ths
January 1, 2013
05:00:00 PM
OPS Orange
RTG
15
p leas e specify th e
contractor Co. n ame; if
the involved person is the
res pons ib le (his mis take)
fo r the incient
January 2, 2013
02:15:00 AM
OPS Red
QC
fo r the incient
January 3, 2013
3:45:00AM
OPS Orange
QC
16
fo r the incient
RT G 15 Lift Twing Con tain er With Sp reade r On 4 0 Mod e W hich Lead To S pre ader Ch ain
Cut.( No D amag e H app en On Co ntainers ).
People cau se:

1 . Lack of att ent ion (t he QC op erat or wasn t a tten tio n that t he twin m ood not o pene d durin g
h andling t win conta ine r).
I was working in 05 B 0 6 and h and led th ree twin con tain ers and th en my sup ervisor informed me to go t o a noth er bay to h andle 40 feet cont aine rs an d the n I went to 0 5 B 06 ag ain t o
complete twin con tain ers .
Before han dling twin con tainer, I op ened t he twin m ood and I saw the t win mood lamp switched on a nd th en I hoiste d down an d cat ch t he co ntainer. W hen I s tarted to h ois t up th e
Ope rat ions : M ohame d Ade l
conta iner, I n oticed t hat cont aine r is fre e from midd le and I called my s upervis or imm edia tely.
M ahmou d Dorman
HS E:
En gin eering :
Moh amed El-Tabee y
Risk=
Probability ( 3 ) * Severity ( 2) = 6
Add t his cas e t o TBT a nd highligh ted th e follo wing:

1 . RTG o perators mus t be more at ten tion d uring h andling twin
cont ain ers .
2. RTG ope rato rs mu st en sure t hat th e twin mo od open ed from twin
lamp o r visu al check)
Sameh Haggag
1- Did yo u sle ep well?

- Ye s.
2- D id you s ee the twin con tainer wh en the y d own?
- No , I didnt s ee and th e vision wasn t clea r becaus e there is st eel ba r on th e m irro r in RTG 15 on ly but I s aw twin la mb only.
wh ile op erat or QC0 9 load in g in below deck h e fo rget t o comm and flippe r up
which caus ed da mage to fou r flip pers and o ne flip per m otor
Lake of attention operator was not being attention to the spreader condition .
While I was working in the cargo deck and in the second move I didnt check if the fl ippers were up or no and it was down and hit the deck walls.
Ope rat ions : H atem Ho sny

Eng inee rin g:
Mah moud Dorm an H SE: Moh amed M ashh our
Risk=
Probability ( 3 ) * Severity ( 2 ) = 6
Involved Pers on: N ame: N ader m oss y Mo hamed ID: 92 0

D epartmen t: Ops
Positio n: QC op era tor
E xp erience: 6 m onth s
CQ 16 loading on bay26 hit 45ft CTR in bay 22 causing damage in fl ipper SQ21
1 . Peop le cau se :
- La ck of experience (th e involved QC op erat or do esn' t have en ough exp erience and h e m ade
fast trolle y).
- Poor decision makin g (th e involved QC op erat or to ok wro ng decis ion wh en he mad e fa st tro lley)
1. Add t his cas e to TBT a nd highligh ted t hat QC op erat ors must b e
more carefu l in th is cases a nd take right d ecision and ma de slow
moveme nt to prevent an y d amag e d uring s prea der s tuck.
I charged 45 ft cont ain er on ves sel in the th ird t ier an d th en I st arte d to ch arg e 4 0 ft con tainer in the be sid e bay.
I mu st pu t the cont ain er from 45 ft cont aine r bot tom and I put t he co ntainer a nd th en I mad e h ois t up for s hort dis tan ce an d made fas t trolley, unfortun ately rig ht qu ay s ide fl ipp er was
st uck in 4 5 ft con tainer corn er an d damag e in flipper is hap pen ed and fl ipp er fall down on d eck.
1- D id you se e t he flipper stu ck in cont aine r?
- Ye s.
2 - Why you mad e fast trolle y?
- I did n't t hin k wh at hap pene d.
3 - D id you exp ose to t his s itu ation before?
- N o b ut in t his ve sse l, b ays was very n ear be cau se th ere is n o wa lke r.
Add the case to TBT
Op erat ions : M ohame d Ad el

Eng inee rin g:
Mah moud D orm an
H SE: Mo hamed E l-Tab eey
Risk=
OPS
0 8/01 /2 013
OPS - OPS tra ining
0 3/01 /2 013
Man ageme nt
S hift Operations
Su perint end ed.
Probability ( 3 ) * Severity (1) = 3

2. 4 5 ft con tainer mu st be charged in las t on vess els which d oesn 't
have walker b etween b ays and bays are n ear.
Open
Sameh Haggag
Un der p rocess
To be imp leme nted
Open
Management
OPS
January 20, 2013
Open
Salah Abd Elaziz
OPS
January 21, 2013
New
1 - ops
2 - op s + ops train ing
January 18, 2012
new
Sameh Haggag
new
Josh
New
Sameh Haggag
new
Josh
Open
Josh
H ow do you th ink this in cid ent could be avoided in future?

- In this kind o f ves sel in which bat s are very n ear, 45 ft conta iner mus t be ch arge d in la st
Immed iate caus es

Ob st ruction ( Man y d ents in the cell-gu ide ).
January 3, 2013
20:00
OPS Orange
QC
CQ 08
Sp read er st uck wit h the ves sel, Aft er releasing sp read er from th e vess el ,ins pected ho ist
wire ropes a nd foun d bot h wires n eed to b e replace d.
fo r the incient
Underline ca use s
Wron g han dling.
Roo t Cause
Org aniz ation Root cau se:
1 - M anag ement & Sup ervisio n
( Decis ion Pro ces s ) - Deck con trollers num bers not ad equa te with t he working loa ds.
D id you s aw the da maged cell-gu ide b efore han dling ?

No.
In you r point of view, wh at was th e reaso n of t his incide nt ?
Nu mber of D eck cont rollers , we mad e ext ra efforts to avoid in cident s & we are working in ve ry narrow areas from long d is tance, so we need t he deck con troller t o b e with every QC
ope rato r to help him.
If the de ck was with yo u in th is case, did yo u think that t his cas e m ay b e avoid ed?
Yes.
Wh y yo u did nt att end th e TBT ?
Be cau se I came early.
D id you receive a p re-sh ift safe ty talk:
YES
NO
D id you receive tra ining in h ow t o do the t ask invo lved:
YE S
NO
Are yo u aware of the rules / proce dures related to t his work: YES
If required , were you wearin g the correct PPE :
YE S
Operation s: Moha med Adel

E ngineerin g: Mah moud D orma n
HS E: Moha med Abba s
Probability ( 5 ) * Severity moderate ( 3 ) = 15
1 To pro vide de ck co ntro ller with eve ry deck.

2 To ass ign d eck cont roller with every cran e with th e ve sse ls which
famou s by th e b ad Cell-guide.
NO
NO
Did yo u receive su pervision in t he las t 1hr of you r work: YE S NO

How do you th ink th is in ciden t cou ld be avo ided in futu re?
- D eck co ntrolle r with eve ry QC ope rato r.
Witnes s Pers on: N ame: M ina G irg is
De partmen t: Ops
ID:
1 953
Pos ition:
D & W con troller
Experien ce: 4 Mon ths
Involve d Pe rso n: Na me: Wale ed Ahmed Aly ID : 36 70
Dep art ment : OPS
Pos ition: TR D river (Kot by)
Exp erience:
6 Mon ths
Immed iate caus es

1. Wro ng pos ition of the TR.
2 . E ngine Failure of th e T R.
January 4, 2013
11:15
OPS White
RTG
39
fo r the incient
Und erline caus es

wh ile RTG 39 was revers ing back fro m 0 6 C t o 06D a nd TR19 was waitin g to pas s to
qu ay, th e RTG h it th e T R.
1. Failure to act from TR driver. ( Stop pin g the T R be hin d the RTG & Using th e TR h and brakes) .
Root Caus e
1 . N ot Followin g Procedu res from TR Driver.
I wa s workin g with T R 19 a t 07 E and wh en I was g oing o ut from th e blo ck toward the qu ay, I fo und RT G 39 go ing o ut from 07 C so I s top ped at 0 7 D to wait fo r the RT G and s ee where it
will go, s ud denly I fo und h im moving towards me th en I tried t o move the TR qu ickly but it did n ot move becau se the air was evacua ted so I u sed t he horn to draw t he ope rat ors
at tent ion b ut the RTG hit the TR.
Why you s topp ed be hin d the RTG ?
To wait and s ee where it will b e d ire cte d.
DO you know that t he SOP is to chan ge your dire ct ion no t to wait th e RTG directio n?
Yes I kn ow.
Did yo u use t he han d bra ke ?
Yes I d id.
W here was yo u sto pping?
I was s top pin g at the righ t to have a chan ce to es ca pe.
Moh amed Mo hamed E lfeeky

TR 53 Collide wit h TT 90
Un derlin e cau ses
January 9, 2013
6:30
OPS Red
TRA
53
fo r the incient
Driving in b ad weath er (very cold and rain y )

wh ile o pera tor TT5 3 Ent ering 02 G The t ruck slippe d wh ich lead to collid es wit h TT9 0
cau sed d amag e t o both TT &TR
Roo t Cause
1- People cau se
Fat igu e(overwork/la ck of rest /b reaks )
2- En viro nmen t cau se
E xpos ure to extreme/un expected wea ther
Immed iate caus es

Revers in g back wit h the TR wit h a b lin d point.
January 12, 2013
11:00
ops white
TRA
47
fo r the incient
Underline ca use s
while TR47 att ach ed wit h TT30 re ve rs ing b ack hit OPS -PU-40 which cau sed d amage in
th e p ick u p.
Th e T R d river was harryin g up.

Roo t Cause
1 . Peop le cau se :
- Lack o f at tent ion
- No t follo wing p rocedures.
7:00
Ops Blue
QC
10
fo r the incient
ID : 3 415
I wa s goin g to my add ress at 03P in side the cost umes a rea to get a cont ain er, I was drivin g bet we en 3 K an d 3 L a nd when I start to tu rn to righ t with t he TR head b etween 3 L highe r
and lower (t he traile r was st ill in the way bet ween 3K&3 L) , on e o f t he x-stu ffing labors st oppe d me to ask me abo ut th e con tain er which I will charg e, an d ask me to ge t back an d wait
th e RS in the way bet ween 3 K an d 3L becaus e t he RS wasn t re ach 3 P yet and t he area was crowd ed with p eople, s o I started t o reverse back with my TR so th e t railer cent er hit PU 40
right m irro r .
1- Did you not ice t hat th e Op s PU 40 was exis tin g before yo u reversed b ack?
- Ye s, I saw it an d pass ed be sid e it before t urn ing rig ht, but wh en I reve rse d back I fo rgot its exis ten ce becau se of my con vers atio n with th e x-stu ffing labor.
2- Did you look at th e TR mirror wh ile re vers ing b ack?
- No, t he area which Ops PU 4 0 was waiting as a b lin d point cant ge t b y t he lift mirror, b eca use th e heat an d the t railer n ot in th e same line (t he hea d only tu rne d rig ht) .
3- D id you kno w t hat reve rsing ba ck in t he yard is forb idd en ?
- Yes, but I need t o.
4- Wh en did you ca n reverse back in th e ya rd if you ne ed to do it?
Op era tion s: Ehab Zah ran
- Th ere mu st be an o bserver t o g uid e me to reverse ba ck if I need in safe ma tter.
Ha did i
H SE:
Probability 5 * Severity 1 = 5
En gin eering : Moham ed

Ramz y M aher
possible 3* minimum 1 = 3
Add t o T BT t o a ll TR driver to inform TR SV in case of feeling s leep y of

fat igu e .
1-Ad d this ca se to TBT and h igh lig hte d the im portance of follo wing t he
p rocedu res of never reversin g back u nle ss in t he presen ce of an
obs erve r and with clear view.
2- Make reas ses smen t to the d rive r and d riving ro les refre shme nt.
YES
NO
YE S
NO
NO
Invo lved Pers on: Name: Moham ed Has san Riz k ID: 011 2
If required , were you wearin g the correct PPE : YE S NO
Dep art ment : OPS
Pos ition: CQ Op erat or
Expe rien ce :
7 years
do you
th ink
th is in
ciden
t cou
be avo ided
intwin
futu from
re? anot her b ay, I m oved by th e cra ne to th is ba y an d sta rte d to
I was d ischa rging twin con tain ers from M/V XIN N AN S HA wh enHow
th e vesse
l sup
ervisor
a ske
d me
tolddischarg
e one
h ois t down on t he 8 tie r und er de ck, the sp read er lan ded o n the twin but t here was a p roblem on th e locks o f t he spreade r so, I ca lled t he deck con troller t o visu ally check t he po sit ion.
He arrive d and to ld me th at the p osit ion is clear an d asked me to h oist u p and t ry to hoist d own again to solve this prob lem, I did so bu t the proble m wa s still exis t the n he asked me to
h oist u p gain but wh ile ho ist ing u p the s prea der left s id e rais ed bu t the righ t sid e did n ot. After t hat we st oppe d and called the E NG te am.
Wa s you hoisting do wn in full spee d at the s eco nd time?
Yes , I was ins ide th e cell guide an d this is a normal move ment.
Was th e wires s lacked ?
Yes it wa s.
Did the cran e movemen ts s topp ed ?
No, it was working n orma lly.
Was you able to see t he pos ition you was working in?
No th e vision was not clea r becaus e it was s hade d and th e time was e arly mo rning.
Wa s there any deformation at th e cell guide?
No, t he sp read er moved s moot hly in sid e it.
Witn ess: N ame: Moha med Abd Elhame d
ID : 1 344
De partment : OPS
Po sit ion: D&W Cont roller
Wh ile CQ 1 0 was dis ch arg ing t win containers from un der d eck, the s ea sid e rig ht wire
rope was d amag ed
1- Sen d the TR driver t o t he Tra ining for a on e d ay refres hmen t

ses sio ns ab out th e ins tru ct ions and proce dures of traffi c.
2- The case to b e p ublis hed for a ll TR drivers a t the da ily sa fe ty talks .
De partmen t: OPS out s ource(Kotby) Position : TR Driver
January 14, 2013
Expe rie nce: 18 mont hs

I was in my way to 02 G in opp osite direct ion in orde r to han dle reefer u nit ,after I ente r the G b lock I adju st my TR exact ly in TR lan e und er RTG t hen I feel d oze till collide wit h front TT .
-D oes to ur TR (53 ) have an y ab normality in braking s yst em or defecte d front g lass ?
No .braking was in good con dit ion bu t I didnt us e it .
Op erat ion s: N ader Helm y
En gin eering: Wa el Abd
-How many ho urs d id you s lep t before coming night s hift?
ELfatah
HS E: M ust afa Fat hy
7 hr
-Did you take any drug ma kes you s lee p wh ile d riving ?
No
-Did you face same situa tion b efore ?
No
-From you r opinio n what is t he cause for this accid ent ?
It was very cold nig ht an d last h our in the n igh t shift wh ich make me fa tig ue and s lep t
Eh ab Za hra n
Ahmed Salah
Ahme d El-M aras y
Involved Person : Nam e: Moh amed N asr N asr ID : 13 62

Dep art ment : OPS
Positio n: RTG Operator
Exp erience:
1 Year & 6 Mon ths
I h ad finishe d my wo rk at 07 C and was g oin g to 07 D , after making wh eels t urn ing o n the p lates , I m oved with t he RTG t hen I h eard t he so und of ho rns s o I sto pped a nd moved b ack.
D id yo u turn ed th e seat b efore moving?
Yes I did b ut th e TR was a t rig ht be hin d the RTG leg so I cou ld no t see it .
Ahmed Hegaz y
Ah med Sa lah
Ahme d El-M aras y & Hesh am Is mail
We was working o n M/V XIN N AN S HA a nd I was with CQ 11 wh ile I h eard a call from CQ 10 op erat or to check the po sit ion of th e s pre ader u nde r the d eck of cen tral hat ch , I directed
t here an d ch ecked t he sp reade r and t he pos ition was clear b ut th e spreader was not ab le to lo ck on th e con tain ers , I as ke d him to h ois t up th en down ag ain on t he conta iners to so lve
t his p roblem the n he hoist do wn in full spee d and th e wires s lacke d but t he pro blem s till exist . I as ked h im to h oist u p again and t ry to close t he sp reade r to 20 mood t hen op en it 40
bu t wh en he s tart ed to ho ist u p the left sid e h ois ted bu t the righ t didnt so I t old him to st op and called th e E NG te am.
D id th e cranes movem ents s top ped afte r the s lack?
No it d id not s top ped as h e hois ted u p again.
D id you s ee any defects in the wire rope ?
Yes
afterp osition
the le ftbsut
ideinrais
t heside
righttodmake
id no t itI saw
a defect
th eewire
on th en sea
side
rightdu
. e to its e last icity (no rmal cond ition) , and
while I mad e t rolley toward t he vess el, I mad
e ,t rim
theed
opand
posite
ba lanced
t hisat
caus
a vibratio
to the
wires
Was
ere th
any
ataine
t herscell
?
when I reached t o m y ad dre ssed row ( 5th ro w s ea sid e) I st art ed to hoist do
wnthwith
e Tde
wofect
cont
un gu
deride
d eck,
bu t it was a blind p oint t o me becaus e the previou s row (6t h row sea
cell th
g uid
was
s id e) was 5 tiers h eigh t aboveNo,
t hethe
deck,
en e
I fou
ndinthgeood
conconditio
tain ers n.
s tuck with t he ce ll gu ide he ad.
January 15, 2013
2:30
ops white
QC
QC 11
fo r the incient
D uring QC 1 1 load ing cont ain er No.MRKU6 842 313 On M/V CMA CG M MAUPASS ANT Ba y
17 th e con tain er hit the cell g uid e head wh ich cau se th e con tain er da mage from t he
b otto m
Immed iate caus es

QC ope rat or failure to act wit h hand lin g the t win conta iners rou ghly wh ile th e twin cont aine rs
were vibrated .
Underline ca use s
Working in a blind p oint withou t obs erver (deck con troller).
Roo t Cause
1 - Peop le ca use :
- Poo r decis ion making from th e QC ope rato r (working in a b lin d point wit hout d eck cont roller)
2- Organizat ion caus e:
- Lake o f s upervis ion du e to lake of deck cont roller nu mbers.
Corrective act ions taken Live
- Secured the s pilt ca rgo are a with cones .
- Han dle d the da maged con tain er an d send it to th e x- stu ffing are a t o re-st uff it in a go od
cond ition one.
- Clean t he ca rgo s pilt.
1- Wa s it th e fi rs t move in th is b ay ( 5th row s ea side)?

- Ye s.
2- What was sup pos ed to do when yo u found that you will work in a b lin d point?
- Work carefu lly and call a d eck cont roller to be with me.
3 - D id you call the de ck co ntro ller before working in tha t blind po int ?
- N o, I called h im after I n oticed t hat th e twin cont ain ers were s tuck.
4 - W hy you didnt call him to guide you in this blind po int ?
- I know he was b usy with other QCs in the sa me vess el becaus e I heard the m, an d if I ca ll him he will come la te and t his will de lay time .
5- Wh at was th e circu msta nces tha t cau se th is da mage?
- First when I made a trim to make balance to the s prea der, it vibra ted du e to the elast icity of the wires (n ormal con dition) an d while hois ting down with th at vibrating mot ion ma de the
sp reade r stu ck wit h the cell g uid e.
- Second th e mid dle ha tch cover in th e p revious ro w ha d a part wa s takin g a space of my curren t ch arging row and I d idn t kn ow t hat b eca use it wa s a b lin d point an d I info rmed b y th is
p art wh en the d eck controlle r was with m e adju sting th e positio n toge ther wh en I chargin g the 2n d twin con tain ers a ft er th e incide nt.
YES
Immed iate caus es

Conta iner hit b y an oth er one .
10
January 19, 2013
22:00
OPS Orange
RTG
CR 36
HIPO W hile RTG 36 loading from Bay 33 Row F ,It Hit anot her cont ain er from Bay 35 Row
B.
fo r the incient
Underline ca use s
Wron g han dling.
Roo t Cause
Environm ent & E ffects :
5- Hou sekeeping
Sta king / Sto rin g. ( Bad s tacking ) .
Operations: Eh ab Zahran
Eng ine ering: Ma hmou d Dorman
Ramz y Ma her
HS E:
Possible3* Minor 2 = 6
1 - Add t his cas e to TBT a nd highligh ted t he imp orta nce o f calling a nd
p rovid ing e ve ry QC is de alin g with t he blind p oint s on ves sels with
de ck co ntro ller.
1- Op s
2 - M anag ement
1 - 21/1/2 013
2- u nder process
2 - To p rovid e d eck cont roller with every QC.
NO
YE S
NO
NO

T he normal.
It was fu ll s peed ?
Yes.
Why you mo ved in full spe ed, as you are in 1st cont ain er in t his b ay?
Becaus e I ch ecked t he height of th e rows from A to F & fo und t hat all are in t he sam e wh ich I han dle fro m row F, then the sp eed of th e t rolley will b e limited when it will reach row A.
Did you ch eck th e dis tan ce be tween th e con tain ers in your bay & oth er ba ys ( 31 & 3 5 ) ?
No.
Why you didnt check t his d ist ance?
Be cau se I pu t all my concent rat ion in t he heigh t of t he rows in the sa me bay of my wo rkin g operation.
Whe n you make trolley forward to take this co ntainer, did th e s prea der h it or t ouch any conta iners from b ay 3 5 ?
N o, be cau se I en tered from bay to ba y & t he sp read er was highe r tha n the cont aine rs.
Did you faced any te ch nical faults in the RTG which may lea d to this incid ent ?
No.
Are you slept well?
Yes , ap prox 7 hou rs.
D id you suffer from any home cond itions which m ay a ffe ct on yo ur concent rat ion ?
No.
Du rin g the inciden t, you was ca lling in p hon e / Sp eakin g with an yone in t he SG p hon e?
Be fo re the inciden t & befo re han dling th e con tain er, I was talking with tower con troller in som e iss ues re gard ing t o the op erat ions , b ut while I was trolle y b ack; I didnt us e anyth ing
except t he st ick.
In you r point of view, what is the rea son of th is in cident ?
Bad st acking.
Why this beh ave rep eated t his d ays in you r opinio n?
- I d ont know, but from long t ime, yard s upervis ors g ive a neg ative commen ts t o t he ope rato r who mad e t he wron g stackin g & I th ink th e t rainin g in th e las t period no t covered all
activitie s.
Sa meh Hag gag / Ade l Kh edr

Ahm ed Salah
M oham ed Ab bas / Moh amed Eltab eey.
Probability ( 5 ) X severity (3) = 15
Mo hamed H egaz y
Am r El Sh orb agy
Ramz y Ma her
Unlikely 2 * Minor 2 = 4
1 To make a da ily ra ndom check for th e wrong st aking in th e ya rd, then

re -stack in th e p rop er way & to be re ported as o bservation .
2 To add every obse rvat ion of bad s tacking in the log file b y t he nam e
& ID of t he in volved op era tor th en to collect t he rep eated n ames t o be
sen t to Ops train ing for re-as sess in g this operator.
3 To add t his inciden t to th e T BT & h igh light th e imp orta nce o f s tacking
in th e p rope r way & to check t he dis tan ce be tween th e bays b efore
h andling a ny con tainer.
Ops Yard Sup ervisor

Ops
Ops
D aily ( St art ing from 20/01 /201 3 )

To be imp leme nted
2 8/01 /2 013
Ma ke a su rvey for all the n ew g utt er covers fo r sta nding on its fixat ion
stat us on t he grou nd an d to st art fi xation process .
project
waiting project respond
1. Ad d this ca se to TBT and h igh lig hted t he followin g:

1 . TR driver mu st be mo re atte ntion and concen trat ed to bo th sides of
T R du ring man euvering und er RTG in first of the b ay.
2. TR d rivers mu st us e left and rig ht mirrors.
OPS
3 1/01 /2 013
2. S end th e involved TR driver to t rainin g for re-a sses sme nt
OPS train ing
2 5/01 /2 013
Ops
Ops
14 -02- 201 3
14 -02- 201 3
ops
February 5, 2013
ENG TS
OPS -Trainin g
OPS - Execu tion
1-Wait ing TS a dvice

2-Already don e 07/02 /201 3
3- 15/02 /201 3
Ops
1 5/02 /2 013
Ops
0 7/02 /2 013
OPS
February 14, 2013
Involve d Pe rso n: Na me: M oham ed Moh amed Abd El M aksood

ID: 32 19
D epartmen t: Ops (Trad emare s ubcon tracto r)
Positio n: TR driver
Exp erience: 2 Years
I was chargin g a con tain er un der QC 11 and this wa s the first cont ain ers charged on t he ves sel an d the wha rf told m e t o move and wait beh ind t he QC un til fi nis hin g the mo vement
con firma tion t hen I d rove my TR from und er QC 1 1 through QC 12 and take a ma neuve rin g and t o e nter the waiting area beh ind QC 11 an d while I drove in the wait ing a rea beh ind QC
1 1, I h eard s omet hin g wrong h appe ned , I st opp ed to see wh at hap pene d, t hen I fou nd on e o f t he gut ter covers hit and st uck with th e T R st airway.
11
January 21, 2013
17:30
White
TRA
TR 93
fo r the incient
While TR 93 moving on one of new unfi xed gutter covers it hit the truck stairway
Immed iate caus es

TR movin g on un fixed heavy gu tte r cove r, wh ich moved an d it th e TR s tairway.
Underline ca use s
The gu tter wa s un fixed wit h its bolt s.
Roo t Cause
- Inad equ ate co nst ruction fixat ion .
1- Aft er in specting th e incid ent site we found one yellow b arrier b eside the rain g utt er, did it barricade d this area as a working a rea?
- No, the ba rrier was as yo u see it wh en safet y a nd eng ine ering came, it was away from th e rain gut ter.
2- Did yo u hit t he barrie r and remove it fro m t he gu tter cove r when you en tered the waitin g area be hin d QC 11?
- No, I didnt even t ouch it .
Did you receive a pre-shift safet y t alk:
YE S NO
D id you rece ive training in h ow to do th e t ask invo lved:
Y ES
NO
Are yo u aware of the rule s / p rocedures related t o t his wo rk: YE S

If requ ired , were you wea rin g the correct PPE :
Y ES
NO
NO
Did yo u receive su pervision in t he las t 1hr of yo ur work: Y ES NO

How do you t hin k th is inciden t cou ld be a vo ided in futu re?
Involved Pers on: N ame:

D epartmen t: OPS
M oham ed Moha med Abde l Az iz ID : 358 7

Positio n: TR d rive r (Tra de mar)
Experien ce: One year a nd 4 mon ths
I was in my way t o 03 A 1 0 and t here was RTG st oppe d in 03 A 02 (fi rs t of b ay). When I made man euverin g und er th e RTG, the RTG made g antry a larm an d I confus ed and I was be
atte ntion to th e RTG side only an d my TR 1 11 hit the cont ain er.
12
13
14
January 24, 2013
January 26, 2013
January 31, 2013
16:30
17:10
6:30
Orange
Ops Blue
white
TRA
RTG
RTG
111
47
20
D uring op erat ion , Tru ck 11 1 hit cont ain er TRLU7 510 791 wh en the d rive r made
the involved person is the m aneu vering un der t he RTG wh ich wa s in 03 A 02 ( First bay) cau se den t in th e rig ht side
co rner pus t
fo r the incient
RT G 47 HAN DLED GE SU94 575 59 from 02 H 14 G4 withou t previous confi rmat ion fro m
reefe r
fo r the incient
fo r the incient
RTG 20 lifting the twin as 40 without calling twin bottom
People cau se:

1 . Lack of at tent ion (t he in volved TR driver wa sn' t bein g atte ntion to his left side and
con cen trated on RTG side only).
1- Wh at are t he safet y t raffic proced ures d uring ma neuve rin g und er RTG ?
- I must b e more att ent ion to RT G and cont ain er and u se mirrors and t ake s afe dis tance.
2 - There are any prob lems in your mirrors ?
- No, mirrors a re good .
3- Why you d idn t u se th e left mirror?
- Because wh en the RT G made g antry alarm, I confu sed an d co ncentrated o nly on RT G sid e becaus e I was afra id th at RTG will hit my TT.
- Yes, I sle pt very well.
5 - Did yo u have any family prob lems or in work?
- No.
6- There wa s any sp illage su rface durin g maneu vering?
- No.
Operatio ns: Adel Khed r

Abo El-Enen
H SE:
People cau se:

1 -1-la ck of atte ntion. ( using n ew reefer un plu gg ing s ystem )
2-p oor de cision m aking . (che ckin g with reefer te ch nician a ft er loa din g the cont aine r)
E ngineering : Said
M ohamed El-Tab eey
Risk=
Probability ( 3 ) * Severity ( 2) = 6
Ops: Ahmed H egaz y

Eng : Ahm ed Sha wky
HS E: His ham Is mail
Risk= severity(1)*likelihood(5) = 5
Operatio ns: Moh amed Se if

En gin eering : Wae l
Ab d El Fat tah
HS E: Ramzy Mah er
Probability 3* severity 1 = 3
1 -To b e dis cu sse d during T BT ab out t he imp ort ance o f p re-checking o f

plug /u nplugg ing reefer s ockets .
2-Refres hmen t for RTG o perators abou t new reefe r socke t syst em.
the re to allow t he right a ddress TR to en ter do wn me, t hen th e incid ent in volved T R came un der my RTG and I s tarted to h and le the cont aine r from it a s 40 ft. con tain er no t as a twin
co ntainer s o one of the m fa ll down o n the trailer an d the ot her was s tuck.
Immed iate caus es

RTG ope rato r han dle d a t win conta iners as 4 0 ft . conta iner.
Underline ca use s
1- RTG operator did nt ch eck th e location shown in the s ystem .
2- Ba d visibility du e t o bad weat her ( heavy rains ).
Roo t Cause
- La ck of atten tio n.
1- Cou ld you kno w th e type of containers ( 40 ft, 20 ft or t win co ntainers) th at you will dis ch arge from the sys tem on RT G screen ?
- Yes, it is s hown in t he screen .
2- S o wh at hap pene d to make you took th e t win conta iners as 4 0 ft . conta iner if it sh own in you r screen ?
- It was rainy hard and th e visibility was n ot good a nd th e t wo con tain ers h ad th e s ame color so I th ough t it was 4 0 ft . conta iner.
3 - D id you che ck the n o. of the cont ain er with t he nu mber o f t he co ntainer yo u shou ld discharge in t he syst em in RTG screen ?
- Yes, I checked t he TR numb er on t he sys tem and it sh ow t he same n umb er of one conta iner of t he twin con tain ers b ut I d idn t check the locat ion of th is cont aine r, t he locat ion of th is
con tainer was in 08 B 63 bu t I was discharg e it in 0 8 B 5 4.
4 - W hen you checked the cont ain er no., d id you check its loca tion ?
- No, I didnt check it, I only compa red th e n umb ers o f th e con tainer with nu mber in the s ystem .
5 - Was t here an y T Rs wa iting in fro nt of the involve d TR wh en you reache d to bay 54 ?
- Yes th ere was two oth er TRs in front of it , on e o f t hem was wait ing a t b ay 5 4 which I called it t o m ove to allow t he right ad dre ss TR to ent er do wn m e
Did yo u receive a pre -shift safety ta lk:
YE S
YE S
Did yo u receive su pervision in t he las t 1hr of you r work:
Add t his cas e t o the TBT sh owing t he imp ort ance of

1- RT G operato r mus t assu re th at the n umbe r and t he location of the
cont aine r in th e yard is iden tical to t he num ber an d location of the
con tain er in the sys tem.
2- If t he RTG o pera tor visib ility is no t good , he mu st call t he yard
s up ervisor t o h elp h im
new
Amr Rashwan
NO
YE S
NO
NO
NO
YE S
NO
Amr M ahmou d Hamed ID: 15 27

Dep art ment : OPS
February 1, 2013
2:00
OPS Red
Terminal Bus
OPS BS 08
fo r the incient
Und erline caus es

W hile bus 0 8 was movin g from th e Qside
to mus ter room parking h e colllides wit h
TT 16 attache d to TR05
N/A
Root Caus e
1-Lack of att ention/du e care
2 - N ot following /incorre ct followin g of stan dards/proce dures
Immed iate caus es

( La ck of com munica tion M iss u nde rst anding t he mess age )
16
February 4, 2013
23:50
OPS Orange
RTG
CR 40
fo r the incient
RTG lifted up connected reefer without any notice from reefer technician.
Underline ca use s
Wrong h and lin g.
Roo t Cause
Peop le caus e:
1- Activities & ta sks.
( Operato r not followin g the p rocedures ).
5-Feb-13
17:10
OPS white
TRA
TR71/ TR14
fo r the incient
D uring t he ope rat ion be tween QC 1 1 QC 12 whe n TR 1 4 co meback hit TR 71 ma ke

dam age in t he fron t of t he truck an d the g lass broken .
1-Poor decis ion making.

2-la ck of atte ntion. ( o nly checking t he mirrors one time not freq uen t ch ecking).
5 years.
I was coming from Q s ide t o m ust er room b etween 0 2 H &L when I reach main d rive ro od after J I che ck my rig ht directio n only ,I decid e to co ntinue moving bu t unfo rtu nat ely wh en I
look to my left side I su rp ris ed by TR 05 comin g so I st opp ed but t he TR hit BS 08 front.
-H ow m uch your BS sp eed ?
Abo ut 25 km /hr
-D id you s top at s top sign befo re main road ?
No ,I did nt
-Did you st oppe d by using brake o r by co llision effe ct ?
I u sed my brake wh en I se e t he TR com ing from my left .
-how man y h our d id you s lep t before coming night s hift ?
5 to 6 hrs and t his my no rmal .
-D o yo u have any problems affect your at ten tion wh ile d riving ?
No all things is OK int ernally & ou tside CO.
-H ow d o yo u think we can avoid this Accide nt ?
I don t kn ow.
N o, be cau se it was nt working & b ut after yo u left th e RTG, someo ne from IT access ed to th e monit or & a ctivated t he sys tem.
Are reported to you r su perviso r abou t the b reakdown o f t he syst em?
No.
Wh y?
I pre ferred t o work manu ally
W hen I was in your cab in, I ask you t o s how me how th is sys tem working , bu t you ca nt reach this sys tem; as you tried t o open it but yo u did nt find it, my qu est ion is : Are you u sed to
work wit hou t this syst em or working by it ?
With out it.
This syst em ins talled from ap prox 6 mon ths , du rin g this period yo u used this syst em?
No.
W hy you didnt us e it?
Becaus e some time s con tainers appe ared clear & read y fo r load ing , bu t wh en we ch eck it b efore we foun d the cables is u nplugg ed.
Are yo u tra ined a bout h ow to use it?
Yes.
Are yo u slep t well b efore working ?
Yes.
Did you ha
ve a ny
circums
tan ces
wh ich
may
affect
o nID
your
concent
rat ion ?
Involve
d home
Pe rso n:
Na me:
Ah med
Moh
amed
S aad
: 36
62
No.
Dep art ment : OPS
17
Positio n: Bu s Driver
E xperien ce:
Imme diat e cau ses

BS 0 8 co llide with T R 05
15
Pos itio n:
Na der H elmy
Eng ine ering: Ahme d Shawky

HSE : M ust afa Fathy
Walid Elkoraey
Moh amed Ha ssa n
Moha med Abba s
likely* min = 4
Probability 4 ( Likely ) X Severity 1=4
1-E NG TS t o pain t new st op sig n at th e e nd of J block sa me like phas e II

2 -In volved D river get o ut of OPS Roos ter till re -ass ess ment
3-TR Su perviso r to highligh t our t raffic rules & t raffic priority durin g
d aily TBT
1 Add t his inciden t to th e d aily TBT & h igh lig ht th e impo rtan ce of
follo wing t he safe ha ndling p rocedu res & t he imp ort ance o f reportin g
any de fect s.
2 To as sig n the RT Gs which working with ree fer to be fu lly equ ipp ed by
th e com munica tion s devices .
New
Amr Rashwan
Opened
Mohamed Elaraby
TR Driver
D id you receive a p re-sh ift safe

ty talk: ce: YES
NO
Experien
10 m
onth s
While I was u nder QC 12 on lane 04 I decide d to ch ang e t o lane 0 6 I asked th e wh arf to mo ve revers e he said its clea r then I ch ecked th e mirror an d while revers ing I hit T R7 1.
D id you receive tra ining in h ow t o do the t ask invo lved: YE S NO
Q:Do you kn ow a bout t raffic SOPs in ou r term inal ?
A:yes ,
Are yo u aware of the rules / proce dures related to t his work: YES NO
Q:Doe s it men tion t hat its pos sib le to move re vers e a t any pla ce in o ut termin al ?
A:N o. it d oesn t .
Q:S o, why you m oved reverse?
A:Normally we d o s o if a W harf is guidin g me.
A: Wh y yo u Hit h owever you h ave a guide?
Q:be cau se I st art m oving wh ile h e was not in b ack s ide of my tra ck.
Q:wh ere he b een ?
A:he was next to my win dow he to ld me it was cle ar back and as k me to g o on and I che cked th e m irro r the n I moved .
Q:did yo u ch eck th e m irror ca refully ?
A: I checke d the mirror once before st art mo ving on ly.
(Truck Su perviso r asked)
Q: d id you left a s afe dis tan ce be tween you an d the fro nt track ?
A: yes I did .
Q: are th ere any Tru cks are n ext to you in lane 0 5 &06 ?
A:No.
Q:So, why don t you t urn t he wheels directly to th e next lan e as lon g its clear from tracks ?
A: I d ecided t o do reverse as it wa s clear.
Also Truck S upervis or add ed if you tu rne d lift to lane 5 and 6 it would be more ea sier and s afer th an reversing your Truck.
Operations: Eh ab Za hra n
E ngineerin g: Mo hamed
Ali HS E: Hisham Ismail
Severity (1) * Probability (4) = 4
To add /hig hlight o n TBT t he ca se and inform all drivers a bout t he

importan ce of following t he correct SOP.
Opened
D epartmen t: OPS
Positio n: FL operato r (Tra de mar)

Experien ce: two mon ths
I was han dling ge arboxes for vesse l in be rth 4 a nd after I put t he las t gearbox in 04 M , I d irected to QC 18 in berth 08 s o I took my way from 04 M.
Whe n I was pas sing from b erth 0 4 M to berth 0 5 M, T R 18 h it my FL at s top s ign at q uay side.
18
February 3, 2013
13:35
OPS Blue
FL
55
fo r the incient
Wh ile T R 18 was movin g from yard t o t he qu ay s ide , it collid es with FL 55 and cau sed
d amag e fo r FL
Pe ople caus e :
1. Not following safe p rocedures (t he invo lved FL op era tor d idn t follow the s afe proced ures wh en
he us e wrong way) .
1- Did you have an y inst ructions t hat you d idn t u se M area d uring pa ssing from b ert h to berth?
- ye s
2 - W hy you use you r way through M a rea when you d ire cte d to berth 0 8?
- Becaus e there wa s TR crowd ed in th e main road.
3 - W hat is your s peed ?
- Normal s peed .
4- Wh y yo u did nt stop to ch eck th e road be fore pas sin g?
- Becaus e I thou ght t hat I wa s far from st op sign an d far from th e TR an d als o there is no st op sign.
5- Did slep t well?
6- Were you occupied with an ything du ring driving?
- No.
- Mu st us e the main road d uring p ass ing fro m b ert h to berth .
Direct S upe rvis or: N ame:
S alah Bad awy
ID:
D epartme nt: ops
Posit ion :
Las h su pervisor
1. Were th ere ins truction s for Fl ope rat ors t hat th ey must nt use M area durin g pas sin g from berth to b ert h?
- Ye s.
In volved Person: Name:
Moh amed Adel Taha
ID: 3 293
D epartmen t: OPS
Positio n: TR d rive r (Tra de mar)
Experien ce : on e ye ar and 10 mon ths
OPS
0 8/02 /2 013
OPS train ing
0 3/02 /2 013
1-OPS Tra ining

2 -OPS
1 0/02 /2 013
1 6/02 /2 013
1. Add t his cas e to TBT a nd highligh ted t he follo wing :

FL ope rat ors mu st u se the ma in way durin g tra ffic from be rth t o berth.
Ahmed Hegaz y
M oham ed Elt abeey
Moh amed Aof
Probability ( 3 ) * Severity ( 1 ) = 3
Closed
2. Add t he following p oin t in sa fety tra ffic SOP:

Prevent a ny equipmen t or veh icle in M range .
Salah Abd Elaziz
I was in my way bet ween berth 0 4 and 0 5 (yard ) to qu ay s ide an d I st art ed to slow m y s peed a t 04 M.
W hen I was n ear t o s top s ign , I n oticed FL wh ich cam e from 04 M L a nd us ed th e b rakes to s top th e TR b ut un fort unat ely I hit the FL.
2. W hat is the s afety traffic p rocedures du rin g pas sin g from yard t o quay side?
D epartme nt: OPS Out S ource(Kotby) Position : T R driver
- I st art t o slow my sp eed at M to s top at s top s ign .
3. We re you occu pie d with an ything
g drivin
g?
Expedu
rierin
nce:
2 Ye
ars
- N o,
was con
cen
tra ted was
wit hsmy
Aft er discharg ing with QC 0 7 ,QC 0 8 Wha rf sho w t o m e & ask to take con tain
erI from
QC 0
8 which
tandwa
byy.so I s topp ed in my Lane ,when t he QC hoist d own the cont aine r it was 4 5
. D id
thebrake
FL? t o s top t he TR but th e TR d idn t s top an d co llide with t he conta iner .
so wh arf ask me to move b ackward ,I s et do wn a nd st art revers e move4 the
n Iyou
useno
TRtice
ha nd
- Bearf
cauco
sentrolle
he was
very
n ear
t overs
OOG
a nd
th tere
blindofp the
oin t.cont ain er ?
-when t he Wh
r ask
you
to re
e bcontainer
ack , W hat
was
he was
pos ition
Imme diat e cau ses
TR 1 25 cabin collid e with conta iner
19
February 8, 2013
13:30
OPS Red
TRA
125
fo r the incient
Und erline caus es

th e TR d rive r reverse to ad jus t the t ruck und er th e con tain er wit h careles s way lead ing
to move t he truck to t he co ntainer
Tacking s hortcut an d brea ch S OP

Root Caus e
2-
20
February 7, 2013
14:30
OPS Red
TRA
97
21
February 10, 2013
21:05
OPS Red
RTG
CR20
1 - TR Driver Ca rele ss
N ot following /incorrect following of sta ndards/p rocedures
People cau se:
Durin g TR 9 7 make m aneu verin g in 0 7 G, it hit reefer s tan d and make dam age in TT 14 1
1 . Lack of att ention (Th e invo lved TR driver was n't b e a tten tio n to his wa y d uring man euverin g).
and s tan d reefer
fo r the incient
fo r the incient
RTG2 0 Hand led con nected re efer which caus ed dam age to th e socket @ 02 G 46F2 with
no pre vious n otification to reefer Tech.
Imme diat e cau ses

RT G 20 Lift conne ct ed reefer unit
Und erline caus es
Ree fer LOG sys tem cover OPS Vess els u nit s only &didnt cover ga te units
Root Caus e
Not followin g/in correct follo wing of st and ards /procedu res
As the op era tor h oist t he conne cte d unit before confi rmat ion fro m reefer t ech .
Above t he Trailer b y a pproximately 1 m eter .

-Did the Wh arf controlle r ask you to re vers e q uickly ?
No.
-Te ll us wh at the s equ ence of you r actio ns when W harf cont roller as k you t o reverse
1 - I set do wn partially (sh oulders toward s right d irection TERBREG Cabin door )
2- relas e Hand bra ke (it wa s app lied wh en I st opp ed first time)
3 -ch ang e the Ge ar from N to R
4 -start moving backward .
5 -app ly han d bra ke ag ain bu t this tim e t he gea r still on R mod e .
-D uring you r Trainin g or in structed b y yo ur TR su pervisors ,is it p oss ible t o sto p the TERBERG TR using Ha nd brake wh ile g ear on D o r R mo de ?
No.
Acc t o your s tate ment ,you didnt se t down completely a nd move the TR ,Do you th ink you can control 10 0 % t he TR in this pos ition ?
No.
-Wh y d idn t yo u set d own in th e norma l pos ition and mo ve t he TR safely an d sta nd up a gain ?
In volved Person : Nam e:
Na gy Sami Fah em
ID : 33 16
I wa s afraid from QC op erat or ro ugh h andling o n my TT wh ich will caus e me low back p ain .
Dep artm ent: OPS
Po sit ion: TR driver ( Trade ma r)
-Do you h ave any history of rough h and lin g with 4 5 un it ?
Exp erience: one year a nd six m onth s
No.
whe n we insp ect the TR ca bin we foun d th at you us e the han d brake arm as a holder for a p las tic bag full of rub bis h ,and on e kiwi Fru it on th e grou nd .
I was in my way to 0 7 G (ne w re efer st and s) and wh en I mad e maneu vering to en ter t he bay in n ort h direct ion , I fou nd Ext erna l TR s topp ed un der RT G in b ay 4 6 so I s topp ed and waited
-D o yo u know its no t allo we d to eat or d rink ins ide an y eq uip ment ,an d imp roper use of ha nd brake arm may cau se any d efect t o its p erformance ?
th e E x. TR.
Yes I kn ow
,I dtidn
e at
bu t I to
eaten
be
fore
art work
an d I colle
t o pthe
ut in
neare
st scra p box .
After
he t
Ex.
T Rins
leide
ft , I TR
s tarted
ter
t hestbay
bu t unfortu
natect
ly my
my rubb
TT 1 ish
41 hit
s tand
reefer.
Ramydu
Elsaid
S heh ata
ID : 18
4
1- Wha t are the s afety traffic p rocedures
rin g mane
uvering
u nder
RTG in the be gin nin g of t he bay?
- I must t ake s afe dis tance and u se bo th mirrors and b e m ore att ention and s low my sp eed.
D epa rtme
n: RTG
2- nt:
DidOPS
you Positio
use mirro
rs? operator
- No , I didnt.
Expe
rie nce:
7 yea rs
3- Why you d idn t u se the
m irro
rs?
I h ave been informed from my yard S V t o g o to 02 G 4 6 for han dling -OPS
vess
/OPS
g tate
a rrivet.I start 2 reh and le move 02 G 4 6 F4&F3 safely b ut when I h and le F2 I
Becau
seels
I th
ough
thareefe
t myrs,
TT when
was sItraigh
foun4d it
was
conn
ect ed .
Did
slep
t well?
-Doe s your
Yardyou
SV con
firm wit
h you
abo ut F2
readdriving?
y fo r han dling?
5- Were
occupied
with
an ything
du ring
NO, bu t its logically if I have t o h and le F2 and fou
nd F3 & F4 un plu gg ed F2 s hou ld be un plu gge d
- No.
-Didayou
check
s yst em
screen
? euverin g und er RTG .
- Mus t be more a tten tion
nd mu
st usLOG
e m irrors
d uring
man
NO. I get confu sed whe n Yard SV was un der RTG arrang ing E xt TR &Terminal TRs form loading an d told me I will arrange t he TRs acc to lo adin g seq uen ce s o I un derstoo d that t he un its
cle ar and ready for loading.
Na der H elmy
Eng ine ering: Ahme d Shawky

HSE : M ust afa Fathy
unlikely (1)* min (2) = 2
1. Ad d this ca se to TBT and h igh lig hted t he followin g:

All TR d rivers mu st be m ore att ention du rin g mane uvering u nder RTG.
Operations : Na der H elmy
Ahmed S hawky
H SE:
E ngineering :
Mo hamed El-Tab eey
Nade r Helmy
Moh amed elhen awy
M ust afa Fath y
22
2/9/2013
13:00
OPS Blue
RTG
CR32
W hile RTG 32 loading from 0 1H bay 10 hit cont aine r which lo cat ed in ro w C3 which lead
to dam age in 2 Cont ain ers .
fo r the incient
hu man error.
o ver co nfid ence
I was re-han dling re efer conta iner at 02H 1 4 and wh ile liftin g the cont aine r I forg et to check t he screen wh ich showing th e con tain er whe ther plu gged o r not .
23
2/7/2013
23:15
OPS white
RTG
CR35
RTG 3 5 HAND LE D reefer cont ain er MWCU6 659 897 from Y 03G 7 0 E 1 witho ut pre vious
co nfirmatio n from reefer wh ich lead t o broken th e reefer s ocket at t his locatio n
fo r the incient
N ot following /incorrect followin g of stan dards/p rocedures.

- Not fully co nce ntrated .
OPS
min 1*likely 4 = 4
New
1 1/02 /2 013
Probability (3) * Severity (1) = 3
New
Amr Rashwan
2 . Sen d the involve d TR d rive r to train ing d epartmen t for reasse ssm ent.
OPS train ing
0 8/02 /2 013
1 -Ree fe r to in clude G ate loa din g in LOG s ystem ASAP

2-Add to RTG operator TBT t o wa it confirmation from ree fe r before
han dling G ate un its t ill LOG m odifi ca tion d one
Ree fe r
OPS
February 20, 2013
New
Sameh Hagag
Ops
E ng
1 -3-2 013
1 -4-2 013
New
Ops
2/18/2013
New
op s
op s
14 /2 /201 3
21 /2 /201 3
New
Amr Rashwan
ops
February 22, 2013
New
Josh
Opened
Mohamed El-Araby
Opened
Amr Rashwan
1-H igh lig ht in TBT for all RTG o pera tor

abou t the importan ce of dou ble checkin g
before h anding an y con tain ers .
(visua l ch ecking befo re rely on s ign als ).
2-To fi x all lig ht indicat ors inside all RTGs op erat or cabin ( lock-un locklan ded )
was Re-han dling a co ntainer from G 3rd tier t o A 1s t tie-D

r the
n I know
lan dedthat
th eGcon
anddidto
e con
i goive
un lock
comman
d and it sho ws unlock to me and s tart han dling for
o you
atetainer
reefers
ntfree
conth
nect
or tainer
ap pear
n LOG
sys tem
?
t he next cont ain er, wh ile h ois tin g up and trolley as I check t here was o nly 1s t tier in A and 1s
t tie r in B and 3rd tie r in C so I move d accordin g to the view I reach to th e t op and fou nd t he
NO.
han gin g co ntainer h it th e con tain ers made th em fall in bad D &E ba ys.
-D id you t ake confi rmat ion fro m reefer Tec. Relate d to this bay be fore han dling ?wh y?
Q: d &
o the
vis ion
clea
in you
ca bin
an dfor
thelong
window
? ugh t all th e bay read y fo r load ing
NO. becau se the re was a lot of EXT.TR
Termin
al TR
war iting
inr my
range
t ime isancle
d Ian
tho
Yes,
Q: Ho w man y h ours did you sle pt befo re com ing t o t he work ?
I s lep t aroun d 6 hou rs .
Q: what d o you think lead t o accid ent ?
A: It was my fau lt becaus e I didnt check whe ther the sp read er is e mpty or n ot.
Als o he add ed:
The jo ystick in th e cab in for lock an d unlock comman d on sp rin g mean s if you pus h forwa rd it ma y re turn to the op pos ite directio n and g ives th e oppo sit e comm and.
After checkin g the ab ove ment ion ed from th e o perator on RTG 32 we fou nd th at: (after a pplying lock an d unlock comman ds se ve ral t imes its working pro perly).
He als o ment ion th e ind icatio n lig ht in sid e the cabin for lock and un lock h avin g the s ame co lor s howin g.
( lock(Re d) and unlock(red) ).ph oto att ach ed
After checkin g the cabin the light indica tion lamps fo r lock a nd un lock a re red.
Q:But in both cas es it s hows you n ot to raise th e con tainer b ecau se it s locked ?
A:yes I wa s jus t ment ioning t hat, but I kn ow the fault from my side.
1 -In volved d rive r out of OPS rota tion t ill reass ess ment
2-Add th is case to TR driver T BT an d hig hligh t the ha zard
&co nseq uen ce of bre ach ing S OP.
Operations : Eha b Za hra n

Engineerin g: Sayed Abo -Elen ieen
severity (2)*likelihood (3)= 6
HSE : Hish am A.Is mail
HSE : His ham A.Ismail.

En g: Moham ed Had idi
Operatio ns: Eha b Za hra n
Q:D o You su ffer from any sight p roblems ?

A: n ever.
Q: was t he vis ion of your screen was clea r ?
A: yes it was .
Q:D o you know abo ut new ree fer sys tem ?
A: yes, I know.
Q:So, why you don t use it ?
A:I was not concent rat ed and focus ed with wo rk.
Q:D o you have an y family pro blem ?
A: N o I don t .
Q:S o, what m ake s you not concen trat ed?
N obod y inform ed me, and I forgot, and with work st ress and what h app ened t o my colleagu es be fore sta rting.
(ope rat or talking ab out t he 4 ca ses which h ad be en tra nsferred t o h osp ital b efore s tart ing t he sh ift.
Q:So, you th ink tha t wa s the re ason of you r accident ?
A: Yes .
Refresh ment t o be don e fo r the op era tor

reg ard ing n ew reefer s ystem .
Refresh ment t o be don e during s afety talk t o dis cu ss all iss ues ma y
effect the work.
Involved Pers on: N ame: Red a M oham ed Ba kr Ibrahim

ID: 130 1
De partmen t: Ops
Pos ition: RTG ope rato r
E xperien ce: 18 mon ths
I wen t to 02 G 7 3 to loa d a con tain er an d when I reach ed to th e ment ione d add ress I fo und o nly one cont aine r in t hat ba y, and I saw from my RTG cabin tha t the conta ine r was
disconn ect ed so I d ecided t o t ake it, aft er I pu t it on t o t he TR and wen t to bay 33 , I received a call from th e reefer t ech . th at th e reefer was con nected an d I mad e a d amage t o t he
socke t in th e s tan d and cut t he reefer cab le.
24
February 14, 2013
17:20
OPS white
RTG
23
fo r the incient
Immed iate caus es

RTG h andle con nected reefer cont aine r with out checking its s tatu s with reefer coord ina tor.
Underline ca use s
Rush ing in work.
RTG lifted up connected reefer unit No. TRIU6668453
Roo t Cause
- La ke of knowle dge of the p rocedu res of the reefer load sys tem.
- Not followin g the p rocedures (d idn t call t he ree fe r tech. to ch eck he s tatu s of the re efer
cont aine r).
1- D id you checke d on the n ew reefer load sys tem th at the reefer cont aine r was disconne cte d?
- I checke d it and t his con tain er was nt in th e reefer load sys tem.
2- Did you call an y on e from the reefer te am to ch eck wit h him b efore han dling th is cont aine r?
- N o, I d idn t call them b ecau se I s aw from my cab in th at the cont aine r wasn t conn ected?
3- In your job train ing , did you dep end on yo ur vis ion wh en you charg e reefer con tain ers ?
- No , I to ok t he risk from my sid e to accomp lis h the job.
YE S NO
YE S
YE S
1- Ma ke a refre shme nt to th e RTG op erat or ab out th e

reefe r load s yste m p rocedu res
Eh ab Za hra n
Amr E l Sho rba gy
Ramz y M aher
Minimum (1) * Likely (4) = 4
NO
2- Add th is case t o t he TBT sho wing th e imp orta nce o f

a) Follow the reefer load pro ced ure.
b) RTG o perators mus t call the reefer te ch nician for ch eck th e s tat us of
the reefer conn ect ion in doub t co ndition , or in sys tem failure an d never
depe nd on live vision
NO
NO

- Ne ver take th e ris k an d call the reefer coord ina tor t o check the s tatu s of the conta iner.
sto pped a nd try t o ris e it aga in be fo re hoist down u nde r deck, so we called the en gin eering t eam whom came and chick up t he prob lem of th e 4 flip pers and mad e some move s with me
on t he QC an d no pro blem s hap pene d again. After 3 0 minu tes I lift up a cont aine r from a TR with flippe r down, and m ade tro lley to t he vess el to charg e it in Bay 01 q uay side und er d ick,
I ad jus t the cont aine r bet ween th e cell guide and s tart to hoist down with full spe ed, I found t hat t he 4 flip pers were dam aged .
25
February 16, 2013
23:30
OPS white
QC
Wh ile cra ne no( 03) loading one cont ain er on ba y 2 6 row 10 un der d eck th e four fl ipp ers
d idn t rise u p ,it hit a ir pipe cause d a damag e.
fo r the incient
Immed iate caus es

Hois t down a sp read er un der d eck wit h flip per d own.
Underline ca use s
Rush ing in work.
Roo t Cause
- Lake o f at tent ion , (d idn t check the p osit ion of th e flipp ers ).
- Failure recog niz e cha nging in circu msta nce s (th e flipp ers did nt ris e up) .
1- After you ca ll th e e ngineering t eam for checkin g up th e fi rs t prob lem wit h the flippe rs, did you sto p operation with t he QC till th ey came or con tin ued t he work?
- I con tin ued t he work till th ey came b eca use th e flip pers retu ned n ormal a ft er th e call, avo iding slow d own th e o peration .
2- How did you know tha t the 4 flippe rs are u p durin g operation?
- I dep end on t he efficien cy of the eq uip ment .
3- From your p osition in the QC cab in can you se e if t he flip pers are do wn or not ?
- Yes I can s ee it.
4- Why d idn t you che ck the fl ipp ers p osit ion b efore hoist ing u p in la nd side?
- I depe nded o n the efficie ncy of th e e quipmen t, a nd I was accomplish ing t he work sa ving a time.
5 - D id th e wharf te ll you th at th e fl ipp ers we re down be fore hoisting up ?
- N o, h e d idn t t ell me ( its n ot pos sib le becau se it is the op erat or man ner).
6- Wh en you ma de a hot se at ch ang e with your colleag ue, did h e ment ion an y p roblems he faced wit h the QC?
- No h e d id nt ment ione d any prob lems with th e QC.
YE S NO
YE S
YE S
Eh ab Za hra n
Mo taz He wila
Ramz y M aher
Possible 3 * Minor 2= 6
Add t his case t o t he TBT sho wing t he imp ort ance o f checkin g the
p osit ion o f th e 4 flip pers before loading on ves sel.
NO
NO
NO

In volved Person : Name :
Dep art ment : OPS
26
February 9, 2013
0645:00 PM
OPS Orange
RTG
37
27
February 15, 2013
2:00
OPS Blue
QC
15
28
February 15, 2013
4:30
OPS Blue
RTG
21
While RTG37 ga ntry t o n ort h parking a t( A) lane h it wire lowbed t hen th e lowbed hit t he
fire fi ght ing p ipe
fo r the incient
Orga niz atio n cau se:

1. Unclear RTG yellow lin e.
People cau se:
1 . Wron g parking ( Involved TR driver p ut the wire low bed in RTG g antry p ath )
2 . Poor d ecisio n making ( In volved RT G operator took wron g decision when h e decide d to
com plet e gant ry for p arkin g however he didn't e nsu re if the low b ed is far from RTG p ath or n ot)
Hisham S arwat G oud a

ID: 537
Posit ion : RTG ope rat or
E xperien ce: Five years
My su pervis or in fo rmed me t o p ark RTG 3 7 in n ort h parking A and I n oticed low b ed which was p arkin g in n orth parking at E -room side of RTG b ut I expe cte d that t he low be d was far
from the RTG becaus e the RTG lane is not clear so th at I decid ed to complete gan try wit h slow s peed b ut un fort unat ely I hit the low b ed and t he low be d hit t he fire fig hting pipe and I
st opp ed imme diat ely and informed my sup ervisor.
1 - W hat is the s afe procedu re tha t you mus t do in t his case ?
- I must inform m y s upervis or if I didn 't ens ure from t he low bed p osition .
2- Why you d idn 't info rm your s upe rvis or to insp ect t he low be d pos itio n for you?
- Be cau se I d idn 't expect th at the low b ed on th e RTG la ne and also th ere is n o RTG yellow lin e.
- I didn' t use h igh s peed a nd if I us ed high sp eed, th e low b ed might ma ke big damag e in fire fi ght ing p ipe .
3- Is t here en oug h lig ht for you during p arking?
- Yes , en oug h lig ht.
Operatio ns:
Moha med Ad el
E ngineerin g:
Az my Shat a
HSE : Moha med El-Tabeey
Brea kd own call asking for h oist wire rope insp ection ,after ins pectio n we fo und a
damag e in lan d sid e hois t wire rop e as sh own in th e atta che d pho tos.
fo r the incient
Wh ile RTG21 Ope rat or makin g han dover in 02 H02 h e fo und pilot la dder damag ed from
both p ilo t ladd er.
fo r the incient
February 19, 2013
2:00
OPS Red
Terminal Pickup
OPS-PU-11
Roo t Cause
People cau se:
- Poor decision making (t he invo lved pe rso n parked t he PU in wron g parking ).
RTG48 hit PickUP 02 while moving between 03J higher and lower
Wa iting
TS
Wa iting
OPS
0 7/03 /2 013
In vo lved Person: Name:

D epa rtm ent: OP S
29
1 7/02 /2 013
TS
3. Ins tall cat eye reflective ro ad or pa int red lin e on bot h sid es of RTG
lan e ( one met er dista nce) in so uth an d north pa rkin g areas to be gu ide
for pa rkin g equipmen ts un der RTGs .
1. Add t his cas e to TBT a nd highligh t tha t all su perviso rs mu st check

the correct p osition o f h is vehicle before leavin g.
Wa el Kh edr M ohame d
ID : 683
Pos ition: Gate cont roller
Expe rie nce: 7 mont hs
2. Prevent t he invo lved pe rso n from drivin g in th e terminal for one

mont h.
- The re was RTG in 03 H an d EX t rucks crowded in the s ame bay an d wh en RTG wa s movin g sou th side, there was EX t rucks which s topp ed on RTG yello w line So t hat I p arked my PU in
t he road an d went q uickly to st op the RT G and p reven t pote ntial accid ent .
- In t he same t ime th ere was RTG 4 8 which was working in 03 J b ut RTG wa s far abo ut 30 me ters, u nfortun ately RT G 48 move d and hit my PU.
fo r the incient
OPS - En g
2. All RTG yellow lin es in p arking area s mus t be rep aint ed.
1. Add t his cas e to TBT a nd highligh ted t he follo wing :

1. All RTG op erat ors m ust inform Yard sup ervisor in ca se of unclea r
vision.
2. All TR d rive rs mu st check t he safe p osit ion of TT or low b ed before
leaving th e equipmen t.
Co ntribu tory facto r

- In adeq uate re act ion to chan gin g circums tances ( there were EX t rucks crowded in the b ay a nd
t his leads t o wrong p osit ion for some trucks becaus e lack o f kno wledg e a nd cult ure for o ur sa fety
traffic rules so th at the involve d person was t ryin g to prevent p oten tial a ccide nt) .
1- Wh at is th e safet y p rocedure during p arking in ya rd?

- I mus t ensu re th at my P U far from the RT G line.
2 - W hy you didn't che ck the correct p osition ?
- Be cau se I was concent rat ed only t o preven t pot ential acciden t betwee n RTG an d EX t ruck.
3 - In your opin ion , can the RT G operato r see you r PU before m oving ?
- No, he ca n't b ecau se th ere is b lin d point for RT G operato r and I s top ped diesel sid e.
W itne ss Pers on: Name:
Moha med Abd Elka der Ahm ed ID : 30 5
D epartmen t: OPS
Positio n: RTG operator
Exp erience: 4 years
OPS
D one
OPS
0 5/04 /2 013
3. S end t he in volved p ers on to train ing for reass ess ment a ft er mon th.
Operatio ns: Nad er Helmy & Moh amed S aber
Eng ine ering: Ahme d Shawky HS E: Moh amed ElTabe ey
Eh ab Za hra n
Moha med Elhadidy
Ramz y Ma her
Possible 3* Minimum 1= 3
***
***
***
Add t his cas e t o TBT a nd highligh t that a ll RTG o perators mus t ch eck
t he co rrect co ntainer p osition before h andling a nd be mo re atte ntion in
case work load an d pres sure.
OPS
March 7, 2013
Open
Josh
20 /3 /201 3
20 /3 /201 3
new
Amr Rashwan
March 20, 2013
new
Amr Rashwan
new
Amr Rashwan
new
sameh haggag
- I was working in 0 3 J and wh en I was mo ving t o 0 3 J L, th e gate cont roller called me to st op but t he RTG h it th e PU and I s topp ed and h e told m e that I can g o a nd he will in fo rm the
sup ervisor.
4 - Can yo u see th e PU p osition from your vision ?
- N o, I can 't see b eca use th ere was b lin d poin t.
D epartmen t: Ops
Pos ition: QC operator

I wa s workin g normally wit h the QC 0 9 all m y 2 working h ours and I did nt com plain from any de fect s durin g my wo rkin g time except on e b reak down h app ened t hat th e twin moo d
didnt work properly but I made re set an d it ret urn ed to work properly for th e rest o f my working time on th e QC09 .
30
March 3, 2013
3:05
ops white
Spreader
SQ11/QC 9
fo r the incient
S tand by team re ceived call wit h twin u p fault , after chan ge Sp read er, received at
works hop ,no ticed th at SQ11 ha d a severe d amage in its Telescope te nsion rod
1- While your workin g tim e d id th e spreader get st uck or hit an y t hin g?

- No, noth ing h app ened mo re than the us ual op era tion .
2- Wh en you re ceived the QC 09, did t he las t operator com plain from any th ing ?
- No, he did nt ment ion ed any th ing .
3- D id you call t he mainten ance team whe n the twin mood was d efect?
- I told th e wh arf and afte r I pu shed t he res et bot tom th e twin moo d worked properly.
YE S NO
Accumulative damage
YE S
YE S
NO
Amr Rashwan
NO
NO

Direct S upe rvis or: N ame: Moha med Heg azy
D epartmen t: ops

Dep art ment : OPS
ID : 776
Po sit ion: Vess el su pervisor
Els ayed Ma hmou d Ab d Elh alem

ID: 1 154
Posit ion : RTG ope rat or
E xperience: 1.5 year
- I wa s workin g in 0 3 H 54 & 5 0 & 70 an d I had m uch wo rk. W hen I wen t to 03 H 5 4 to han dle cont aine r in ro w E, un fortu nat ely I han dle d con tainer in row D with m ist ake which was
plugg ed an d cau sed d amage in reefer s ocket .
31
March 3, 2013
17:20:00 PM
ops Red
RTG
RTG 0 3 han dled reefer M NBU009 264 9 @ 03 H 54 D1 I/O E1 wit h no pre vious notificatio n
which caus ed dama ge to th e con erne d socke t
fo r the incient
Roo t Cause
Pe ople caus e :
1. Lack of a tten tion .
Con tribut ory factors:
- Work loa d and press ure.
1- Wh at is th e safet y p rocedures du rin g han dling ree fer containers?

- 1. Adjus t the RTG on the b ay a nd go to t he co ntainer p osition .
2. check from th e n ew s yst em if the conta iner is plugg ed or u nplugg ed.
2 - W hy did yo u han dle wron g co ntainer?
- Becaus e of work load an d pre ssu re and I d idn t che ck the cont ain er pos ition befo re hand ling.
3- How lon g tim e yo u was working?
- I was in th e last h alf hou r.
4- Were you occu pie d with an ything?
- No.
- Yes, I sle pt six h ours.
Operations : Na der H elmy

Ahme d Sala held in
HS E:
E ngineering :
Moh amed E l-Tabe ey
If th e d eck controller was at tend ed this case, did you think t hat h e can avo id th is in cident ?
I don t t hin k s o, be cau se it was n orma l operations, but s omet imes h e can s ee the s tru ct ure of th e ve sse l wh ich I cant see it from the cabin.
YES
NO
YE S
32
March 10, 2013
17:00
ops white
QC
QC 06
fo r the incient
During loading under deck the wire stuck in a small ladder (vessel structure)
Underline ca use s
Activities a nd tas ks:
Th at du e t o the actua l emerg ency sit uations , ab sence of deck cont roller who is res pons ible to
make t he su rvey on th e structure wh ich may affect on the no rmal op erat ion s, cau sed th at cran e
op era tor didn t n otifi ed abou t the wea k po int s & blind p oint s (Th e ladd er) .
Roo t Cause
Wo rk environmen t effect :
Vess el st ru ctu re.
33
March 12, 2013
10:00
OPS RED
Terminal Bus
OPA BS 05
fo r the incient
34
March 12, 2013
10:30
OPS RED
RTG
RTG 25
fo r the incient
While Bus NO.0 5 movin g in th e road of 01 J the b us driver s lep t in th e wa y an d hit the
con tain ers No MSKU 0 907 316 . which located t here.
While RTG 25 is loading container NO.PONU0627104 on T 123 the container

stucked on the trailer
Und erline caus es

-Presen ce of old d amag e in the t railer ed ge (d ent) wh ich cau se th e stu ck bet we en the u nit &
ed ge
Root Caus e
-Traile r structu re with b lin d poin ts to o pera tor
Immed iate caus es

Cont ain er No. SZLU96 275 92 h it TT 141 a nd RTG 1 7
35
March 14, 2013
12:00
Ops Orange
RTG
RTG 17
Underline ca use s
The involve d person hit the fallen cont ain er du rin g full s peed t rolley back.
Roo t Cause
Pe ople caus e :
1. Lack o f exp erience.
NO
Mo hamed S eif
Mo ataz H weila
Moham ed Abbas
1- To add th is case t o t he TBT & to highligh t

the importan ce of safe working o pera tion s.
Probability 3 X Severity 3 = 6
2- To let th e d eck cont rollers ma ke a su rvey on th e vess el structu re

which m ay a ffect on t he operations & I cas e of deck ab sen ce it will be
th e resp ons ibilit y of th e vesse l sup ervisor.
1 - ops
2 - ops (VSV)
BS Driver
D id h e/she g ive a pre-s hift s afety talk: YES NO

Exp erience: 2years RTG Ope rato r the n retu rn BS Driver fro m 6 we eks .
I was d riving OPS BS 0 5 from
rth
b arking
to muyou
stersproom
suodde
nly esse
I feel
nooz
e and I s
urprised
by
cont ain er in fro nt of me .
Whenno
wa
s the
last time
oke to
r witn
d sthe
involved
pers
ons wo
rk?
- Ho w
mangythe
h ours
did you
sletion
pt yest
Durin
no rmal
op era
s timerd
e. ay?
Fromt he
9:30
pmels
t o st
4:30
am
Who is t he res pon sib le of monitoring
vess
ructu
re which may affect the op era tion s?
Khalid
ID: 101
8
- Did
yo u con
feeltroller.
fatigue ?
Deck
N O ,but t he weath er was du sty an d very hot which m ake me s nooz e .
De partmen t: OPS Positio n: RTG Op era tor
- When did you fe lt sn ooze ?
While I was in front of amen ity bu ild ing A

Exp erience: 2.5 years
- Did yo u take a ny medicat ion affect your con sciou snes s du rin g working hou rs ?
I was loading twin moves fro m this bay the n sub jected TR ent er un der RTG I catch th e rear un it an d hoist down 1 m eter ab ove the t railer t ill t he TR d river adjus t his p osition .when t he
- NO.
D river st oppe d .i cont inu e hois t down an d land t he un it th en I went t o next unit (fron t one )
- D id t here was p ass enge r with you ?
W hile load ing fro nt un it I su rp ris ed by so me cargo comin g from the rear un it from its bot tom.
NO. the bu s was emp ty from pas sen ger .
- Wh at was your hois t down s peed wh ile lo adin g rear unit?
- Did
you
yourlasnding
eat b elt
? sure correct p osition .
S low spe ed ,g enerally we
s top
hofast
ist ben
efore
to en
Ye tra
s, iler ( DUTCH LAN KA ) while loading p rocess ?
- What is the RT G operato r guide for t his t ype- of
Bu t wh en we (in vest igat ion t eam )in spe ct t he scene we foun d the b elt was fas ten on em pty se at
This type o f trailer have two b lin d poin t for th e operator
-wh y you
d idInt
use make
th e seat
b elt in prop
er way ?
- No,
didnt
any
ent.
1-t
he rear edg
e smovem
mall
All of m y colleagu e use
th e seat
elt in
that
way (o nly up per b elt on ly )
7- How
lon
g byou
was
working?
2 - the main ch ass is is ve ry narrow
and
middle
locks
not ap pear t o operator wh ile loading
wa ssto
workin
2 sure
h ours.
S o we d epen d on th e T R driver- Iwho
ppedgaFrom
ft er en
t he traile r is correct ly stop ped .
8 -opin
D id ion
youhsow
leep
wewe
ll yest
erdthis
ay? accid ent ?
- From your
can
avoid
Ye ible
s. to operator as th e m odifi cat ion on TT 1 18 .
To ma ke th e DUTCH LAN KA t railer d imen sio ns-vis
W hile RTG 17 loading ree fer co ntainer N o. MW CU658 030 2 From Bay 03 H 5 8 Row F 0 1 ,
It Hit Anot her Con tainer N o. SZLU9 627 59 2 From Ro w A Which Lead To Dama ge (Big
D ent ) In TT14 1 and fallen cont ain er, RTG 17 o ut of ord er for en g ch eck.G 46
fo r the incient
NO
NO
Direct Sup ervisor:

Name: Moham ed Heg azy
ID :
N ame:
ed Moha med
Soliman
086
D epa rtm
ent: OpWale
s
Position
: VesID:
sel s
upe5rvis or
D epa rtm ent: OP S Pos ition:
Imme diat e cau ses

OPS BS 0 5 Collide wit h con tainer in 01 J
Un derlin e cau ses
Lack o f at tent ion /d ue care
Misu se of seat b elt
Root Caus e People cau se
Imme diat e cau ses
-cont ain er st uck on t he traile r
N ot following /incorrect followin g of stan dards/p rocedures
YE S

Really I dont kno w.
YES
Hate m H osn y
Mah moud D orma n
M ust afa Fath y
Minor* possible = 2*3 =6
Severity (1) X possible (3) = 3
NO
YE S
N ader Helmy
Moh amed Elhad idy
Mu stafa Arn ous
YE S
NO
NO
Sa meh Hag gag + Moh amed Adel

Amr Ham za + Ah med Sa lahe ldin
M ohamed El-Tab eey + M ohame d At ef
NO
Probability (3) * (4) = 12

- We can in stall ce ll gu ide in a ll ba ys in A a nd G to p reven t any falle n con tainers.
Tamer Ab u Sle ma
ID:
150 1
Depa rtm ent: OPS
Pos ition: Yard sup ervisor
D id h e/she g ive a pre-s hift s afety talk: YES
Add to all driver TBT :

1-re port any abn ormalities ,feeling fatigue or snoo ze to direct
s upe rvis or .
2 -Imp orta nce o f s eat belt and exp lain con seq uences of misus e
OPS
E NG WS t o start app lyin g the mo difi cat ion for a ll DU TCH LANKA traile r
a s samp le trailer 11 8
ENG WS
1 Se nd th e involved operator to training d epartmen t for re-t rainin g.

2 Add th is case to TBT an d hig hlight ed tha t
1 . All RT G operators mu st us e t he scree n for check p rocess d uring
o peratio n and in form th e Yard su perviso r abou t any defe cte d screen .
2. All RTG op erat ors mu st u se slow t rolley s pee d in case of 5 tie r.
3. All RTG o pera tors mus t ensu re th at spreader in ze ro pos ition before
tro lley.
3 Add n ew m odifi cat ion for all RTG that in ca se of hois t level above 3
tier, the trolley s peed will be s low aut omatically.
4 Det ect the places in which t he sam e incide nts h appe ned d uring th e
last year in ord er to s tud y t he reas ons b ehin d th ese kind o f inciden ts
( RTG h it conta iners) .
OPS-Train ing
OPS
ENG - OPS
S afety - OPS
1 5/03 /2 013
1 7/03 /2 013
Un der t est
Und er st udy
NO
W hen was t he las t tim e yo u spoke to or witnes sed t he in volved p ers ons work
h our
Witness Person: Name :

Abd Allah Ah med Na em
ID : 34 00
W hy you didnt ope n it?
D epa rtmIn
ent:
OPS
ition:
TR driver
( Cambell)
dischargin
g operations wePos
us ed
to work
wit hout
it.
Immed iate caus es

Twin twent y Ft conta iners lift ed by 40 Ft mo de .
36
March 16, 2013
19:30
Ops Orange
Spreader
37
March 18, 2013
3:30
Ops Blue
TRA
38
March 19, 2013
1:30
Ops Blue
Terminal Pickup
39
March 19, 2013
23:30
ops white
TRA
SQ 14
TR120 & TR85/TT137
ENG PU10
TR 39 & ENG PU 08
contractor Co. n ame; if While QC0 4 S Q 14 was h and lin g on CMA CGM CORNE ILLE @ bay6 2 ,t he ope rat or lift t win
co ntainers while the sp read er was in 40 feet mod e
fo r the incient
Underline ca use s
People cau se:
1- Commu nication ( Commu nication of rules )- As th e wh arf controlle r didnt gave t he clear
ins tru ct ions of b ay plan a ft er ope nin g the cent er hat ch cover.
Mana gemen t & Su pervision
( D ecision Process ) - D eck cont rollers n umbe rs n ot adeq uat e with th e wo rkin g load s.
Roo t Cause
People cau se:
3- Attitud e & beh avior:
No t follo wing th e ru les.
A- The op era tor us in g the Bypas s with out p ermis sion from his sup ervisor.
B- The op erat or no t using th e s creen.
Poo r decis ion ta ken , as t he operato r decide d the kin d of con tain ers witho ut check, he ju st
d epen ds on h is p reviou s experien ce.
N ot follo wing correct procedures/sta ndards. (Driv er didnt keep a sa fe dista nce between his Truck a nd fro nt o ne).
T R120 collided with T R85/T T137 causing slight dent in T T137 and bro ken gla ss of TR120 and slight dent
in the cha ssis.
-lack of attention.
fo r the incient
Techno logy Ca use:
Eng -PU10 righ t front g las s broken d ue to falling wrench durin g tig hten ing CR41 o perator -Equipment to fit for purpose (As the pla ce which the technician wa s tightening the bo lt was very narrow to rea ch
by human hand.
ca bin b olts
fo r the incient
fo r the incient
While TR39 at tached TT1 42 doing man euverin g behind QC14 hit Eng -PU-08 wh ich wa s
wa iting in waitin g area.
Bad decision making (miss calculating the distance of maneuvering)
Are you train ed for th at you men tion ed in t he abo ve?

No , we traine d abou t using th e screen in all cond itions.
Ca n you des cribe wh at hap pened ?
Why you didnt as k th e wharf cont roller in ste ad of using th e b ypas s?
-I wa s dis ch arging 2 twin co ntainer from my a ddre ss un der QC 13 th en I moved to berth I waited for clea rnes s from moving trucks on berth , th en I ad jus t my t ru ck straig ht I fou nd Tru ck
I think tha t this con tain er as a n open t op & th e spreader deal wit h it as t his t ype, so I us ed th is comman d.
su pervisor was in th e mid dle of my way a nd I s aw h im asking th e front truck t o dis ch arge , th en the t ruck driver slow down and then s top ped su dde nly an d sud denly I hit t he truck was
D id you ma ke th is be have in you r gen era l operations?
movin g in fro nt of me.
Afte r open ing the ha tch cover I saw th e cont ain er in t he 1s t raw in s easide was 40 Ft & a s the n ormal op era tion t he 1s t raw sea sid e is th e s ame in t he 1s t in la nds ide, so I d eal with it as
Do you ha ve a ny family p roblems may effect the work ?
40 Ft.
-No, I do nt.
Befo re start discharg ing from this bay, did you ask the wha rf abou t your d ischa rgin g plan?
What wa s your s peed ?
No.think I have sh ifted t he 2nd gear, I was less t han 2 0.
-I was just mo ved down of th e crane an d I even do nt
But I was m oving with two cont aine rs each on e was abou t 18-1 9 tons wh ich may ca use th e tru ck not t o stop immed iate ly.
D id
you
receive
p re-shnce
ift safe
ty well
talk: before
YES m oving
NO
D id yo
u ch
eck
for th ea cleara
very
?
-Yes, I hit him after my tru ck was in s tra igh t pos ition.
Wha t abou t the fron t driver ? h ow wa s he drive?
-He slowed down s lig htly a nd imm edia tely st opp ed, a nd I d id so as well.
Are yo
aware
of the
proceen
dures
related
t his
Whuat
was the
d istrules
ance /betwe
your
t ru ck to
and
t hework:
front oYES
ne? NO
-It was abou t 40 con tain er.
required
you
wearin
correct
PPE
S NO
I t hin k 4 0 con tain erIfis
e noug h, were
to st op
if you
aregdthe
riving
le ss th
an: 20YE
Kmph
, what d o you think ?
-Ye s, b ut du e to weigh t of two con tainers I co uld n ot be ab le to st op the t ruck and I me ant to mo ve t he TR head awa y fro m t he accident b y stee rin g right b ut I failed. ( I said
yo u treceive
su ce
pervision
in tcont
he las
1hrdistan
of you
work:
YE SainNO
ap proximately Im n ot suDid
re with
he dis tan
if it s 40
aint er
cer or
20 cont
er len gth ). T he driver s aid.
Did you obs erve t he sto p lig hts fo r the fro nt TT? D oes th ey we re workin g?
1- To follow th e s afe han dling proced ure s.
-N o, actu ally I d idn t n otice.
2 - To as k th e dire ct s upervis or be fo re using th e Byp ass comma nd.
Als o h e adde d this is no t the place wh ich the Truck can st op on th e wa y s o I did nt expect him t o s top .
Involved Pers on ll : Name: Ahm ed Rag ab ID : 32 19
Invo lved Person II: N ame: Adel M ohame d Elwakeel
ID: 01 566
Dep art ment: OPS
Positio n: T R D rive r.
Experien ce: 1 Year and half.

Can
escribe
appe
ned ??
Ca
n You
you d
des
cribe what
wh at h
hap
pened
-- II wa
so
on
4 1 to
s ome
tig
ing
inside
erat
orgcabin
is jo TR
b requ
ired
ers Ions
o ne
for tight
and thorns
he othto
er ha
forrry
g ras
pinbut
g the
oltnt
it self
an dthe
tha
for
was
n RTG
my way
todo
b ert
h 08bolt
to ge
t hten
a con
tain
er forop
cha
rgin
I founadnd
cath
ptain
s top
ped2tp
hen
s low
down
an d ening
give s ome
him
h e bdid
move
n tI place
moved
t overy
t he
for Ihan
age
ha my
nd movem
ent, Cap
so I lo
e tool
an d it fallen
oth er la ne ( the op pos ite directio n), I ch ecked tnarrow
he mirror
foudndtothman
e tru
ck at
back, t hen
Trst
ascontrol
k m e t ofor
gothfor
discharge
(by usdo
ingwn.
hand s ign s which is a comm on lan guag e for us ).
Did yo
u you
use a
t he
globves
thden
is proce
D id
pply
reakfor
sud
ly ? ss?
s, It used
it. d own. (the t ruck did nt sto p)
N o, I d idn t it was a slight p resYe
s jus
to slow
Did g
the
wre
nchd wa
I was just re ducin
my
spee
to scooily
me?und er th e QC.
it was
no t. was clos e to you ?
Can you o bserve if theNo,
b ack
TR driver
H ow do youNo
th ink
we nt
canobs
a void
th at incid ent ?
I could
ervereo
,thccurrence
en I askedfor
h im
We can
aout
spe4cia
tool for
such
proce
Wasuitseab
0l conta
iner
leng
th ? ss.
Experien ce: 14 Mon ths
N o, arou nd 20 co ntainer leng th.
I was wait ing behind QC 1 4, t o g et my co ntainer con firmed b y the QC 1 4 Wharf, b ut he to ld me to move t o QC 12 to confi rm the cont aine r, a nd when I was don t he co nfirm atio n behind
QC 12, the re was a T R waiting beside me and there was ENG PU 0 8 wa iting in front of this TR, an d the re was als o anot her TR was be hin d the PU by a distan ce of a leng th of a TR
Did you ch eck for yo ur ta il light s before g et in to your Truck ?
( a pprox 13 m eter).So I st art t o maneu ver be hin d the EN G PU 08, but u nfortun ately my TR rear rig ht rubb er wheel cla she d with th e PU back, causing th e ENG PU forced t o move toward
Yes , I was wo rkin g becaus e wh ile I was dis mant lin g it in W S the cable fo r lig hts wa s plu gge d.s
the fro nt TR and also hit it .
Direct Sup ervisor: Name: Moah med Abde lgawad .
ID:
1- Could
se: eOps
t he PU in you r mirror
whe n you
mane
d?
Dep artyou
ment
Pos ition:
Truck
supuvere
ervisor.
- I st art ed to couldnt see it when I b egan t o s traigh t my TR in the main drive way, an d hen ce th e accid ent h appe ned.
2 - Did t he ENG PU 08 was in t he wait ing area before yo u cam e t o QC 12?
S tat ement : the driver jus t slo w do wn but h e d idn t stop I had do ubt t hat he was u sin g a mobile ph one
- Yes , it wa s in th e wa iting are a, an d was the re even after I get t he co ntainer confi rmed a nd st art t o m ove my T R.
Bu t I ch ecked h is jacket but I did nt found a h eadp hon e.
3- Did you see t hat th e dis tan ce bet ween th e othe r TR a nd ENG PU 08 could let you pa ss be tween th em?
-an d the d ist ance he was ke epin g bet ween th e t wo t ru cks was n arro w.
Yes , I sa
it he
waswas
enou
gh, it was
proximately
d istwhich
ance of
Rshle
ngt h.
-th e- twins
whwich
moving
wit hap
was
abou t 32 a
t ons
is Tnot
eavy
twins .
Did yo
a pre -shift
ta lk:
S an
NOd accord ing ly he slow d own.
Also Cap Tru ck feel th at he was respo nsible
t ou areceive
sk t he driver
wh ilesafety
h e was
on theYEway
YE S
YE S
NO
NO
NO

- No p ick up s wait in this area (t he wait ing area beh ind t he back reach).
D irect Su perviso r: Na me: H any Nou r
ID : 358 8
De partmen t: o ps
Pos ition: T R su pervis or
Mo hamed Adel
Moh amed E lhad idy
Moh amed Abb as / Moham ed At ef.
Probability possible (3 ) X Severity ( 2 ) = 6
1- To add th is case t o t he TBT & to highligh t the importan ce of following

th e safe working proce dures .
Ops
April 1, 2013
Open
Mohamed Elaraby
Khaled hega zy
Ahmed S alah eld in
H ish am Is mail
Add t o TBT t he imp ort ance of keep ing

a s afe dis tan ce
b etween t rucks es pecially with lo adin g twin
cont ain ers with hea vy weight .
Ops
March 25, 2013
Open
Mohamed Elaraby.
Khaled hega zy
Ahmed S alah eld in
H ish am Is mail
Severity ( 1) * Probability (4) = 4
1-A s pecial t ool has been re ques ted from Eng . De p. To be us ed in ste ad
of hu man ha nd to be ea sily access ible fo r work pu rpo se.
2-Ad d to TBT abou t the im portance of using PPE all the time as th is to ol
might fa ll on s omebo dys head .
Eng.
1-Reass ess ment of th e d river

2-Add to th e TBT t he imp ort ance of n ever t aking t he risk and ge t
maneu vering in s uch situat ion.
1- ops t rain ing

2-op s
Eh ab Za hra n
Ahmed Salah
Ramz y Ma her
Possible 3* Minimum 1 = 3
19 -04- 201 3
Open
31 -03- 201 3
1-2 1/3/20 13
2 - 24/3/2 013
new
Amr Rashwan

Dep art ment : OPS
Immed iate caus es

TR 36 Hit TR 23, wh ich st oppe d on lan e 0 2
Underline ca use s
The TR driver was d riving & maneu vering in a h igh s peed o n a slipping ground .
40
41
March 24, 2013
March 26, 2013
5:00
20:00
OPS Orange
OPS Blue
TRA
Spreader
36
SQ 22
fo r the incient
fo r the incient
while TR 36 make Man euver h it TR 23 which lead to h eavy d ent on tru ck 36 righ t and
left sid e bod y frame and b rooke the fro nt glass.
During loading a container, the fl ipper hit the hatch cover in blind side
Roo t Cause
Pe ople caus e :
1. Lack of a tten tion .
2. Not followin g the p rocedures (involve d TR d rive r was man euvering with a hig h sp eed) .
3 . Poor d ecision makin g (Th e involve d TR d river directed to lane 01 an d su dden ly ch ang ed his
d ecision to lan e 0 2).
En viro nmen t cau se:
1 . Slipp ing g rou nd.
Organizat ion caus e: tas k requireme nt (Nu mber of d eck cont rollers a re not ad equa te with n umb er of operated QC).
People cau se:Poor de cision m aking ( h ois tin g up wit h full s peed on blind point) .
Immed iate caus es

RTG 38 hit TR 14 0.
Underline ca use s
TR 1 40 was in wrong p osition ( on RTG lane) .
Wh ile RT G 38 Mo ved from lowe r to higher in 06 E , it h it TR 140 wh ich stop ped clos e to 06
Roo t Cause
E L and lead to d amage in RTG 38 guard and s teel chain gua rd
Pe ople caus e :
fo r the incient
1. Lack of atte ntion (Th e involved TR d river concentrate d to his sup ervisor an d forg et to re-ad jus t
his pos ition).
2. Not followin g pro ced ures (The in volved TR d river did nt ens ure th at his TR away fro m RTG
lan e).
42
March 29, 2013
17:00
OPS Orange
RTG
38
43
March 29, 2013
15:30
OPS Orange
QC
CQ13
fo r the incient
Du ring normal op erat ion on QC13 we received a BD N ca ll as king for h ois t wire rop e
in sp ect ion ,after insp ection we fou nd clear d amag e in right s ea sid e hoist wire rop e.
44
April 6, 2013
1:30
OPS White
Spreader
15
fo r the incient
While QC1 1 dis c on M /V ALABAMA t he twin box h it corne r co st of one of th e remain on

ves sel while vess el moving.
Im mediate ca use s
Th e spreader hit t he un even twin con tain ers in the n ext row
Un derlin e cau ses
The vess el moved s ud denly wh ile QC 1 1 hoist down u nde r deck.
Root Caus e
People Cau se:
1- Failure t o reco gnize ch ang ing in circumst ances (t he deck cou ldn t reco gnize tha t the ves sel
cou ld move ).
2 - Ineffective iden tifi cat ion of ha zard ( t he un even twin con tain ers wa s so close t o t he pre vious
row wh ich the QC workin g in it , that rais e the risk of co llision ).
Yass er Mo hamed Ab d Elwakel ID: 3 165

Position : TR d rive r (Camp bell)
Exp erience: 2.5 years
TR 3 6 parked a t Campb ell carava n and TR su pervisor informed me to t ake th e TR. I took th e TR an d open ed th e s creen an d found m y d irection to QC 15 on the s cre en.
Wh en I directed t o QC 15, I not iced many TRs were s tand by for ves sel on b ert h 06 an d I ch ose th e fewest t raffic lane wh ich wa s lan e 0 2.
Wh en I was ma neuve rin g, I used the brakes and my TR slipp ed and I lost t he co ntrol so th at My TR h it TT 57 wh ich stop ped on lane 02 then m y TR mad e V-sha pe and cont inu e slipping
toward sea side th en I pu lle d the ha nd brake an d fort una tely th e TR s topp ed at qu ay marg in.
1 - What was yo ur s peed ?
- Norm al sp eed.
2- Did you know you r spe ed exactly?
- No , I didn t b ecau se th ere is s peed omet er.
3- What wa s the dista nce b etween you and TR 23 wh en you us ed the b rakes?
Involve d Pe rso n: Na me:- ApOsam
a M oss2
ad
ID : 36 96
proximately
0 Selim
m.
Dep artm ent: OPS 4- Is the b rakes working
Po sit ion:
TR d rive r (Kot bey)
well?
- Ye s. Exp erience: Nin e mont hs
OPS: Moh amed Adel

E NG : Moa taz He wila
Safe ty: Moha med Eltabe ey & Moha med At ef
5 - How hours you was working a ft er your las t rest ?

- I came from t he qua y an d directed to 0 6 E H. Wh en I arrived to 06 -E,2I hou
not iced
rs . 2 TRs which s topp ed in t he beg in of 06 E H s o I waited t he 2 TRs.
- 06 E 3 8 A d idn t h ave6 -any
ntainer
ed ay?
my pos ition at 06 E 3 8 B.
D idco
you
s leeps o
weI lladjust
yest erd
- I foun d TR wh ich ca me from 06 E L (un der RT G) so I revers ed back to allow t he TR to pas
s the
- Ye
s. n I not ice d TR s upe rvis or came bes ide me a nd I concent rat ed with h im and was nt pay
att ention to RTG sire n and I forgot t o re-adjust m y7p-osition
a gain
s o tra
unfortu
nately
RTG 38
D id you
con cen
te durin
g driving
? h it my TT becaus e my TT was o n the RTG lane .
- Ye s.
1 - W hat is the sa fety proced ures you
fo llow
when
uatstop
o n?the ro ad bet we en hig her & lower?
Can
Yo
u describe
wha
tse
happ
ened
8-must
D id
you
wear
theyo
belt?
I adwh
jusich
t my
n after
RTG
tu
rning
late sain
away
RTGI Lane
-I wa s load ing cont ain er at 4t h raw se a s- ide
is positio
a blindnpbetwee
oint a nd
free
thep cont
er I from
hit while
was .raisin g the s prea der caus e the d amage.
- No.
2-- W
Wh
t he
o f tyou
rcran
mirrors?
Was
itisyo
ur st
1satus
t wear
move
on sea
9
hyatyou
didnt
he
t e?
belt ?
ood.
-n o it was th e 4th mo- -ve
b
ut 1s t at th e blind point.
IG
forgot.
3- Did you us e yoDid
ur
tofuen
sure
t hat
youhoist
rgTT
away
yoWa
u use
sp
eed
while
up ? from RTG lane?
10-mirrors
s the
slleat
belt
workin
well?
- N o, bu t my Truck wa s in man
mood so I d idn t see th is case.
Yes.
- I euverin
don
t kngow.
Was th ere a deck con troller with you at t he tim e o f inciden t?
4- Did you
not iceon
any
in he
06 may
E L when
youwit
a rrived?
- No, we were working
4 cranes
veRTG
sse lsso
be b usy
h othe r QC ope rato r.
No,
nt call
any him
RTG ?
.
S- o,
whthere
y youwas
d ont
-becaus e its normal procedure fo r me and Im fam iliar with it.
D id you re ceive a p re-s hift sa fe ty talk:
YES NO
If its a no rmal p rocedure wh at you th ink th e role of deck con troller ?
D id
you
rece
ive training
h ow
to do
thch
e targ
asking
invo
Y ES
Fo r open ing
/clo
sin g
h atch
covers ainnd
loa din
g/dis
inlved:
cas e of
stu ckNO
con tainers.
yonuot
aware
thesprule
/ p rocedures
o take
his an
woyrk:
YE S ceNO
IfAre
you
usingoffull
eedswhile
hoist uprelated
d oes it tm
d ifferen
?
volved
Person
: Name
Abd
E l Megee
d Ah
med
E l Mege
ID: 281
-ye s, a nyInalso
t here
was an
open: to
p con
tainer an
d it
h asAbd
a wide
ba seed.
which mad e it more d ifficult
fo r vision.
epa rtm
Opyou
s
Po sit ion
: : QCYope
IfDrequ
iredent:
, were
wea rin g the correct
PPE
ES rato
NOr
Expthat
erience:
Live s tat ement h ad bee n taken for th e deck cont roller, he men tion
h e wa6s yea
not rs
wit h the Crane time of incide nt.
I s tarted wit h QC 11 t o dis ch arge t he co ntainers and
t he
first
move
was
u nder
deck
the
row
Qu ay
sid
ehat
to
han dle
a twin
tain
ers b ut we foun d (me & t he deck con troller) that t he
Did
receive
su is
pervision
in any
t4t
heh las
t 1hr
ofion
yotur
work:
Y ES
Also
st ructu
reyoofu the
ves
sel
freein
from
d
eformat
may
caus
e tNO
hecon
dam
age.
twin was u neven ( one of th e t win conta iners was a little b it to wa
rd th
e you
previous
3rd rowt cou
Qu ay
sid e)
and
t he
reade
How
do
t hin kro
thwis(inciden
ld be
a vo
ided
in sp
futu
re? r co uld nt cat ch it. S o we d ecided t hat th is t win co ntainers will
be han dle d as a two sep arat ed singles co ntainers (no
I know
t with
tha
t he
t this
twin
my
mo
mist
od)ake
an db left
ut I th
mu
isst4tbe
h row
mo re
and
atte
g ontion
t o the
to ot
my
hers.
posW
ition
henand
I reach
RT Ged
siren.
to discharge from th e 3rd ro w q uay sid e I han dled
t he first twin con tainers and
while I ho
ist d:own
toe:get tMo
hehamed
next twin
rpris
ed tha t the s pread
er82
st uck & stop ped s udd enly.
Involved
Person
Nam
AbdI su
Elha
med
ID : 14
D epartmen t: OPS
1- Was th e t win conta iners which you h and led in t he 3rd row quay s ide in the s ame leve
l to the u neven
t win co ntainers in t he 4th row q uay side which you h it?
E xperience:
1.5 year
N o, it wa snt even b eca use t he twin wh ich I was in tend t o hand le in t he 3rd row wa s in 1s t tie r and t he twin wh ich I hit in the 4 th row qu ay s id e was in th e 4 th tier, and t here was n o
pro
wh ile to
I h0
andled
t win in tthe
3rd
row
qua
y sat
ide0which
lso was
th ant here
the uwas
neven
win conta
iners
instoheI use
4thdrow
q uay
side
- I was in 0 6 E L th
enblem
I directed
6 E H. th
I seurprised
hat2n
thdetier
RTGinga
ntry
s top
ped
6 E 40aand
I tholower
ugh t that
a ptroblem
in ga
ntry
bypas
s bu
tton. a nd I completed
2- Did you feel t hat
ganth
trye th
vesse
en I lsmoved
topp ed (m
when
ake TR
listdriver
or trim)
informed
while you
mehoist
to st op.
do wn t he sp read er?
5- Wh at is t he safe
I d idn
tytprocedu
n otice th
res
atdthe
uring
vemove
ssel mfro
oved.
m b lock t o block?
3- Was th ere
with
youed
atat
t he
1. aI deck
slow RT
G spe
batime
y 3 8.of inciden t?
Yesthe
, heswas
me.
2 . I clos ed
preawith
der t o
2 0 mood .
4- W hy did nt you han dle th e une ve n twin cont ain ers in 4th row
uayckside
sin gle scont
rs be
ha ndled
the
3 . I qche
that ansoavehicle
comaine
e and
nofore
RT Gyou
make
9 0 gan
try.t win co ntainers at 3rd row quay s ide to avoid such acciden t?
It was th e D eck d ecisio n not
mine
becaus
e
he
see
t
he
sit
uat
ion
more
cle
ar
th
an
me.
4. Did yo u sto p at end of 06 E L?
5- Wha t wa s your s peed wh ile you were
hois tin g down in the time of accid ent?
- Ye s.
5.
It was
D id you
th e norm
n oticealth
speeed.
T R?
- No , becau se the TR was st opp ing clos e to the cont ain ers an d mos t of b ay wa s 5 tie r which consider a b lin d point to me an d even if th e s pre ader was in 20 mo od, I will n ot be ab le to
D id you rece ive
a pre-s
s afety talk:
YES N O
n otice
th hift
e TR.
6. Was th e RTG siren working well?
D id you rece ive training in h ow- Ye
to s.
do th e t ask invo lved: Y ES NO
YES NO
Are yo u aware of the rule s / p rocedures related t o t his wo rk: YE S NO
D id you rece ive training in h ow to do th e t ask invo lved: Y ES NO
If requ ired , were you wea rin g the correct PPE : Y ES NO
How
doired
you, were
t hin k you
th is wea
inciden
coucorrect
ld be a vo
ided
inES
futu NO
re?
If requ
rin gt the
PPE
: Y
Start to han dle t he un even twin con tain ers fi rs t.
D irect Su perviso r: Nam e: S aad Ka mel Ashry
ID: 8 83
D epartme
Did yo u nt:
receive
ops su pervision in t he las t 1hr ofPo
yosit
urion
work:
: VessYel
ESsu perviso
NO
r
D id h e/she g ive
a pre-s
- I don
t knhift
ow.s afety talk: YES NO
D irect Su pervisor: Nam e:
Ta mer Abu S lema
ID : 15 01
When
s the la
time you sp oke to or witn esse d Positio
the in volved
p erssons
D wa
epartme
nt:stOPS
n:
Yard
upework
rvis or
Involve d Person : Na
AdelgD
yaa
D een
y.
ID: 11 96
Didme:
h e/she
ive
a El
preshift Bayoum
s afety talk:
YES NO
D epa rtm ent: Op s
Po sit ion : D&W Controlle r
yea rs wo rk half ho ur.
Whe n was the last time you sp oke t o o r witn ess edExp
theerience:
involve d6persons
We s tarted working wit h QC 11 at b ay 30 by ha ndling a twin con tainers from th e 4 th row qu ay sid e u nd er deck but we could nt du e t o the twin was une ven. S o we s tarted t o h and le the
con tainers in th e o ther rows (1 st ,2nd row q uay side) an d after fi nis hin g them we st art ed to ha ndle t he twins conta iners in t he 3rd row. We han dled from th e 3 rd row qu ay sid e 3 twins
co ntainers and n o p rob lems h appe ned an d while t he QC op erat or ho ist ed down t he spreade r to get t he 4t h twin from t he sam e row, it h it th e uneve n con tainers on the 4 th row qu ay sid e
(the n ext row).
1. Prepare Ris k As sess men t fo r traffic un der Qua y cra nes ro ad.
2. Add t o Traffic SOP t hat an y veh icle driver mu st ma neuve r with s low
spe ed (es pecially in a slipp ing g roun d).
3. Add t his cas e to TBT a nd highligh t tha t:
1- TR drivers m ust check their trucks before d riving (S eatb elt, Brakes,
Mirrors, et c ..).
2- TR drivers m ust b e m ore att ention du rin g drivin g und er Q.Cs .
3- TR drivers m ust ma neuve rin g with s low sp eed.
4- TR drivers m ust inform th eir S.V abo ut an y d efect in the Truck.
5- All TR driver mu st fast en se at belt during d riving .
3. M aking S urvey fo r all Trucks seat b elt an d send to worksh op for
repa ir.
4. Trucks with u nlimite d spe ed mus t be sen t to work sh op to lo ck spe ed
(limit s peed ).
5. S end t he in volved TR driver t o Train ing D ep. Fo r reas ses smen t
OPS
0 1/04 /2 013
OPS Trainin g
27/03 /020 13
OPS
2 9/03 /2 013
new
Sameh Haggag
Wa iting
OPS
HSE : His ham A.Ismail.

En g: Moham ed Had idi
Op erat ions : Khaled Heg azy
WS
Wa iting
OPS train ing
OPS
Recommen dations t o p rovid e with ea ch QC o ne deck con troller

t o ensu re safe r han dling st eps .
Ad din g to th e briefing
Give ins tru ct ions fo r QC op erat ors t o redu ce sp eed ho ist u p while
ha ndling in blind po int s.
waitin g
14 -04- 201 3
Josh
op s
HS E: Moham ed Elt abee y + Moh amed Atef.

E ng: Azmy Sh ata
Op erat ion s: M oham ed Ad el
1. Add t his cas e to TBT a nd highligh t tha t all TR drivers must p ay more
atte ntion to RTG s ire n and check h is righ t pos ition to ens ure t hat his TR
away from RTG lane.
2. Paint 2 red line s for each block (fro m A to G ) in th e road be tween
hig her a nd lowe r to be gu ide for TR d rive r durin g waiting be tween
hig her & lower (s ee the at tached p hot o N o. 02 fo r more clarification) .
OPS
6/04 /201 3
Term inal Serice
un der stu dy
new
Amr Rashwan
Op era tion s: Ehab Zah ran

E ngineering : Mota z
H ewela
HS E: Ramzy Mah er
Possible (3) * Min 2= 6
Add to t he TBT the im portance of giving more a tten tion in su ch

s itu ations an d be more carefu l while hand lin g in s uch environmen t, a nd
always t aking in con sidera tion s th e u n expectin g ch ang ing in
circu mst ances
OPS
April 11, 2013
new
Amr Rashwan
OPS
4/15/2013
New
Amr Rashwan
New
Sameh Haggag
New
Sameh Haggag
new
Amr Rashwan
new
Josh
1- Did the you r vision was clear during e very move?

No, becaus e I wa s sta nd on th e cat walk o f ba y 3 4 due t o n o hand rail wa s exist in the cat walk of bay 30 ( Natu re of the ves sel).
2- Wh at was th e spee d of t he hoisting do wn the sp read er at th e time o f acciden t?
It was the n ormal s pee d, an d the s ame sp eed of han dling th e p revious 3 twins cont aine rs on t he same b ay (3rd row quay side) .
Immediate causes
TR 09 Reverse back and collide with ENG PU 01
45
April 6, 2013
20:10
OPS Red
TRA
TR09
fo r the incient
Underline causes
While TR09 was moving between 02 lower & Higher to get quay side,he
notice his colleague coming from quay side ,he stopped to talk with him. and
while reversing back he hit ENG PU 01
TR Driver
1-Failure to recognize changing in circumstances(presence of PU in blind point to
him )
2- Lack of attention/due care
Root Cause
TR Driver didnt follow SOP (Reverse back without guide )
- while your training period

or working
,did(m
you
to reverse
back
Yard
or under
QC without guide ?
3- Did you
feel t hat in
th eoperation
vesse l moved
aketrained
list or trim)
while you
hoistindoside
wn t he
sp read
er?
Yes ,No
it mo
a lit tle.
,I ved
didnt
4 - W hy did nt you st art ed to ha ndle t he un even twin con tain ers in the 4 th row qu -Why
ay sid eyou
a s areverse
sin gle cont
? aine rs (n ot with twin moo d) befo re you sta rt ha ndled the t win conta iners in t he
3rd row q uay side?
To ask my colleague which QC he working
with, I was stopped near RTG turning plates .
Becaus e it nee ded to s hift th e QC 11 to t he lift an d it was nt poss ib le becaus e QC 14 was b roke d own and t his fo rbid the mo vement o f QCs 13,12 ,11.
-Did you check
the way behind you before moving backward ?why
5 - D id you a sk the en gin eering te am to move QC 14 ?
No , because I have reefer unit on
my trailer which block my vision .
No.
-How
many
meter
Did you
receive
a pyou
re-shmoved
ift safet ybackward
t alk:
Y ES? NO
About 1.5 or 2 meter
D id you rece ive
training
in h ow
to do you
th e tby
ask horn
invo lved:
Y ES NO
-Did
PU Driver
notify
?
Yes but I didnt hear due to my TR engine noise but my colleague try to stop me by shouting and horn but I realized after collision tack place .
Are yo u aware
of the
/ p rocedures
related
t o t his
-Did
therule
PUs driver
switch
the light
onwo
? rk: YE S NO
Yes ,after accident I descend the
TR I found light on but he was in the middle of my trailer and visible to me .
Witness: Name: Wael Abd ELshafi Mohamed ID: 0060
Did yo u receive su pervision in t he las t 1hr of yo ur work:
Y ES
Hatem Hosny
Moataz Hewella
Mustafa Fathy
Min2* possible3=6
1-Exclude this TR Driver from OPS rooster till reassessment

2-Add to TR Driver TBT Traffic rules refreshment
NO
Elec.T
ech.
How Department:
do you t hin k thENG
is incidenPosition:
t cou ld be First
a vo ided
in futu
re?
Start to han dle
t he un even: twin
con tain
Experience
9 years
. ers fi rs t.
D irect Su
perviso
e: S aad
Ka melunit
Ashry
ID: 8his
83 maneuvering then start move when we reach F
I was in my way to BND at 02 E I notice TR 09 coming
from
02r:GNam
carrying
reefer
so I wait him to make
D epartme
nt:he
opsstopped and moved backward
Po sit ion
: Vess
el su. perviso r
block
and
hit me
Involve d Person : Nam-Did
e:
Ahme
d Rag ab
Saye
ID:
15 55
you
notify
him
bydhorn ?
epartmen t: OPS
Yes , but I get confused whenDthe
TRDid
stopped
predict
if talk:
he will
or he will revered his direction
h e/she ,as
g iveI didnt
a pre- shift
s afety
YEScontinue
NO
Exp erience:
1.5
years
-when you realized that he reversing back ,Why
didnt you
try to avoid him?
I the
start
moving
he
was
already
hitlved
mepe.cont
W her
hen bwas
t he
lasves
t time
totoorbay
witnes
t he
invo
rso ns
- I was working in anot
ay on
sel tyou
hensback
ipoke
wen tbut
58 Used
and
ha ndled
twin
ainwork
er th en 40 feet con tain er.
- When I wa s load ing 4 0 feet conta iner, t he co ntainer t end ed on th e cell guide the n back t o its n ormal p osition a gain then I hois ted d own the cont aine r in th e und er de ck.
- I tried t o unlock sp read er twis t lock b ut it wa s not working s o I asked for en gin eering an d the y t old me to p ut th e con tain er on lane 06 t hen t he wharf cont roller to ld me th at the re is
dama ge in t he co ntainer.
46
47
April 10, 2013
April 11, 2013
3:00
2:30
OPS Orange
OPS Blue
Spreader
TRA
22
fo r the incient
Kotby Co.
W hile QC 12 load o ne co ntainer on bay 58U on M /V Ned llo yd Mercator , it s tuck in cell
guide.
while TR07 man euverin g in 04 J27 A1 Scratch cont aine r MSKU292 646 5 ca used cut a bout
10CM.
1 - D id you notice th e damag e of t he conta iner on the ves sel?

- N o, it wa s not clear for me.
Immed iate caus es
2 - W hat was t he co ntainer weight ?
The cont ain er st uck in ve sse l sea side cell gu ide .
- The cont ain er was he avy a pproximately 3 0 ton .
3- Wa s there deck wit h you du ring han dling?
Underline ca use s
- No, t here was nt.
The QC op era tor loaded t he conta iner with h igh s peed h ois t in th e u nde r deck.
Ope rations :
Ayman Tah a
E ngineering :
Roo t Cause
4 - In your o pin ion, how th is acciden t happ ened ?
Ib rah im Mogy
HS E: Moh amed Abas s + Moham ed
Orga niz atio n cau se:
- In no rmal, th ere is s ea sid e cell guide higher than quay side cell gu ide an d I ad jus t the sp read er on t he hig h ce ll gu ide. Beca use of qu ay s id e cell guide is lower th an the an oth er one ; so
At ef + Mo hamed E lta beey
- Ina dequ ate work p lann ing ( num ber of de ck co ntro llers are n ot enou gh) .
tha t the conta iner corner cos t base d on the t his cell guide the n the cont aine r tren ded on s ea side ce ll gu ide (h igh cell guide) . Beca use of th e con tain er weight was h eavy, t he co ntainer
People cau se:
co rner post s tu ck in se a s id e cell guide and caus ed conta iner damag e.
- Poor d ecision makin g (QC op erat or to ok wro ng decis ion wh en he hoiste d down th e con tainer in
- In my opinio n als o t hat th e spreader was in trim mod e.
t he un der d eck with h ig h spee d & when h e take t he decis ion withou t ch eck or as k for ass ist ance).
5 - H ow long t ime you was working aft er las t res t?
- H alf hou r.
- Ye s.
7- Did yo u feel fatigue ?
- Yes, due to t he normal conditio n of t he night s hift working, sp ecially t he 2nd n igh t sh ift.
8- D id you at tend T BT to day?
- N o, :b eca M
use
I came
early.
Involved Person I : Name
osta
fa Weh
ba ID: 3 695 (KOTBY)
9- Wh at was your hois t spe ed?
Normal
s
peed
.
D epartme nt: OPS
Position : TR Driver .
1 . D eck controller mus t be wit
h each
crane.
Expe
rie nce:
7 mon ths .
Poor Decision making ( when h e decide d to make m aneu vering in crowd ed area an d not waitin g
fo r clearn ess )
I was wo rkin g in 04 J 27 th en my address chan ged on t he display to 05 J t hen I d irected t o there and while mane uvering my truck t ail h it th e con tain er.
Did you sle pt well ?
Yes.
D id you s uffer from an y fa tigu e or st ress ?
No.
D o you have an y fam ily proble ms ?
No.
-Was th e a rea crowded with external truck t hat en forced you to ma ke sh arp ma neuve rin g ?
Yes it wa s, b ut it was not th at much crowded .
-S o why did you d o sha rp man euverin g ?
Because t here was a truck in fron t of me a nd oth er on e b ack to me which m ade me to man euver that wa y
-why you n ot wait for cle arne ss ?
Actua lly it was a b ad est imat ion fro m m yself an d I did nt expect th at may cau se an acciden t.
Probability (3) * Severity (2 ) =6
1 4/04/2 013
OPS
Wa iting
Man ageme nt
1 . Add th is case to TBT and h ig hlight t hat all QC operators mu st hoist

down conta iners with slow sp eed du ring working un der d eck.
2. Pro vide de ck co ntro ller for each QC.
1-To add t o TBT t he imp ort ance of keep ing a n adeq uate s pace
b etween t he truck an d con tainers before s tart maneu vering.
Operatio ns: Kh aled H egaz y En gin eering : Ahmed
S alah HSE : H ish am Ism ail
OPS
20 -04- 201 3
To a dd to TBT don t s tart mane uvering u nles s you ha ve cle ar and

en ough s pace for tu rning you r truck whee l gra dually.
2- Driver to b e retrain ed on th e m aneu vering techn iqu e.
OPS - train ing
E xperien ce: 18 mon ths

We we re workin g on MV EGY PRIN CE SS an d wh ile QC 14 mad e t he las t move I checke d the ga ng way pos ition becaus e the QC 1 4 would be moved t o a noth er ba y an d I foun d the g ang
wa y was a t the ed ge of the Quay (th ere was n o QC gant ry yellow line fro m bollard 7 3:91) , an d there wa s anot her ves sel b ehind MV EGY PRINCE SS was s ailing caus ing M V EGY Princess
moved su dde nly and h ence the g ang way moved from its p lace during the movem ent of th e QC cau sin g a dama ge to th e g ang way.
48
April 11, 2013
18:40
ops white
QC
14
fo r the incient
D uring cran e 14 making gan try and p ass th e gang way To complete carg o o peration
the ves sel s udd enly moved caus ed da mage in t he gan gway.
Im mediate ca use s
- QC 14 clas hed wit h MV E GY PRINCES S gan gway.
Un derlin e cau ses
- The g ang way pos ition chang ed du e to the s udd en moveme nt of the ves sel.
Root Caus e
- Unexp ect ed ch ang ing in circumst ances of MV EGY PRINCE SS du e t o the s ailing of th e b ehind
vesse l.
1 - When d id you checked the g angway?

- Aprox. 5 m inu tes b efore th e QC 14 moving, durin g the la st conta iner move of the QC.
2- Did you no tice that t he oth er ves sel which in beh ind M V EGY Princess wa s movin g?
- No, I did nt not ice.
3 - W hat is yo ur po sit ion while th e QC is ga ntry?
- I could obse rve th e g ant ry move at se a s id e wh en the op era tion will st art , an d from lan d sid e (back reach) in the middle o f th e operation becaus e there we re trucks m oving t o preven t
an y cla sh.
4 - From your poin t of view, wh at was th e cau se of the da mage?
- The ves sel was mo ved su dden ly and u nexpecte d wh ich made t he gan gway ch ang e its po sit ion.
D id you receive a p re-s hift sa fety talk:
YES
YE S
Moh amed S eif

Ahmed Salah
Ramz y Ma her
Possible (3) * Min (2) = 6
1- Ad d this case to th e TBT a nd in struct the VSVs who se in charge of

sailing any ves sel to n otify all VS V to ta ke more care wh ile op erat ing
t he su rrou nding vess els .
1 - ops
2- TS
1 9/04 /2 013
Wa iting
2 - Painting th e QC gan try yellow lin e from bollard 7 3 : b olla rd 91 .
NO
YE S
NO
NO
NO

E xperience: 2 years
- The wha rf mus t notify by th e movemen t of any bes ide ves sel.
49
April 13, 2013
1:30
ops white
TRA
129
fo r the incient
While TR 129 reversing back, it hit the container MSKU7031950 located in 03L55A1
I was en tering 0 3 L (cus toms ins pection area) u nder the RTG and I fou nd th at ano ther TR was e ntering but in the way opp osite of me, t hen th e RTG op erat or told me to ge t back t o o pen
th e wa y t o t he oth er TR. S o I started t o reverse back a nd while I adjus ting my T R, my tra iler hit t he con tainer.
1 - D id you kn ow t hat t he reversing back is not a llo we d ins ide th e yard?
- Yes I kn ow b ut it permitte d only to ad jus t my TR b out ap rox. 2 -3 meters.
2 - W hile you reversed b ack ,Wa s your T R st raight o r not ?
- It wa s straig ht.
3- In your p oint o f view, why did you hit t he conta iner?
Imme diat e cau ses
- Wh ile I re vers ed back, t he trailer deviated a little and so I d ecided t o adju st it and while I was do ing t hat th e left end o f my trailer disap peared from my left mirror a nd I reve rse d for a
- TR 129 h it th e con tainer
d ist ance more th an it d emand s.
Unde rline cause s
4- Wh ile yo u reversed b ack, we re you loo king to t he front o r to th e e nd of your t railer?
- Th e TR d rive r did nt see t he con tainer wh ile reve rsing b ack (b lin d poin t).
- To th e end un til it dis app eared t o the he ad deviatio n.
Root Caus e
5 - Were you bus y with an y t hin g while yo u reversed ba ck.
- Po or decis ion ma king fro m t he TR driver, he reve rse d back altho ugh h e d idn t see th e con tain er
- No,
from the left d ire ction,
D id you receive a p re-s hift sa fety talk:
YES N O
1-Name:
D id you
receive Mohamed
tra ining in hMahmoud
ow t o do theRashad
t ask invo ID:
lved:0181
YE S
Mo hamed H egaz y
Hany Mag ed
Ramz y Ma her
Possible (3) * Minimum (1)= 3
1- Ad d this ca se in t he TBT and highligh t the importan ce of never

reversing back in th e blind points a nd if neces sary t he
TR d rive rs mu st as king for a h elpe r (TS V) t o help T R
drivers for reve rsing ba ck safely
2-D river to be se nd for re tra ining on re vers e t ech nique.
4/19/2013
ops
Probability Unlikely ( 2 ) * Severity ( 3 ) (Wire Due )= 6
1 Involved person to be re-indu ct ed abou t how to ta ke th e rig ht

decision & to as k t he direct sup ervisor ab out a ny critical s itu ations.
2 To add th is case to t he daily TBT & hig hlight t he imp ort ance of
followin g the work p rocedures & th e safe working rules .
3-we ha ve t o be ens ure we have a clear comm unicat ion b etween E NG /
OPS while test ing the cran e.
Eng.
May 5, 2013
Severity 4 *(probability 3 )=12
Add to all D&W TBT not to start operation before insure that
deck controller inspect all working bays and report any
abnormalities
OPS
230/04/2013
New
Salah
1- ops +ops t rainin g

2 - ops
3-OPS
1- waiting
2-2 6/4/20 13
3- 12/05 /201 3
New
Amr Rashwan
op s
CHE
TS
4/5/20 13
Un der p rocess
waitin g
New
Amr Rashwan
Eng.
May 15, 2013
New
Salah Abd elaziz
Ops
May 15, 2013
New
Salah Abd elaziz
Possible (3) * severity (2) = 6
Open
Salah Abd elaziz
Open
Josh
new
Mohamed El Araby
NO
Are yo u aware
Department:
of the rulesOPS
/ proce dures
Position:
related toQC
t his
operator
work: YES
NO
If required , were you wearin g the correct

PPE : YE S 8 Y
NO
Experience:
ears
Imme diat e cau ses
50
April 16, 2013
4:30
Eng Shift C
QC
QC 12
fo r the incient
Wire co llided wit h the h ead block doo r.

Du ring normal op erat ion on QC12 we re ceived a hois t BDN call ,after che ck we found
hoist over s lack a nd du ring han dling th e sla ck the wire stu ck und er he ad blo ck door
ca using da mage for t he lan dside right wire
Und erline caus es

Poor de cision making d ue to over con fide nce .
Root Caus e
Did nt follow t he work proced ure s.
YE S
NO
I was working on QC 05 then all the gang shift to QC 09

at 5:45 am ,we start
loading
process normally for 3 moves ,unfortunately the 4thmove stuck in the cell
How do you th ink th is
Int
inociden
t he E-Room.
t cou ld be avo ided in futu re?
guide.
D id he can se e t he
sp read er from his point?
-What is the SOP for
on vessel ?
Fo rstart
sure operation
n o.
Wh y yo
u asked him,
p ermiss
ion?position of each Unit before loading.
Wharf controller adjust TR acc. To loading
sequence
theasadvice
the
No, just
givemove
me th e
bypa ss
er to let the
op era
tor mo?ve u p.
-Int olast
,what
is ord
happened
before
stuck
tier
Are yo
userow
d to take
s ame
decis
ions a s awith
regu lar?
It was my 1st
in uthis
so I the
hoist
down
carefully
medium speed.
times.controller ?
-Where wasS ome
the deck
Wh y?
dont
know
From my expeI rie
nce in
simila r sit uat ions .
- do you know that there was a deck controller assigned
you as you are the only QC working on this vessel ?
Th e radioto
chwork
anne l with
wa s clear?
Yes,
Yes , we take the cra ne ch ann el
to get t he clear commu nicat ion.
- Why did you start without deck inspection for theunder
In yo urdeck
p ointcell
o f vie
guide
w, what
status
was is
t heitroo
clear
t cau
from
se ofabnormalities
this incid ent ? or not ? & why didnt you inform Vessel SV about
Take the d ecisio
n witho
this
? ut th inking.
Normally ,we (QC operators) start working after Wharf controller confirmation not Deck controller
-When
you
ask
for
Deck
controller
assistance
?
YES NO
In blind point handling or when I feel something wrong with any move under deck or on deck. And sometimes we work without Deck controller at all and we ask
onh ow
board
check
D id you wharf
receiveto
tracome
ining in
t o dotothe
t ask something
invo lved: YE S NO
-Did you notified about this type of cell guide before working ?
Are yo u aware of the rules / proceNo.
dures related to t his work: YES NO
-Who give you loading instruction to start 4 moves?
If working
required , were
you wearin
g the Icorrect
PPE
: QC
YE SI see
NO both of them under QC .
I dont remember who was
as wharf
but when
ascend
the
2-Name: Abd Elrahman Rafaat ID: 0979
YE S
Ade l Khe dr
Ahmed S alah
Moh amed Abb as
Hany Mustafa
NO
H ow d o you think this incid ent could be avoided in fu ture?
51
52
53
April 15, 2013
April 10, 2013
April 22, 2013
6:00
10:30
6:30
OPS Red
ops white
ops white
QC
TRL
TRL
QC 09SQ 25
96
59
54
April 27, 2013
3:45
Eng Shift C
Terminal Pickup
10
55
April 30, 2013
2:30
ops white
QC
QC 05
56
May 2, 2013
3:30 PM
Ops Blue
QC
16
fo r the incient
fo r the incient
Durin g load ing u nder deck of ba y 2 4 the cont aine r set on the le ft cell g uid e due t o t he
ce ll gu ide h as gap s "cre ated of two se parated p eaces"
while TR 46 was making man euvering b etween the wait ing a rea and t he beg inn ing o f
t he Mike area ,th e rig ht rear tire exp lode d, t hen t he TR was moved to t he Mike waiting
a rea on th e metal rim directly which also mad e a d amag e t o the met al rim.
Immediate causes
Twin container stuck under deck
Underline causes
Poor design for Vessel cell guide
Root Cause
1-Deck controller didnt make pre operation inspection ( Ahmed ELsawaf)
2-Over confidence from both Deck and wharf .
3-Both of Deck and wharf breach SOP as they
i) start loading before Deck in his position
ii) Changing their position without confirmation from their direct supervisor.
Imme diat e cau ses

- Th e tire s were sq ueez ed while takin g maneu vering in a s mall d ist ance while it loa ded wit h a
heavy twin con tain ers ( the t ire exploded ).
- M ovin g dire ct ly on the rim wit hout t he tire (ca using th e damag e of t he rim).
Unde rline cause s
- TR driver miscalculat e the dista nce wh ich make t he man euvering .
Root Caus e
- Poor d ecision makin g from th e T R driver
1 - M iscalculating th e d is tance which ta ke th e m aneu vering
2- Mo ving with th e T R on its rim direct ly (didnt wait fo r co ming o f TS V)
fo r the incient
Before fi rst left the QC operator noticed that QC 05 head block pulley's guard damage
Immed iate caus es
the involved person is the After finishing operation, MV K Stream Gang way was hit by CQ16 while moving gantry
fo r the incient
QC 16 M oved ga ntry withou t monitoring .

Root Caus e
-Lack of commun ication(from Wharf &QC op erat or whom d idn t rece ive clear me ssag e from each
othe r ).
- failure to act from the wha rf who didnt st and ne ar to ga ngway/eme rgen cy bu tto n wh ile mo ving
g antry ch eck for clearance.
- Po or De cision from QC ope rato r who st art ed to move ga ntry withou t info rmin g from Wh arf via
radio.
-Not following in struction s from wha rf who did nt lis ten t o ve sse l SV wh o asked him wh ethe r its
clear for gant ry or n ot.
People Cau se:

1- Lack of exp erience.
2- Not followin g proced ures ( RTG op erat or us ed Bypas s but ton in reefer s tan ds wit hout
confirma
May 1, 2013
10:15
Ops Orange
RTG
58
May 10, 2013
3:00
RED
Spreader
SQ 24
59
May 12, 2013
17:30
White
RTG
RTG 05 & RTG 38
Experience: 7 years
When we arrive to QC 09 I found my colleague ELsawaf waiting in wharf cabinet. he was assigned to work as Deck controller and I work as wharf controller, I
told him to go for his position as a deck on board bue to bad history for this vessel which spreader stuck many times today morning, but he asked me to changing
our positions (I work as a deck &he work as a wharf ),while I was in my was to our working bay and before I arrive, I surprised by the spreader stuck .
Nader Helmy
-Did you take confirmation from the Vessel SV about changing position ?
No,
-Who give instruction to start loading process to QC operator?
I did,
That mean you give instruction to QC operator while your deck controller stand beside you under the QC ,Why?
Involved
Pers on: N ame:
Ah med
Se rag E l deen
Instruction
for start
operation
comeH eseen
directly from Vessel SV ID:
. 330 8
art ment
: Ops situation
(Camp bell).
: TR driver
-Did you inform Vessel SVDep
about
current
(D & W stand under the Position
crane )before
confirm start operation ?
Experien ce: 26 mon ths
No,
- Yes , I kne w th
ey were heavy.
-Do you think presence2of
- Deck
Whilecontroller
your m aneu
with
ve rinthe
g, did
operator
t he rear on
tireboard
s squ eeze
will? prevent this accident ?
I went to my ad dres s at 05 C 58 , an d there wa s anot her TR 11 4 was wait ing in the ad dres s of 05 C 42. While I was en tering u nder the RTG 07 to b ay 5 8, I heard the RTG operator
- No, I was see th e left rea r tires in my mirrors and t hey weren
t s que ezin g (th e damag e was in th e doub le le ft rear tires) .
Sure.
s hou ted s o I asked my colleag ue in T R 11 4 Wh at was his add ress and h e informed me th at his add ress was in bay 42 s o I st art ed to move ag ain to en ter t he to my add ress (bay 58 )
3- D id you n oticed t hat th e dis tance bet ween th e wa iting area -if
& the
be
gin ninscenario
g of t he Mike would allow
you
r TR
for get
g the ma neuve rin g with out s quee ze the t ires s pecially the TR
the
same
what
will
you
?tin
u nder the RTG but I surprised t hat t he RTG op era tor s hout ed to me
ag ain
to s top an d let repeated
t he oth er TR
No. 1
14 to
en do
ter fi
rst . So t here was a conversat ion b etween t hem an d I decid ed to
loaded with he avy t wins ?
re vert b ack a lit tle t o g et outI owill
f t henot
RTG
start
lane,without
as a sta nd
insure
by while
the finishing
Deck controller
th ere conversat
make ions
sufficient
, an d while
check
thatfor
t hethe
RTGbay
s tartin
wegare
to gan
working
try an din.
the cage h it my TR left mirror.
fo r the incient
While RTG 0 8 made g antry, it hit t he reefe r sta nd at 02 G 70 wh ich cau sed d amage for
t he ree fe r st and st ru ctu re
while RTG 05 gantry Hit RTG 38
Ahmed Shawky
Fathy
Mustafa
- Yes, with my point of view it wou ld ge t my T R mane uvering withou t squ eeze t he tires.
1 - What was the dista nce b etween yo ur TR and t he RTG wh en you st oppe d out s ide th e lane ?
4 - D id you kn ow t hat it was wrong t o move direct ly on th e rim of th e t ire?
- Th e RTG
was at Ahmed
b ay 5 8 and
I myELsawaf
T R he ad app
rox1876
a t bay 52.
3-Name:
- Yes , I kno w
bu t theSamir
TR was
blocking thID:
e way.
2 - Did yo u stop yo ur TR in a sa fe p osition a way from the RTG lane ?
- No , I was a little close to th e lane in uns afe pos ition becaus e I was read y t o ente r the ad dre ss after they fin ish ing t here conve rsa tion .
Department:
DWidhere
you hreceive
OPS
abepen
re-s
Position:
hift sat he
fety
D&W
talk:
YES TR?
NO
3ad you
when
RTG
hController
it your
- I was out o f my TR becaus e there were a d is cus sions be tween TR 11 4 and th e RTG op erat or an d TR s upe rvis ors wh om cam e t o solve t he pro blem s.
D id you receive
in h
t o do
t ask
invo
YE
S months
NO
Experience:
+8
4- Dtra
id ining
anyo ne
caow
ll you
to the
leave
your
T lved:
R1year
?
I was in rest , My vessel SV give order to work as deck controller,
- NoIone
arrive
as k &
me
wait
t o leave
in wharf
my TR.
cabinet till the operator and wharf arrive , I take the wharf vessel
Are yo u aware
ofdthe
rules
/pproce
related
to
t his
YES NO
5- Why
idn
t
you
ush eddures
th e RTG
Emeto
rgen
cywork:
st
op?duties
planning papers to check loading sequence , then
the wharf
ask
me
to ascend
the
vessel
start
my
as a deck controller but I make a deal with him to
- Becaus e the dista nce wa s so close b etween t he RTG
an d the our
TR, positions
and we were
discus
e t he pro blem with TR SV, an d did nt recogn ize his moving.
changing
he PPE
agreed.
If required
, were you wearin
g theand
correct
: YE S NO
6- -When
Did youthe
hea rQC
thestart
RT G gan
try ho?rn?
loading
- Ye s.
While
we were
still
under
QC.
Did yo u receive
pervision
he
las
t 1hr
ofthe
you
r work:
SO NO
D id su
you
rece ive in
a tpre-s
hift
s afety
talk:
YES YEN
How do
you the
th inkOperator
th is in ciden
t cou ld be avo
futu re?
-Who
gives
instruction
for ided
startinloading?
- If any thing Wron
g hap
penive
totraining
my TR Abd
Iin
will
stop
no
move
from
th eYpES
lace NO
unt il TS V come.
El-Rahman
D id you
rece
h ow
to and
do th
e tt.ask
invo
lved:
Did you or your colleague inform the Operator about any abnormalities in this vessel cell guide design ?
Direct Sup ervisor: Name :
Han y N our
ID : 14 23
Are yo u aware of the rule s / p rocedures
No. related Pos
t o t his wo rk: YE S NO
De partmen t: o ps
ition: T R su pervis or
-What is Deck controller activities on deck ?
If requany
ired old
, were
you wea rinOperator
g the correct
: Yany
ES stuck
NO and to Vessel SV & C/O disclaimer
To make pre operation inspection and report
damage
to PPE
avoid
D id h e/s
he give to
a p re-s hift sa fety
talk: YES
NO
-When you arrive to
the QC why you didnt ascend the vessel to make the pre operation check ?
wait
check
papers
wharf.
How Ido
youto
t hin
k th is planning
inciden t cou
ld be awith
vo ided
in futu re?
-Did you take- confirmation
Vessel
SV
before
changing
I mu st lea ve t hefrom
safe your
d ist ance
away
from
the RTG
lan e. positions ?
No.
Invo lved Pers on: Name: Hayt ham
Is maeel
T habe
ID: 755
Is this
normal
? t
Depa rtm ent: Ops
. have to inform him for approval
Position
No ,I
. : RT G operato r
Imme diat e cau ses

- While The RTG made ga ntry it hit T R 59 s left mirror
Unde rline cause s
- Th e TR was s o close to t he RTG lane (u nsafe p osit ion ), an d its driver was ou tside th e T R.
Root Caus e
While RTG 07 make gantry in 05 C hit TR 59 mirror by ladder from cabin side
1 - N ot following p rocedu res (from the TR driver b y leavin g his T R in uns afe positio n).
Exp erience: 7 Years
2 - M iscommu nicat ion be tween RTG operator, TR drivers and t he SVs.
fo r the incient
3- Failure t o recognize haz ard ( t he RTG op era tor d idn t do uble che ck with t he su pervisor that h is
I was h and lin g a con tainer at 0 5 C 5 8 and TR 11 4 was sto pped a t bay 42, so I s hou ted from my cabin windo w b eca use th e microph one was nt exist t o t he TR driver un der my RTG to
m ess age th at he will gant ry receive d or not , sp ecially h e saw the area und er his RTG was
inform TR 1 14 driver t o ente r to bay 58 b ut TR 11 4 driver didnt an swer s o. Wh ile th at I fou nd TR 59 was en tering u nder the RTG but I s top ped h im and inform ed him t hat I n eed ano ther
crowded ).
TR with him int o t his b ay 58 an d then T R 59 s tarted t o e nter the ba y fro m o ut side th e RTG lan e in th e s ame time TR 1 14 also sta rte d to move, hen ce I s hout ed to th em to let TR 59
en tere d firs t, b ut I s urp rised th at a third TR driver ( his T R was at 0 5 C Lower) came an d st oppe d them b oth (T R 59 & TR 114 ), a nd I fou nd th em stop ped an d left th ere TRs an d stan d on
t he ground a nd st art ed to talk t o e ach o ther, s o I hois t down t he sp reade r and I called my Yard s upe rvis or to s olve th e prob lem. The YS V se nt th e T SV wh o came an d while he dis cu ss ed
the proble m with th em, I came o ut from my cabin t o inform t he TR SV t hat I will move t o b ay 42 and I did nt know if he get my mes sag e or not t hen I m ade gan try an d hit t he TR mirror.
We were working on PM (Preven tive Ma int enan ce) o n RTG 45 t hen I we nt to th e Worksho p to dro p the workers th en I ret urn ed back t o the workplace to pick th e t ools I felt sleepy while
riving
su ddhenly
h it sth
e b arrier.
1- Wdhy
did you
ois t Ithe
pread
er do wn?
D id
you T
fas
ed groun
your sdeatb
heing
timte
f inciden
t ? ot hers, an d th ey d idn t wan t to ent er th e bay.
- When I found t he th ree TR drivers came ou t of
t here
Rsten
o nto
andelt
sttart
o otalk
to each
2- Is it allo wing to h ois t down th-yes.
e spre ader t o be close th e grou nd?
Im mediate ca use s
What in
wapres
s your
s peed
? mainte nance team .
- No, its fo rbidde n unless
ence
of the
Pick-up driver hit t he co ncrete ba rrier.
It was
und
5 Km/h
r. decid ed to make gan try?
3- We re the re any TRs st oppe
d ataro
bay
422wh
en you
mwere
any hou
d id you
slept
atLo
t he
- No, butHtow
here
TRsrswaitin
g on
05 C
wemornin
r to entger? th e bay.
Und erline caus es
-I slept around 5 to 6 hou rs as
oday
Frid
ay th
and
h ave
to gostfor
p rayer
0 noon
a nd?I slept fro m 1 :00 to 6:0 0 PM.
4 - tCo
uld is
you
s ee
at ITR
5 9 was
opping
closate 12:0
t o the
RTG lane
the involved person is the During one of Eng. Team was driving PU10 he felt drowsy and collided with concrete barrier.
Felt d rowsy while drivin g.
- N o I cou ldn t b ecause it was a blind po int ?
D o you su ffe r from any diseas e tha t make s you take a medicat ion th at may effect your concen tra tion ?
5 - W here was TR 59 s top ped whe n you sta rt to g antry?
fo r the incient
Root Caus e
I don
t at b ay 4 8.
- Im not su-no,
re may
be
-Fatig ue/la ck of rest
Were
you
ad aconfirm
co mpanthat
y while
?
6- W
hy did
nthyou
you drivin
will gagntry?
myself h
o im
nly.tha t I will g ant ry to bay 42 a nd I didnt know if he g et my mess age or n ot.
- I fo und t hat th ere discuss ion wou ld ta ke a lon g tim e s o I sh outed to TR S -No,
V to inform
W hy you don t as
k yo
ur rece
su perviso
r to take
t astalk:
lon g asYES
you were
D id
you
ive a pre-s
hift sres
afety
N O t ired ?
-we h ad a overwork
as we we:re
workin
g ion:
on PM
at RTG
, so
I d idn t take a re st.
De partment
OPS
Po sit
Wharf
Co45
ntro
ller.
QC 1 6 hit K-s tream g angwa y.

Unde rline cause s
57
Department: OPS Position: D&W Controller
Eh ab Za hra n
M ohame d Hadidi
Ramz y Ma her
Eh ab Za hra n
Amr Sh orb agy
Ramz y Ma her
Likely (4) * Minimum (1)= 3
1 -Rea sse ssme nt for t he TR d river

2-Add t his case t o T BT an d hig hlight the imp ort ance of
- Neve r to take mane uvering with TRs in s uch area be tween t he waiting
area & t he beg inn ing t he Mike (ma in drive way).
- N ever move t he TR o n the tire rim dire ct ly (when t he ru bber tire is
exp lod ed).
3- E nsu re to activat e the TR ch eck list du ring sh ift han dover ( GM
comme nt)
1-Add th is case to t he TBT a nd highligh t the importan ce of

- Never leave th e e quipmen ts in u nsa fe a rea (make a safe dista nce
away fro m t he RTG lane) .
- Ne ver hoist do wn the RTG spre ader to be close t o t he gro und .
- In su ch case s and th e area un der t he RTG wa s cro wded, the RT G
op era tor mu st confirm that h e will mo ve.
2-- Collect t he RTG s with out micro phon es for fi xing t hem
3-- Draw a red lin e bes ide th e RTG ga ntry line t o d efin e t he safe area to
st op the eq uip ment s
Operations : Khale d Hega zy

En gin eering: Ahm ed Salah
H SE: Hisham Ismail

Experien ce: 5 years
I Ch ecked th e gang way and I fou nd it was behind th e yello w line an d I had b een in formed from vess el sup ervisor that we will move gan try from K-st ream MV to ALABAM MV to raise
hat ch covers and g earboxe s, t hen I informed th e QC operator to
moveired
gan
try toyou
ALBAM
thgen
I foun
d the
K-st
ngway hit by QC 16 t hen I informe d the op erat or to s top moving
If requ
, were
weaArin
the
correct
PPE
: ream
Y ES gaNO
g antry.
When dsu
id pervision
you inform
o perator
o stop ?Y ES NO
Did yo u receive
ined
t hethe
lasQC
t 1hr
of yo urt work:
-IHow
info rmed
h im
when
nd tht at
thld
eg
way
h itinby
QC16.
do you
t hin
k th isI fou
inciden
cou
beang
a vo
ided
futu
re?
hen
d id th et he
QC TR
operator
stop
g antry
? lea ving it.
- TR d river W
mus
t secure
in a safe
poped
sit ion
be fore
-h e -stop
pedt he
with
th emlast
STOP
Fixing
RTG
icroph
ones . call.
Was t he dam age as we checked o n live s cen e ?
-N o, it wa s mino r bu t wh en I as ked t he QC op erat or for mo ving b ack Aft er th e accid ent the ga ngway st uck wit h berth bo llard ca using se rio us dam age in t he gan g way.
Wh at was your positio n the time of accid ent ?
-I was o n lan e 3 , th e vess el SV as ked me did you che cked th e ve sse l gang way I told h im yes its clear.
How did you ch ecked t he gan gway was save ?
- I ch ecked b ecau se we had t o adju st a conta iner on pos ition 2 berth- sid e a nd I was clos e to the g angwa y.
W hen moving ga ntry wh at is you r pro per p osition o n QC ?
-N ot always n ear to t he sea .
Involved Pers on I : Na me: Amr Wa leed ID : 18 2
1- Add to TBT the Importan ce of ha ving s ufficient t ime for s leep ing
before s tart work
an d never take t he risk for drivin g or working in ca se of fe elin g
t ired /fa tig ue,
an d ask your sup ervisor t o take rest if ne eded .
2- Every s upervis or has to ens ure his team g et the required re st du rin g
t he sh ift. ( GM commen t)
Severity (1)*possible(3) = 3
Opera tion s: Kh aled H egaz y

Eng ine ering: Ahme d Sha wky
HS E: H ish am Ism ail
Add t o T BT a go od and clea r way o f commu nication mu st be

esta blished b etwee n QCs op erat ors a nd Wh arf Cont roller and e nsu re
tha t the all mess ages h ave been delivered clea rly.
Refres hmen t to Wharf con trollers to ens ure t he pro per p osit ion d uring
gan try movem ent for QCs.
D epartmen t: Op s Po sit ion: QC operato r

Exp erience:
I heard from vess el Sup ervisor that we ha ve t o move to ALABAMA MV t hen I mo ved gan try to t he vess el the n I heard S TOP..S TOP mess age fro m t he Wha rf.
Did you not iced tha t you are ne ar to ga ngway or t he is a po ssibility to h it the g ang wa y ?
-No , I ju st as ked h im to s ecu re the area and ma ke su re its clea r from obs tacles .
D id you wat ch from your cabin Wha rf pos ition ?
-Yes , he was nt near to gan gway.
In normal proced ure h ow is the commu nicat ion be tween QC& Wha rf ?
-we have t o g et clear m ess age with con firmat ion .
Wh y you asked him t o che ck for ga ngway ? did you no ticed ga ngway from you r ca bin ?
No, I jus t asked him to do so I was in tro lley be rth -sid e as I was s tartin g to move gan try an d the ves sel h eig ht lower the Quay ce ll be am, which it was difficu lt to s ee the ga ngway.
What t rainin g/in structio n that you received while moving ga ntry ?
-th e wh arf sh ould be close t o g ang wa y b efore st art g antry.

I mu st be more atten tio n.
D irect Su pervisor: Nam e:
D epartmen t: OPS
Immed iate caus es

RTG 3 8 hit RTG 33 d uring g antry.
60
May 16, 2013
22:50
Red
RTG
RTG 38 & RTG 33
fo r the incient
wh ile RTG 38 ga ntry h it RTG 33 which caus ed a dama ge on bot h Rtg gan try s ins or
( antico lleg en )
Underline ca use s
- RTG 3 8 operator made g antry b efore RT G 33 ga ntry.
- RTG 3 8 operato r dep ende d on the s ens or.
Roo t Cause
People cau se:
1. Lack of d ue care (Care less from RTG op erat or) .
2 . Poor d ecision makin g (The involve d RTG op erat or to ok wro ng decis ion wh en make g ant ry early
an d used b ypas s more times ).
Han y S amir
Posit ion :
ID: 51 2
OPS su pervisor
In vo lved Person: Name: Moah moud M E lsaid At tia
ID:
3 389
D id hnt:
e/she
ive as ource
pre-s hift
s afety
talk:
YES
D epartme
OPSgOut
(Camp
bell)
Po sit
ion: NO
TR D river
Wh en was th e last t ime you s poke t o or wit ness ed th
e involved
s work
o ne hou r
Exp
erience: person
2 Ye ars
I wen t to load ing und er QC 17 la ne 02 ,th ere was no s pace t o ente r bet ween QC 16 & 17 so I h ad to en ter QC 1 6 first to re ach QC 17 (QC 1 6 was so clos e to QC 17 ),but I fou nd t here
was an oth er TR was s top ped to h and le a con tain er u nder QC 17 an d the s pread er of QC 16 wa s on Vess el so I d ecided t o ente r and wait betwe en the t wo QCs. I sto pped a t the first of
Wit
Pe rsoso
n:clos
Na e
me:
Wael
E l-Arab
y Edista
l-Had
edyb ehind
ID : me
5 01
QC 1 7 waiting th e front TR to fin alize han dling to en ter aft
ernes
it (sI was
t o it to
make
a safe
nce
away from QC 1 6 spreader path way) .wh ile I was wa iting I
partmen
n: RTG
operator
sDe
urprised
b yt:sOPS
ud den hit by QC 16 an dPositio
my empt
y u nit
fall down .
xperience:
6 year
1 - D id you che ck your p osition a ft er you sE
topp
ed bet ween
2 cran es ?
- Yes ,visa my TR mirrors ,It was in sa fe p osition far from the QC 16 sp read er pat hway .
- I was working on RTG
int 07
Ge4ins
2 and
Ih
ads pro
conta
iner ed
onto
Exwait
tru ck
t thepos
p roblem
is so
lvedtwo
th en
I ha
d con solidat ion in bay 50 .
2- 33
Wha
is th
tru ct
ion
youblem
took in
in han
youdling
r train
ing relat
in bu
a safe
ition bet
ween
clos
e QCs?
- Whe
n Ismade
g antry,
I n oticed
RTG wait
38 b esid
e me un
and
h it
myend
RTGed
. load .
- To check
the
pread er
pa thway
and dont
o r move
der
s usp
H atem Ho sny
Ahme d Shawky
M oham ed El-Tab eey
Add t his case t o TBT an d highligh t that

1. RTG op erat ors m ust keep s afe dis tance bet ween him and ot her RT G.
2 . RTG operators mus tnt de pend o n sen sor collision only a nd mu st be
atten tio n for his way.
Propability (3) * Severity (1) = 3
OPS
June 4, 2013
Josh
- Never t o e nter und er QC till th e n ext TR o n my lane fin ish h is h andling p rocess or t ake a s afe positio n betwe en two close QCs .
1 - D id re3ceived
commun
from
RTGed
38
rato
bytra
SG
p hon
W hatany
Ha ppen
ed inication
t his cas
e relat
toope
what
yor u
ined
? e?
No, becaus
e SG
phion
onebdo
esnt
- I d ecided t o ente r and- wait
in a safe
p osit
ehin
d thwork.
e T R next in same lane (0 2).
4- How did you calcu late t his s afe dis tance ?
id you
ift(safe
ty was
talk:waitYES
NO rging from QC 1 6 lan e 0 3).
- I checked tha t is my Trailer pDass
t hereceive
leve l TRa 9p1re-sh
head
which
ing d ischa
61
May 4, 2013
12:30
White
QC
QC 09
fo r the incient
We received a BDN call on CQ1 3 askin g for hoist wire rope in sp ect ion ,after insp ection
we foun d clear da mage in the le ft lands id e h ois t wire rop e and he ad block as sh own in
th e a ttached p hot os.
QC 02
fo r the incient
We re ceived a BD N call on CQ02 in forming us abou t h oist wire rop e Cu t . Aft er

ins pectio n we fou nd t hat th e wire was st uck beh ind cell guide hea d and he ad blo ck
Pu lle y .please check the att ached ph otos .
YES
NO
Person
:
anin
DIn
idvolved
you rece
ive training
inName
h ow :toAmro
do thHas
e t ask
invo lved: ID:
Y ES 6 98
NO
Dep artm
ent:rule
Operation
Pos ition:
Are yo u aware
of the
s / p rocedures related
t o t hisQC
wooperator
rk: YE S
E xperience:
2 years
62
May 16, 2013
13:30
Orange
QC
Working en viron ment :

As t he st ructu re of t he vess el (Bay 01 ) helps th e h ois t wire to s tuck b ehind th e cell guide head
Imme diat e cau ses

Wh ile t he QC 16 was trolley back with a twin con tain er, the t win co ntainer h it 40 ft . conta iner on
a TR 1 07 which was waitin g in th e next lan e.
Und erline caus es
Wrong p osition o f TR 10 7 und er QC 16 .
63
May 30, 2013
10:00
red
QC
QC 16, TR 91, TR 107
D uring d ischargin g twin left on truck 10 7 h it an emp ty co ntainer o n tru ck 91 leading to
Root Caus e
fall d own on th e firs t
People cau se:
1 - M iss calcu lation of the s afe dis tance bet ween th e t wo TRs due to Lack of at tent ion fro m t he TR
fo r the incient
d river & t he wharf cont roller of TR 107 waitin g pos ition.
2 - Not following procedu res fro m t he TR driver ab out making a safe dist ance b etwee n his TR an d
th e front TR abou t 3 mete rs away (aft er ent ering be tween th e two QCs h e kn ew t hat th e dis tan ce
be tween th e two QCs was clo se to each oth er, so he tried to be more clos e to the TR in front of
h im toward QC 17 t o a void th e spreader p ath way o f QC 1 6, b ut th e end of his traile r was in t he
sp read er pa thway).
Immed iate caus es
The truck was maneuvering while the container was at the head of the trailer..
64
June 1,2013
1:45
White
TRL
TR 71
fo r the incient
While TR 71 (was loaded by a 20 feet OOG container toward the head) was
maneuvering beside QC 16 the OOG container suddenly fall down from the
tractor leaving no injuries to anyone.
Root Cause
Poor decision making:
For both:
Truck driver: as he made a maneuver while he was holding the container at the head
of the trailer although he know that it is not a safe procedure.
Vessel Supervisor: as he didnt wait for the fork lift to handle the case and decided to
let the truck turn over unsafely resulted in a safety breech.
Add th is case to TBT reg ard ing : For vess els with sp ecial st ru ctu re th e
Deck con troller g ives t he top p rio rit y t o ch eck the e ntire bay (be low
deck) before u nde rgoing an y op era tion al proces s and informing QC
operator abou t any abn ormality fou nd.
Nad er He lmy
Ah med Sa lah
Mu sta fe Arn ous , Ram zy Mahe r
unlikely 2* Possible 2 = 4
1 - Add t o the TBT of TR d rive rs th at in cas e o f d oubt a bout waitin g in a

s afe pos itio n bet we en two close n earb y QCs, they mu st ask th e wh arf
cont roller if th e dis tance bet ween th e two QCs is safe to wait in or n ot.
2- Add to t he TBT fo r the wh arf co ntrolle r to pay more a tten tio n fo r the
TRs traffic an d pos itions u nder QCs.
3 - Re-ass ess ment t o be don e fo r the TR driver
4- In surin g that t he TBT mus t be don e fo r all o ps st uffs.
Operations : Mo hamed S eif Eng in eering: Azm y

Sh ata HS E: Mos tafa Fath y, Mo hamed a tef
Op era tion s: Moham ed Ad el En gin eering: Ahm ed

S alah H SE: Mo hamed Aba ss, Moh amed at ef
June 8, 2013
Open
Sameh Haggag
1 - ops
2 - ops
3- ops t rain ing
4-- op s
1- 5 /6 /201 3
5/6/20 13
3- waiting
5/6/20 13
Open
Mohamed El Araby
OP
June 10, 2013
Open
Amr Rashwan
ops
June 14, 2013
new
Josh
Ops/Eng
June 22, 2013
new
OPS
It wa s full s peed
Dep art ment : Op erat ion s
Positio n: TR driver
5 - D id TR 10 7 wa s movin g or no t?
It was s topp ed.
Expe rie nce :
2 years & 8 mont hs
6- Was the h ois t limit swit ch working o r not ?
It was working p rope rly .
7- Did the wh arf not ify you abou t TR wait ing in lan e 0 2 near your h andlin g TR ?
I was driving TR 71 holding 2*2 0 Fee t OOG containers su ppos ed to loaded b y QC 16, the cran e bega n with t he head con tain er bu t the re was a prob lem wit h the cont aine r so th e o perator
No. h e d id nt
decid ed to ha ndle t he container in th e t ail t hen th e operator retu rned b ack from t he vess el trying t o hand le th e h ead cont aine r but t he pro blem was s till exis ted till I g et info rmed to t urn
Did you receive a pre-sh ift safet y t alk:
YE S NO
over on t he sam e lane to ap pro ach t he crane in the op pos ite directio n but wh ile I was m aneu verin g the cont ain er su dde nly fall d own.
OOG Container fall down from the trailer of TR 71.

Underline causes
NO
I wa s hand lin g 20 'Did

fe etyocountainers
forpervision
dischargin
from
ile d ischa
receive su
in gt he
lasbay
t 1hr01
of, an
yo d
urwh
work:
Y ES rging
NO th e last cont ain er
i foun d the h ois t wire
ile kthth
eisspreader
s ld
abou
e bin
eginning
Howget
docut
youwh
t hin
inciden twa
cou
be taat
vo th
ided
futu re? of the b elow deck.
1 -QC Operator take more att ention an d pay more at tent ion wh ile he h andling con tain er
2 -Wh arf cont roller to ad vice m e t hat t he dis tan ce is n ot sa fe b etween t he two QCs an d preve nt me to en ter
Did the d eck controlle r was st anding on t he bay you work on ?
D irect Su pervisor: Nam e:No
Has san H amed ID :
D id you n otice an y t hin g abno rmal in the ba y ?
No, the ba y looke dDepa
goodrtm
an d
th ere
da mage
pa rts in the cell guide
ent:
OPSwas
Posno
ition:
TR SV
Did yo u get an y p roblems in t he sp read er?
N o, t he sp reade r was normal.
wh at Did
washyour
yo u wa
s hoisting
downNO
t he bay?
e/shespee
g ived awhile
pre- shift
s afety
talk: YES
It was t he normal sp eed an d the re was no wire -sla ck hap pene d.
Didt he
yo las
u notice
ifferen
ceor
inwitne
the s ssed
peed tof
you p
was
ho ist
ing u 1
p?hrs ag o
When was
t tim ean
yoyudspo
ke to
hewhile
in volved
ers ons
work
No.
Do
h ave
any codmment
a bout
at hap
pene
2-Nyou
ame:
M ahmou
Moha med
Metwh
waly
ID:1
726d?
I n oticed t he complete situat ion , and i thin k t hat t he it was th e inn er wire t hat g et cu t not th e oute r one.
From your p oint
f view,
reason
b ehind
what h app ened ?
Depoart
mentwhat
: OPSis the
Position
: QC
Operator
I d ont now, it is my fi rst time facin g this incid ent
D o yo u have any th ing E
more
to sa
xperien
ce:y? 1.5 Year
r the ing
a ccide
hap pen
ed, i 0
wa
informed
th e VS
thch
at ath
e wire
wasn,wh
t lubricated
we
ll and
h ehois
was
info rmed
ab outI th
from
heTR
beg
inn
ing in
of lane
th e shift
Aft er Afte
discharg
t winntmove
in lane
3 sI moved
t o by
ve ssel
to V
cat
noth
er Twin
ile ma king
my
pas s(
t down
+t rolley)
suat
rpris
ed tby
wa
iting
02 bworking
ut un fortday.
una tely I
couldnt st op th e collis ion.
1 - D id you noticed T R in lane 0 2 (TR 107 ) before you d is ch arge th e Twin ?
Yes I n oticed h is presen ce bu t I th ough t it was ou t of my s prea der p athwa y .
2 - W hen did you not ice the TR 107 positio n?
Wh ile I was a t lane 0 2 but I wa s so close to t he co ntainer o n the TR 10 7.
3- Did yo u use you r cabin m irro r wh ich provide a backward vision ?
No I did nt .
In volved
:
Nam
S haba
n ID:
4-Person
what was
s preae:der pMoh
ath ammed
move ment
s peed
? 3 178
Y ES
NO
Wh o gives yo u the in struction to tu rn over?

It was th e VSV
Which Eq uip ment h and led th ese cont aine rs on t he trailer?
Bot h con tainers were han dle d by Reach St acker eq uip ped with OHF.
What was yo ur s peed while you was m aneu ve rin g?
It was th e minimum sp eed, bu t the na ture of th e trailer (Du tch tra iler) was th e reaso n for th e con tain er to fall down.
Ho w d o yo u think t his incid ent could be avoid ed in fu ture ?
1-Wh arf sh ould notify me th at th ere was TR in my pat hway to take in my cons ideration and a void collision.
D o you know the
p oten
h aza
tha ter
may
arise from su ch a ct ion?
2-No
TR tial
st op
in Srdpread
pa thway.
Yes, I already in structed n ot to man euver wh ile h olding a 20 fee t con tainer clos e to the h ead as it may fa ll down , bu t allowed in on e cas e only if I h ave to han dle 2 *20 feet con tain ers
from t he yard I can h andle the h ead co ntainer fi rs tly th en move forwa rd (n ot to man euver) to han dle th e tail con tain er.
S o, W hy you didnt follow t he reg ula tion s tha t we re give n to you?
3-N ame: Os ama Ali Moh amed ID: 1 343
Becau se I was t hin king t hat th ere will be no haz ard t o occur if I moved slowly.
Involved Person :
Na me:
Mah moud E lHam amsy
ID: 11 80
Dep art ment : OPS Pos ition: D &W Con troller
1-Add t his case t o T BT regard ing : t ruck drivers have not t o make
ma neuve r while hold ing o nly a 20 feet con tain er at t he head p art .
2 -Add t his cas e to Op erat ion b rie fing re gard ing : n ot to take any un safe
decis ion s in case of urg ent s itu ations.
D epartmen t: Operation
Position
: Ves sel
S upervis
or
Exp erience:
6 Ye
ars
I was working wit h QC 16 a nd we was dis ch arg ing a t win co ntainers on lan e 03 wit h TR 9 1 and t here was a TR 107 wa iting at la ne 02 an d a part of its trailer was a little in th e rang e of
E xperience:
2 years
th e QC 16 sp read er pat hway and wh ile QC 1 6 hoist down with th e t win conta iner on TR 9 1 it h it th e e nd of the 4 0 ft cont ain er on TR 10 7.
T he crane was h and lin g 2*2 0 OOG conta iners by O.H.F b ut we foun d a p roblem in t he 2nd con tain er as t he left do or was crooked and the cran e wa s not ab le to han dle t he co ntainer s o
1- Did you not iced tha t TR 1 07 st op in lane 02 |?
a sked for th e fo rk lift in o rder to bring t he door back t o its n ormal p osition b ut as t he F.L was dela yed I in formed t he truck driver to turn over in the sa me lan e b ut in t he opp osite side
- Yes
dsource
it was
wait
ing . TR Driver
Department:
OPS an
Outerat
(Sinai)
Position:
(reg arding th at th e ve sse l wa s abou t to lea ve a nd2-I Did
wasyou
h urry
h cargo
ionwa
) then
I found
s udd enly
t he way?
co ntainer fa ll down from the truck wh ile tu rning over.
nott o
icefinis
t hat
TR 10 op
7 tra
iler
s in QC
1 6 spreader
path
Imme diat e cau ses

wh ile TR32 gett ing u nde r the cran e it hit TR 1 13 in t he in TT7 7.
Und erline caus es
The d rive r felt d rowsines s wh ile d riving .
67
June 10, 2013
4:00
Red
TRA
TR 32 & TT 77/ TR 113
Sinai Co.
while T R3 2 get tin g und er th e crane he hit TR 1 13 in the in TT 77 which caus ed a dama ge
in front of th e t ru ck and t he ment ion ed tail.
Root Caus e
People cau se:
1 - Fa tig ue
2- Not followin g pro ced ures ( did nt info rm his TR S V abo ut his sta tus ).
3- Po or decis ion ma king ( whe n he felt d rowsines s in th e firs t time h e decided to con tin ue wit hout
st op and informing h is TS V) .
Experience:
1.5th
Years
- No, I did nt think that it was
in h is pa
way.
I was driving straight on lane 3 to ent er under QC 18 and there was anot her TR 113 was in front
in taction
he same lane
waiting t o enter
under
and while
I was driving I slumbered ( feel drows iness), and when I waked I st arted t o push the brakes but
D of
idme
t his
waswas
a normal
op erat
ionQC
al 18,
proced
ure?
3- Is it noTT
rmal
TRs
77 / for
TR 113
wasto
so wait
close sin
o I this
hit it . positio n?
NO, bu t I was obliga ted to d o t hat b ecau se th e vesse1l was
abou
t to
lea
ve a nd
Iblock?
wan ted to fin is h all carg o o peratio n as soon as pos sib le.
Is this
first night
hifteinpyour
- Som etim
es the
in case
of sth
ositio
n is sa fe .
Who d o you think we can avoid
- No,su
it is
chtheinciden
3rd one. t from hap pen ing in the fut ure ?
4 - W hy TR Did
1 07
was
g in th is are a?
sleepwaitin
well
yesterday?
I well not t ake su2-ch
dyou
ecision
and
will no t take t he risk.
slept
about
6.5an
Hrs.
- It was wait ing fo r ent ering QC 17 -aYes,
ndI th
ere
was
othe r TR h and lin g in th e same la ne.
3- Did you feel fat igue previously in this shift?
5- Wa s there any marks t o ind icate -ifI had
th
ea T
Rs wa s wa iting in a s afe positio n (away from sp read er pa thway)?
slight flue and a took a medic ine (Paramol) .
- No. in this shift before?
4- Did you feel t he drowsiness
- Yes, I f elt t he drowsiness
one
before t he
of acc
andyI washed
face
cont inued my work
Did you
receive
a time
pre-sh
iftident
safet
t alk: myYE
S andNO
5- Did you tell your SV about t hat?
- No, I t hought it was little fat igue and will be gone by washing my face.
6- What
is yourgt raining
whenta
you
f at igue?
Did you receive
t rainin
in hoinstructions
w t o d o the
skfeel
involved:
YES NO
- I call my TSV who send me to clinic which dec ided t o c ontinue or not.
Are you awa re of tDid

heyou
rurec
leseive
/ pro
a pre-shift
ced ures
safety
relat
talk:edYES
to thNO
is work: YES
Did you rec eive t raining in how to do t he task involved: YES
NO
Y ES
Are you aware of the rules / procedures related to this work: YES
Em ad Salah
Ah med Sh awky
Ramz y Ma her
NO
Add th is case to th e TBT a nd highligh t the importance of

- In case of feeling fat igu e or drowsin ess , the d rive rs mu st st op drivin g,
inform T SV t o get su fficient rest.
- Incase of takin g any kin d of m edicin e, t he drivers must t ell t he SV in
the b egin nin g of the s hift and go to th e clinic for evaluating if th e
medicine will effect in their sa fe ty during wo rk or not .
likely 4* Minimum 1=4
NO
NO
Did yo u receive
su pervision
t he las
1hr of
yoYES
ur work:
Y ES NO
If required,
were you in
wearing
the t
correct
PPE:
NO
Did you rec eive supervision in the last 1hr of your work: YES NO
How do you t hink t his incident c ould be avoided in future?
1- TR drivers n ever en ter u nde r QCs u ntil ins ure th at his lan e u nde r QC is ready.
Direct Supervisor: Name: Waleed Hussen ID: 1166
Depart ment: OPS Position: TR SV
Did he/she give a pre- shift safety talk: YES
2-N ame:
M ohamed Samir ELkhodary ID: 1887
Depa rtment: EN G
Position: junior Mech. Eng.
Ex perience: 1.5 years
NO
I was a ssigned to check the fa ult a t E-Room and co mmunicate with my colleague Eng Domah ,D&W controller and QC o perator the wire situa tio n before enable ho ist a ga in .all of us hav e o ne radio cha nnel.
I fo und over slack fa ult , in this case we reduce the hoist speed a nd dont depend o n operato r sensitivity .
Then I a sk Eng Do mah about wire situation but he reply it is difficult to check fro m main catwa lk & he hav e to descend to under deck at this time I left the E-ro om a nd notice Eng Do mah walking towards Vessel bridge .
I hear D&W talk ing to QC Operato r informing him that this Vessel ha vent smo oth access to under deck.
After that the QC Operator a sk for ENG team so I reply to him .he a sk to enable him hoist mo ve a s he see the situation from his ca bin and fo und the wire in safe position a nd free from a ny o bstacle a nd he ask fo r
bypass o n hoist to ho ist up but I inform twice him to av oid ho ist up in case of any doubt and he sho uld insure 100% fro m wire pathway but he ask a ga in to ena ble ho ist move .
I inform him he don t need bypass to ho ist but he ha ve to turn the Crane contro l to be ON and I call my co llea gue Eng Doma h o n Radio to check the situatio n but he didn t reply ,I ca ll him via mobile phone & he
answered me ,while I check with him the o perator call o n ra dio and inform us tha t he hoist up but abno rma l situa tio n do ne fo r wire a nd stuck with the hea d blo ck .
I ask him to turn the crane off a nd wait.
69
June 6, 2013
5:30
Blu e
QC
Du ring lo adin g on M/V N ED LLOYD ASIA QC 1 5 operator ask for En g. Team re gard ing BD N,
-What is yo ur SOP for handling wire o ver sla ck ?
and aft er checking s prea der p osit ion on Vesse l found t he wire s tuck und er hea d block
Poor decision made from the operator who asked to hoist up without clear confi rmation from all sides 1- decrea se hoist speed
2-unify Radio channel fo r ENG & opera tio n team form clear communicatio ns
d oor caus ing d amage for land sid e rig ht wire.
15
3-Enable hoist a fter confirmation regard wire situation .

-What is yo ur collea gue on vessel role ?
To check the wire position and sta tus before confirm with me for hoist o r no t .
-Why yo u didn t wait confirma tio n from your colleague before ena ble hoist ?
Fo r sev eral reasons
1-QC opera tor a dvice tha t the wire is clear from his loca tion and he will be responsible fo r ho ist
2-there was no smo oth access to spreader position
3-my co lleague o n sa me Ra dio cha nnel any listen to our discussion/
4-i saw the a rea around the bay was clear from a ny huma n ma y be at risk if we ho ist up.
-If this C ase repeated with you a ga in, Wha t will be y our reactio n?
I will not trust Operato r advice and wa it my co llea gue co nfirmation then check with operato r befo re hoist up a nd Safety SV should be inv olved in this decisio n
If required, were yo u wearing the correct P PE:
Immed iate caus es

RTG 4 3 hit TR 1 09 du rin g han dling conta iner on TR 105 .
Underline ca use s
TR 1 09 was in wrong p osit ion ( it was in t he container p ath way).
YES
June 12, 2013
4:30
Orange
RTG
43
Direct Superv iso r: Name:

Depa rtment: ops
Immed iate caus es

TR 1 11 hit TR 1 08 d uring man euverin g.
71
June 10, 2013
18:30
Orange
TRA
111
Kotbey
When TR 111 was maneuve ring in front of TR 108 w hich stoppe d in back reac h and wa s talking in mobile phone , it hit T R 108
and caused cut in TR 108 hea d.
Underline ca use s
TR 111 d rive r did nt too k th e safe distan ce an d did nt us e h is mirrors du rin g mane uvering .
Roo t Cause
Pe ople caus e :
- Lack of att ention.
Immed iate caus es

T R 61 h it TT 12 4 in 01 E 5 5.
72
73
June 9, 2013
June 9, 2013
15:00
11:00
Orange
Orange
TRA
TRA
61
91
Trade mar
Mostafa Rahma
When T R 61 wa s ente r 01 E H, it h it TT 124 wh ich sto pped in this bay an d lead to fron t
g las s crack
TR 9 1 hit con tain er du ring reversing ba ck in 03 H 3 8 ca using cut in con tain er No.
INKU6 466 765 . B88
Underline ca use s
Th e front TR st opp ed sud den ly and th e invo lved TR driver was n ot co ncentrated t o his way.
Immed iate caus es
Roo
t Cause
TR 91 hit the cont
ain
er du rin g revering back.
Pe ople caus e :
Lack of att
Underline
caent
useion.
s
1. The in volved T R driver reversed b ack in t he yard withou t guide in t he yard .
2. The vis ion was n ot clear fo r him .
Roo t Cause
Pe ople caus e :
Not followin g proced ure (t he in vo lved TR driver revers ed back witho ut gu ide ).
Operatio ns:
Moha med Ad el
E ngineerin g:
Ahm ed Sha wky
HSE : Moham ed El-Ta beey
To b e adde d on TBT regardin g a clear ag reemen t

on vess el tea m ( Eng t eam ) and t he ope rat or
abou t the clea rnes s of wire condition and
wait everyone on h is p lace fo r co nfirmatio n.
Ahmed Essam
Position:
NO
ID:
881
OPS supervisor
Ad d this cas e to TBT and h igh lig ht th at

1 . RTG o perators mus t ch eck th e T Rs positio n und er RTG b efore
ha ndling t he co ntainer.
2. TR d rivers mu st st op in rig ht pos ition un der RT G and awa y fro m
con tainer p athwa y.
Did he/she give a pre-shift safety ta lk: YES N O

o ne ho ur
Roo t Cause
Pe ople caus e :
Inv olved Person: N ame:
Mohamed Taha Za her
I D: 3384
While RTG 4 3 was han dling conta iner in 03 K 58 A 0 1, it hit TR 1 09 which s topp ed in t he
1. Poor d ecision makin g.
Depa rtment: OPS
Position: TR driver (Campell)
cont ain er pat hway and cau sed sm all d amage for T R 10 9 left frame gla ss
Ex perience: 2 years
1 . RTG operator t ook wrong d ecision when he h and led th e con tain er h owever he n oticed t hat TR
- I sto pped in 03 K 56 in front of 2 TRs beca use I wa s waiting to enter bay 64.
fo r the incient
in wron g pos ition and h e depe nded on TR d river action .
- RTG 43 wa s working in ba y 66 a nd suddenly he ba ck to bay 58 a nd started to ha ndle conta iner in A tier 01 and my T R was switching off.
2. TR d river too k th e decision to re -adju st his pos ition lat e becaus e h e tho ugh t that RT G will n ot - W hen I was switching on my T R, the co nta iner hit my TR.
work in t his bay)
Con tribut ory factors:
- RTG 43 m icroph one not work.
Risk Value: Severity (3) *likelihood (3)=9
NO
Did yo u receive superv isio n in the la st 1hr of yo ur work: Y ES

Ho w do yo u think this incident co uld be a vo ided in future?
When was the la st time yo u spoke to o r witnessed the invo lved persons work
70
Op era tion s: Khaled Heg azy

E ngineering : Mohm oaud D orma n
HSE : His ham Is mail
1 6/06/2 013
OPS
Hatem Hosny
1 3/06/2 013
E NG
Rep air RT G 43 micropho ne
1. Where were yo u in this time?

- I was in the T R.
Involved
Person:
Name:
Osama Farag El-said Hassan ID: 3275
2. Why yo
u didnt switch on yo ur T R and reverse back after yo u a lready sa w RT G ga ntry?
Operations
driver (C ampbell)
-Department:
Because I didn
t expect that it will wo Position:
rk in this TR
bay.
Experience:
2 years and
half. on yo ur TR?
3. When you started
to switch
- During the RT G wa s handling the conta iner but there a re so me types o f TRs which is switched off a utoma tically.
I4.was
berth
02 from
E container block (lower) slowing my speed taking my right-hand direction and my left side was free from any trucks, but there was a truck in front of me (at the right side) so I passed beside it (but still within my
Didentering
yo u sleep
inside
thethe
TR?
direction)
and was avoidin g the hollows in the route but when I was at the of the C containe r block I was surprised by an ext. truck coming in front of me (between C and D-Higher) because I couldnt believe that their will be trucks moving at my
- N o.
left side a nd so I hit it then I used the brakes (after collision happened) and found the ext. truck shifting inside the container block as a result of collision.
What was your speed before collision h appened?
my speed wasnt high, and I was going to load from inside the yard.
Inv olved Person: N ame:
Are you alw ays check for one side direction when you are driving in the yard?
Department:
OPS
No, When I get into the G or even H container blocks I look carefully at the both directions
in order
not to
be hit by any ext. truck passing over.
Ahmed M ohamed Saa d

ID: 3662
Po sitio n: T R driv er (Kotbey)
I had
under
QCseat
16 and
-Do
you wo
wasrkfasten
your
belt?I was in south a nd directed to QC 16. T here was T R 108 which stopped in back rea ch behind QC 14. When I wa s maneuvering in front of TR 108 to enter QC lane, I sto pped a nd a sked the
TR driver for wa ter and I drank then I co ntinued to QC lane but unfo rtunately I hit TR 108.
Yes I was fasten my seat belt.
1- What was the sta tus of yo ur mirro rs?
- Go od.
2- Did yo u used yo ur mirro rs?
- No . I didnt use mirrors.
3- Why yo u didnt use mirro rs?
- Because I wa s in hurry for wo rk .
4- Did yo u sleep well yesterday?
Involved Person: Name:
Ahmed Said Ali Al-gedawy ID: N/A
- Yes.
- I was going to 01 D 49 through 01 E H a nd there wa s TR in fro nt o f me but the front TR sto pped
hit last
the rest?
TR a nd caused fro nt glass crack .
5- suddenly
When wassoy Iour
Inv olved
P erson:N/A
Name:
Elsay ed Kamel
Elnahy
9285
Department:
Position:
EXT. TR driver ID:
- 2.5 hours ago.
1. Wha
was distance
the other
R? (Mostafa Rahma)
Depat rtment:
OPS between you a nd
Po sition:
TR Tdriver
- Sa fe distance.
Experience:Ex perience:
N/A
2 years
2. Wha t was y our speed?
I- entered
ISlow
was speed.
inthe
03yard
H L in
a nd
order
directed
to load to
2*203
0 feet
H 46.
Empty
W hen
containers
I rea ch and
RTGI was
turning
accompa
plates
nied
between
by a PU 03
belonging
H (H /L),
to Igate
found
service
TR which
to drive
stopped
me to my
in location
bay 46 and
so I left
decided
me, after
to Ireverse
got the 2back
containers
to stopI tried
in 03toHget
38out
but
then
unfortunately
I found 2 Ext.I TR.
hit co
(One
ntainer
of them
in was
ba y
3. Wa
38
loaded
during
s and
yo ureversing
the
co other
ncentra
was
bated
ck
un.loaded)
for yourwere
waytrying
?
to get ou t from the left side so I decided to follow them and there was no PU accompa nied them. At the time I was about 1 meter from the bays margin when I wa s maneuvering to the left sid e I get
- I was coby
surprised
ncentrated
a TR movinognly
towwith
ard me
themoving
co ntaat
iner
theside.
opposite side of the traffic route from the seaside and hit me strongly and drive me inside the bay.
1. Wha t was y our mirro rs sta tus?
- Goo d.
2. Yo ur T R was in straight o r not?
- What
your speed
you
to maneuver?
Whenwas
I reversed
ba when
ck, my
TRtried
make
little devia tion so visio n wa s no t clea r in mirro rs.
I3.was
driving
low speed
(about
20 km/h)
becauseba
I was
Why
yo u at
asked
fo r guide
before
reversing
ck? loaded by an e mpty containers and I was afraid that the containers may fall down at any moment if I increase m y speed over that.
Was it your first h our in working rotation?
No, it was my second hour.
Operatio ns:
Ad el Kh edr
Ahmed S hawky
H SE:
Eng ine erin g:

Mo hamed El-Tab eey
Possible (3) * Severity (1) = 3
Operatio ns:
Ad el Kh edr
Ahmed S hawky
H SE:
Eng ine erin g:

Mo hamed El-Tab eey
Add th is case to T BT an d hig hlight t hat TR drivers mus t be more

att ent ion an d take s afe distan ce du ring man euvering and us e his
mirrors du ring man euvering .
6/24/2013
OPS
Hatem Hosny
Did you sleep well yesterday?

Inv olved
erson:
Mahmoud
Yes, I Pslept
well,Name:
and today Mohamed
is my first working
day. Mohamed ID: 3324
Depa rtment: OPS
Position: TR driver (Trade ma r)
Ex perience: 2 years
- I didnt know that I will hit the co nta iner.

4.Was
your
entering
the terminal?
Did ityo
u tafirst
ke time
during
training
tha t yo u mustnt reverse ba ck in the y ard without guide?
I entered the terminal many times before through the last 2 months.
-No,
Yes.

1 . TR drivers m ust b e more att ent ion to h is way.

1 . TR drivers must nt reverse ba ck with out gu ide .
Operatio ns:
Ad el Kh edr
Eng ine erin g:
Azmy S hata
HS E: Moh amed E l-Tabe ey
6/16/2013
1 6/06/2 013

Send t he in volved TR driver t o tra ining for re -ass essm ent.
OPS
hatem Hosny
OPS
hatem Hosny
1 2/06/2 013
Do you aware about the traffic directions inside the terminal?

No I didnt know the traffic directions inside the terminal and I was depe nding on the other ext. trucks as a guide, and I noticed the direction arrows outside the containers blocks because I was familiar to it b ut inside the container blocks It was
difficult for me to be noticed.
: Mahmoud
ID : 1047 the driving instructions inside the terminal?
Involved
Do you Person:
understand whatName:
is written
in the batEl-Mor
number regarding
No, as I cant read or e ven write, so I wasnt able to understand what is written and when I got that bat number I use it as a sign to ask for my location.
Department: Ops. Position: QC Operator
Do you have a driving licen se?
Experience:
Yes, I have a 2nd class license.
1.5 years.
Sum mary of statements :

Do you have an entry permit?
I was loading 2 20 containers in land side bay then I moved to load another 2 20 C ontainers sea side and the view from QC cabin showing that the bay and cell guide of the bay is looking sm ooth and clear, normally to make easy while loading we
Yes, I have. But after the accident happened I searched for it but I didnt find it.
depend on cell guide, I reach to the ground then I felt something wrong happened.
74
June 14, 2013
7:00
Blu e
QC
W hile cra ne 13 loa d twin cont aine r on ba y (6 1/63 )U, t he loa ded cont aine r on bay (6 3)
was s tu ck in th e vesse l tank
13
wasthe
your
hoistdriver
speed
Are you
main
of?
tha t truck?
N ot pre sence of D&W co ntro ller during h and lin g as we ch ecked wit h ros ter t hey ment ione d there ItWhat
normal
speed
butasI slow
dow driver
n before
I reach
toconditions
under deckinhibit
for a him
distance
containers
Nowas
I am
a spare
driver
the main
has
special
from 2working
so I height.
am working instead of him.
was les s tha t 7 Deck con trollers and 1 3 Wharf on shift.
What was your load ?
Around 60 tons, then it showed overlo ad after I stacked 77 or 78 tons.
Did you no ticed the truck before collision ha ppened?
Was there is a Deck controller with you on vessel ?
Yes, I noticed it but I didnt imagine that it will hit me because the TR driver should take his right-hand direction and I was taking my left-hand direction.
No, he wasMohamed
with me but
loading
single
Name:
Abdduring
El-Latif
Sa lemfirstID:
N/Aunits but he mo ved to other QC as we were w orking with 1 Deck controller with 4 QC th en he moved to QC 14 for hatch cover discharging.
Operations: Khaled Hega zy

Eng ine ering: Ah med Salah/Ahmed Bah aa
HSE : His ham Is mail
Risk Value:
Severity (3) / 3685 $ *likelihood (3)
= 9
1-To p rovid e D eck cont roller for e ach QC as its es sen tial fo r QCs
o pera tor wh ile ha ndling
2-t o give clear stat us wit h ce ll gu ide an d ship structu re.
Waiting
Management
new
1 - ops
2- train ing /roste r
3-g ate
4-- Sa fety
1- 25 /0 6/20 13
2- 20 /0 6/20 13
3- waiting
4- waiting
Open
Ehab Zahran
1- ops /training
2 - ops
1- 25 /0 6/20 13
3- waiting
Open
Amr Rashwan
1 -Ops train ing

2-op s
3- ops a nd man ageme nt
1- waiting
2 - 24/6/2 013
3- in progre ss
new
Amr Rashwan
Open
Hatem Hosny
I face the same conditions for another time w hat you are going to do?
Department:
Operation
Position:
TR d
riverand
(Sinai)
I will take my caution
asking for the directions
inside the
yard
will follow the instructions because my life w as in danger.
Experience:
2 days training
Witness Person:
Name:
Ahmed Megahed Hassan
ID: 3225
I started my training period at 11:30 PM by receiving the TR from my colleague then started my training and every thing was looking normal to me till I reached the stoppage mark, I tried many times to push the brake pedal but I found that it w asnt
working so I thought to use the hand brakes but I returned in my decision in the end.
Department: Operation
Position: TR driver (Trademar)
When exactly you thought in using the hand brakes?
Experience:
3 years
When I became at the stoppage mark.
1 .Lack Of atte ntion:
75
June 13, 2013
8:20
white
TRA
82
Campbell
TR 82 h it an exte rnal t ru ck (2417 ) while it was ma neuve rin g to get o ut from 02 C 02

at t he wrong d ire ction lea d to sh iftin g the exte rnal t ru ck strongly toward 0 2 D 02
containers block and h itt ing t he conta iner at t he A raw.
1.Add th is case to TBT reg ard ing : truck d rivers h ave to bay more
at tent ion while drivin g across con tain er blocks a nd lo ok as ide at b oth
dire ct ions e specia lly at cros s rout es in sid e t he yard .
2.Truck driver ne ed to be se nt to th e tra ining secto r in order t o b e reass ess ed, and d uring th is pe rio d of t ime he s hou ld be ou t of working
rotation.
Can you explain in details what did you see?

Did you no tice the presence of extinguisher on the cabin floor when you enter the truck?
I was
entering
from
the A container
block
going
from and
QC put
14 toward
3G
42TR
and
there was a truck in front of
No,
I didnt
notice
anything,
I just took
off my
helmet
it beside
the
screen.
me but suddenly found the ext. truck w as moving fast within the blocks, the Terberg truck was moving in its
normal speed but slightly shifted tow ard the left direction and there was no other trucks in front of it.
Did you check the brakes before driving?
No, because It was ok with my previous colleague and I was working on the same truck before taking my
Did you no tice the Ext. Truck before collision happened?
last rest.
It w as fast and trucks he ad and the front tail were out of the block and the half of the back tail was still
As t he Termin al driver has en ough s pace enab le him to not ice t he ext. t ru ck while movin g but h e
inside the block.
didnt take tha t int o con sid erat ion ( that t here will be a truck coming from his left s ide) .
Did you fasten the seat belt?
2.Abse nce of proper con trol o n the Ext erna l tru ck driver:
As the external t ruck wa s load ed in a s pecial cond ition (th e oppo sit e ya rd direction ) and t here
was no sup ervisio n while t he driver wa s trying to mo ve o ut of the cont aine r blo ck.
Operations : Eh ab Zahran
E ngineerin g: Amr Shorbag y
HS E: Moh amed at ef
Yes.
Did you no tice any other trucks except for these 2 trucks?
There
were
other
trucks
exceptsession?
for the Ext & Terberg trucks. And the traffic route was very clear to m e
Was
it the
firstno
trial
in today
training
and
accident
ppened
container
blothat
ck. truck.
No, the
It was
my 5thhatrial
an d I when
w as inI was
rest at
the
hourB before
I took
Risk Value:
Severity (2) *likelihood (3)
= 6
Did you rece ive a pre-shift safety talk?

Did you know that you have to check for the extinguisher position before driving?
Yes.
Yes, I know but I forgot to check.
Nam e:
Abd El-Razeq Abd El-khaleq Attia
1.Lack Of E xperience/Tra ining:
ID: 1235
Position: RT G Operator
Experience:
2 years
What did know about the mentioned accident?

I start my w ork at 8 oclock working in 03 G 78 and after about 15 minutes I heard a strong brakes sound w hen I realized it I found out it was our termina l truck and also I heard the high sound from the ext. truck engine but I didnt see the accident
As t he invo lved TR driver is a fresh t rainee (h is 2n d tra ining da y) and ha snt su fficient exp erience while it happened. But when I noticed our trucks Tail so I thought that it may hit the containers but I didnt see the ext. truck from by position in the cabin, bu t after I get out of the cabin in order to get a better vie w I found the ext trucks head shifted
to d eal with s uch circums tances .
inside the container block and the fro nt container fall aside the front tail.
2.In aprop riate pre-tas k check:
76
June 13, 2013
23:30
white
TRA
128
Sinai Co.
New subcontractor trainee while training hit TT 35 by TR 128 (training TR).
3.A St and ard Operatin g Procedu re need t o be

pres ent ed reg arding: how to cont rol external t rucks in s pecial case s
and es pecially in areas where t here is an in terfering bet ween gat e
operations an d normal ope rat ions .
4.Safet y Awaren ess Prog ram n eed to b e h eld t o ext . truck d rivers in
o rder to be su re tha t all drivers are aware abou t our s afety in struction s
regardin g driving inst ru ct ions ins ide th e terminal.
Did you he ar any sound indicatin g th e extinguisher sliding on the cabin floor?
No.
Witness Person:
Did you think the Ext truck was movin g fast or no t?

I doubt that the truck was moving fast as the head container fall from the front tail.
Operations : Eh ab Zahran
En gin eering : Moh amed H ass an
HS E: Moh amed at ef
As t he TR driver forg ot to check t hat if t here is any thing lo oking ab normal in t he ca bin a nd so he Did you no tice any other trucks except for the mentioned trucks?
d idn t n oticed t he abn ormal p osition o f t he extin guishe r.
No, I didn t notice any other trucks betwe en container blocks. But there might be trucks but I couldnt see.
1. Ad d this ca se to TBT reg arding: truck d rivers ha ve t o ch eck for an y

a bnormalitie s notice d ins ide truck cab in befo re operation and p ay more
a tten tion fo r the ext ing uis her p osition a nd rep ort t hat to t heir direct TR
sup ervisors.
Risk Value:
= 9
3.Fire Extingu ish er was im prop erly fi xed :
2 . Broad s urvey s hou ld be p erformed to all TRs ins pecting th e

presen ce/ab sen ce of extingu ish er st ands and se nding th e defected TRs
to Works hop in ord er to fix new st and s.
The wron g placem ent of th e ext ing uis her h elp s in it s sliding toward the b rake ped al.
D epartmen t: OPS Position : QC op erat or

E xperience:
Imme diat e cau ses
Rig ht la nd side flip per hit th e cen tral hat ch cover & con tainers and ha ndrails
Und erline caus es
Working in b lind point wit hout g uid ance
77
June 18, 2013
5:00
Red
QC
while QC05 discharg ing from sea side un der d eck bay 54 MV CMA CGM MU SSE T in blind
poin t sp reade r was stu ck in cent er of the h atch co ve r.
Root Caus e
Organ izat ion :
- In sufficie nt work dem ands ( abse nce o f D eck controller).
People cau se:
- Lack of exp erience of the QC op era tor.
- Ina dequ ate checking p rocess fro m QC operator on the s prea der aft er the fi rst h it
- Poor d ecision makin g from QC op erat or du e to over confi dence when working in blind p oint
with out g uid ance while h e cou ld work in unveiled rows till the p resen ce of th e deck cont roller
1 mont h
I wa s dis ch arg ing cont ain ers fro m s ea hat ch u nder deck at the 5t h row sea side, I discharg ed 5 conta iners from th is ro w an d while I hois t down t o g et th e last o ne, t he sp read er hoiste d
down from th e left side and t he right s ide was s tayed o n the cell g uid e, s o I sta rted t o hois t up s lowly an d while t hat th e spreader stu ck and g o up in s udd en way and h it th e u p deck
cont aine rs, th en I st arte d to adjust it and I s aw that t he flipper wa s a lit tle de nted wh en I checked it after t he hit, t hen I informe d the wha rf to in fo rm the VSV abo ut th at then I decide d to
go to 4t h row sea side to discharge the cont aine rs in unveiled row, I ge t a con tain er from 4 th row se a s ide an d dro p it to th e TR an d I checked t he movem ent of th e fl ipp ers with th e
wharf while th e s pre ader wa s on the cont ain er on th e TR an d it was ok bu t the wha rf informed me th at th ere was a pro blem in the righ t lan d sid e flipp er (s hap e of t he flip per), t hen
1- QC o perator mu st g ave a t rainin g ses sio n

a bout t he sa fe h andling procedu res
a nd th e correct ins pectio n to ass ure th e safe han dling
2- - Add this cas e to the TBT sh owin g the im portance of follo wing th e
s afe ins pectio n procedu res afte r incid ent s and whe n doub t the y mu st
s top th e operation till full ins pection
3- - Provid e a d eck cont roller for ea ch QC
Involved
Pers
ame:el and
Wael
Ga deck
mal AliwaID:
3484 on my rig ht catwalk to h elp me in the blind row, an d while I hois ted d own, t he sp read er could nt ent er th e row t hen an d while I was
re turn
ed on:
to th eNvess
t he
s there
Depa rtment: Operatio ns
Position: T R driver (Ca mpbell)
Experience:
2 yea rs
adju sting it t he sp read er st uck s o I started t o h ois t up an d while t hat t he spreade r went up in su dden wa y an d made a st ron g screw and hit the lift sid e of t he row (h and rail) , th en I tried
e it stafo
ble
d after
t hat Iatt old
thaenddeck
roller
to Isgo
tart
enterin
g the
ro w agblock
ain bthro
ut he
formeblo
d ck
me
that
it cou
becaus
t hequay
flipper
wasnoticed
hit cauRTG
sin g18a in
sha
gey and
I to
gotmad
an address
r a an
reefer
co ntainer
03 G
a ftercont
being
lo aded
t out
from the
container
ughinLower
a nd
while
I wald
s nt
in my
way toethe
sideguard
I suddenly
frorp
nt ed
of ba
38 in
th erebeca
wasuse
a cu
t inafra
t he
in RTG
th e was
6th row
nder
deck.
03 C a nd wa s cro ssing toward the 03 C Higher so I was enforced to continue
I was
id two
tha t co
If I ntainers
stopped the
go inguto
hit the
T R head a nd if I co ntinued it wo uld hit the trailer, so I decided to get mo re
closer to the container block in order to a void co llisio n.
N ader H elmy
Eng inee rin g: Moha med Had idy

HS E: Ra mzy Mah er
Likely4*2=8
1 - D id you call the de ck co ntro ller before yo u started t o dealing wit h blind ro w?
Did yo u feel the co llisio n?

- No , becau se I knew th at he dea lin g with QC 0 6 in th e same ves sel, an d there wa s one deck con troller dealing wit h two QCs in the s ame vess el.
No I didnt, but after I stopped I found the RT G was stopped to o so I felt that something wrong ha s happened a nd then I ca lled my truck superv iso r.
2 - What is your t rainin g ins truction s when you wan t to han dle cont ain ers in blind ro w?
Do you k now the tra ffic priorities inside the ya rd?
- Calland
t he
deckHa
con
troller t o help m e a nd if he was b usy wit h anot her QC I can h and le with m y s elf.
Yes, RT G ha s the first priority followed by Reach stacker
Empty
ndler.
3 - In th e fi rs t hit , what issu es did you check in your s prea der?
Did yo u check yo ur both

directio
pa ssing
to 03
- I ch
eckednsthbefore
e flip per
an dfrom
foun03
d Cthat
it B?
was a sma ll den t in th e rig ht on e a nd when I was in qu ay sid e I ch ecked t he spreade r movemen t and it was ok.
Yes, but I expected tha t RT G will be stopped
bay 38
I wa
s surprised
by tin
its ue
movement
toward
myyou
sidefin
sodI wa
ted
tosget
oided gin
by shifting
toward
container
4a
- tWhy
didbut
you
decid
e t o con
th e work
wh en
thas tobliga
there
wa
a pmy
robself
lemav(chan
g in flippe
r sha
pe)? block.
- I t hou ght th at it was a s mall d ent an d I wouldnt us e the flippe r becaus e I was in d ischa rgin g pro ces s.
Did yo u try to use the brakes?
5 - W hen you check the s pread er s tatu s after t he first hit did you s ee th at there wa s a broken na il from th e flip per?
Yes, but a s the truck wa s loa ded by a full conta iner it wasnt a ble to stop a t once.
- I didnt check it well.
Wha t about yo ur speed before the accident ha ppened?
It was the norma l speed.
Did yo ur hea r the sound o f the RTG Gantry Siren?
No, but I no ticed it locatio n o nly.
Po or decis ion ma king:

As t he TR d river decid ed to ta ke th e ris k of pa ssing be fo re the RT G in order t o a void collision.
78
June 21, 2013
11:00
white
TRA
68
Campbell
While RTG 18 was cro ssing in 03 C from lower to higher conta iner blocks it suddenly hit reefer co nta iner
loa ded on TR 68 which wa s try ing to pass quick ly towa rd the Quay side before the RT G cro ssing over.
N ot following o f s afety traffic st and ards :
Sa iedy
ID: 1713
Depa rtment: Operatio n
Experience:
1 y ea r
Involved Pers on:
Na me: Tarek Ma hmo ud El
1. T R D rive r to be se nt f
Position: RTG Operator
I was cro ssing from 03 C lower to higher so I lowered my speed a t the stop mark then I no ticed the truck was mo ving to ward me so I expected that it will stop, but suddenly I found the truck in fro nt of me so I raise my
ha nd fro m the gantry joy stick then I fo und the first half of the truck (head & o f the conta iner) in front of me.
Did yo u feel the co llisio n?
Yes, I noticed the RTG while it wa s hitting the co ntainer at the end tip of the trailer.
Since t he TR d river didnt give the priority to t he RTG t o cro ss firstly a nd decid ed to pa ss be fore it
dep end ing on that t he RTG will st op allowing h im to pa ss first ly.
Did the RTG Ga ntry siren wa s working?
Operations :E hab Zahran

Eng inee rin g: Ahm ed Salah
HSE : Moham ed At ef
Risk Value:
= 3
Yes.
While yo u wa s crossing wha t was the mo od of yo ur sprea der?
The spreader wa s in 20 feet mode.
When you was at bay 38 where wa s the truck exa ctly ?
It was a t the turning plates o f 3 D.
How do you think this incident co uld be a voided in future?
I think that it wa s the respo nsibility of the T R driv er that he should sto p a s the priority wa s mine.
78
June 22, 2013
04:30
Blue
RTG
19
While RTG 19 discharge twin in truck 145 he Lift Twin Container With Spreader On 40 Mode.
Severity (2) * Probability (3) = 6.
79
June 22, 2013
12:00
White
QC
Risk Value:
80
June 22, 2013
17:40
White
QC
15
Risk Value:
Ops
July 1, 2013
Open
Severity (3) *likelihood (3) =9
Ops
July 1, 2013
Open
Amr Rashwan
Severity (1) *likelihood (2)=2
Management
12th Nov. 2013
Open
Amr Rashwan
Invo lved Perso n: N ame: I sa ac Ata Abd El Ma lak ID: 535

Department: OPS Positio n: RTG opera tor
Ex perience:
7 y ea rs
I was discha rging 40 ft co ntainer at 07 J 62 F 1, and while I was hoisting down the co ntainer in the m entio ned location, I observed that the conta iner was stuck by something under it so I ho isted it up to check the
do ors o f the beside conta iners and I find it closed a nd ok so I made trolley to ward G ro w to see what was under it, I found that the SS do or wa s opened towa rd F ro w.
Imme diat e cau ses

RTG 47 h it SS 30 trans fo rmer d oor
83
June 25, 2013
21:00
ENG - TS
RTG
W hile RTG 47 d ischa rged con tain er at 07 J 62 F 1, it h it su bs tation 30 d oor which loca ted
at ro w G cau sed to d amage it.
47
Und erline caus es

S S 30 t ran sforme r door was open
Root Caus e
La ck of ch eck for S S 30 doo rs
1- Did you see the status of SS 30 do or, wa s it opened o r no t?

- No I co uldn t see it opened because it wa s a blind point, there wa s three tiers in the previo us ro w E row.
Invo lved Perso n: N ame: Eng. Hassan Alla m ID: 1784
Depa rtment: EN G
Involved Person: Na me:

Department: OPS
Immed iate caus es

The involve d TR d rive r moved an d fuel n ozz le was in TR tan k.
84
June 29, 2013
21:00
Orange
TRA
101
Kotbey
Tru ck 10 1 moved be fore remo ving t he fuel n ozzle from truck t ank and caus e a d amage
in fuel n ozzle & pu mp.H1 00
Underline ca use s
Th e involved TR driver forg ot to rem ove the fue l noz zle.
Po sitio n:
T S engineer
Experience:
3 yea rs
In 1st day shift 24/06/2013, according to the sent ma il fro m fire department fo r insta lling fire fighting system in SS 30 & SS 31, we disconnected the po wer from SS 30 & SS 31 then a fter fire team finished, they called
us to re connect the po wer so one o f my tea m went to co nnect the power.
After a fternoon, one o f fire team info rmed me that the A/C in the SS do esn t work.
I went with A/C technicia n to SS 30 & SS 31 @ 07:00 PM to repair the A/C then I checked SS do ors a nd ensured that a ll SS doo rs closed before I left.
In 2nd da y shift 25/06/2013, I didnt have any wo rk o r any ca ll for SS 30 & SS 31.
1- T here is a ny da ily check fo r all substatio ns in the shift?
- Yes, we do daily check for a ll substations.
2- Did yo ur team made a ny check for SS 30 & SS 31 in 25/06/2013?
- No, they didnt check.
3- Why they didn t check?
- Beca use we dont hav e time to ma ke this check in this da y.
4- There is any pro blem in the door?
- N o.
Op era tion s: N ader H elmy

E ngineering : Ahm ed
Salah
HS E: Ram zy Mahe r (Re d shift)
Operations: Moha med Ad el
E ngineering : Amr
E lsh obag y
H SE: M ohame d Elt abeey (Ora nge
s hift)
Probability (2) * Severity ( 1 )=2
1. In stall doo r closer fo r all s ubs tat ions d oor

2. Prevent s tacking con tain ers b ehind ph ase 2 su bst ations (row F) t o
p reven t any pot ential collisio n haz ard for t he su bst atio ns
3. Ad d this cas e to TBT and high lig ht th at:
T S team mu st make ch eck for a ll su bst atio n doors daily in each sh ift
TS
Man ageme nt
TS
Wa iting
Wa iting
2 8/06 /2 013
Open
Hatem Honey
Ahmed Mohamed Ahmed

ID: 3078
Po sitio n: T R driv er (Kotbey)
- I went to fuel sta tio n and I used fuel dispenser #04 but system didn t work then I went to fuel dispenser #01 but also the sy stem didnt work so I decided to go to manua l fuel dispenser but unfortunately I moved
befo re remo ving the fuel nozzle from T R tank a nd dama ged happened.
Operatio ns:
Moha med Ad el
E ngineerin g:
Amr E lsh orb agy
HSE : Moha med El-Tabeey
1- Where was yo ur position?

- Beside the fuel no zzle.
2- Were yo u occupied with anything?
- N o.
3- Did yo u sleep well yesterday?
- Yes.
4- When was y our last rest?
- 2.5 hours ago.
Roo t Cause
Pe ople caus e :
Rare (1) * Severity ( 1) = 1
Add th is case to T BT an d hig hlight t hat TR drivers mus t be more

at ten tion a nd remo ve fu el noz zle from TR t ank before m oving .
OPS
July 2, 2013
Probability (3) X Severity ( 2 ) = 6
1 -Add t his cas e t o TBT regardin g: QC operators sh ould take t heir safe
hoist le vel before m aking t heir path a nd to b e s ure t hat th e dis ch arged
con tain er is com plet ely out of th e cell guide be fo re makin g trolley
moveme nt.
2 -Rep airing t he defected CM S syst em in QC 0 1 in order to e nable us to
retain requ ire d data .
1-OPS
2 -ENG
10 -07- 201 3
15 -07- 201 3
Probability (3) X Severity (2) = 6
Add t his case t o TBT regard in g the followin g: if QC operators were

working in con dit ion s of p oor vision from their side th ey h ave to ask for
t he deck help a nd if th e crane became b reakdown t hey have to wait for
the mainte nance help and d idn t t ry to make any su dde n movemen t by
t heir own.
OPS
20 -07- 201 3
OPS
7/15/2013
Hatem Honey
Did you not ice wh eth er deck con troller wa s on the b ay o r not ?
N o, as he was working with anot her cran e ass ist ing t he QC ope rat or in H C op ening.
Immed iate caus es
QC 01 h it on d eck mid dle catwalk b y a cont aine r while reversin g toward Qua ysid e.
Underline ca use s
85
June 30, 2013
8:10
White
QC
W hile QC 01 was d ischargin g Twin move from b ay 2 6 und er de ck at th e s econd ro w of

th e seas ide , th e crane su dden ly st oppe d during m aking t rolley to the Quays ide an d the
left 2 0 feet conta iner of t he twin hit t he mid dle Quay side ca t wa lk.
QC01
The cra ne was su dde nly st oppe d wh ile t rolley back t oward Quays ide re sulted in t he swing
movem ent of the cont ain ers .
Roo t Cause
Incorre ct followin g of p rocedu res: th e o perator d idn t fo llow th e stan dard procedu res for making
p ath (b y s tartin g trolley be fo re get ting comp let ely out of th e cell guide) .
Over con fiden ce from QC operator: th e operator did nt take t he sa fe h ois t level b efore tro lley
ba ck thinkin g that it will n ot make any pro blem .
In volved Person :
Nam e: Ash raf So lima n
ID : 550
The t win you was ho lding was h eavy or not ?
No, it was nt heavy as th e weigh t of both cont ain ers was abou t 3 4 ton .
D epartmen t: Operation s
Pos ition: QC Ope rat or
Was it you r first ho ur on t he crane ?
No , as t he incid ent h appe ned E
inxperien
t he beg
in nin4
g years
of m y and
2 nd ha
hou
ce:
lf r.
Did yo u com plain abou t any previou s fault s in you r 1s t wo rkin g hour?
I was loa din g a t win conta iners (in 45 sp read er mod e) in -betwee n 2 rows of 40 fee t con tain ers o n deck, an d the de ck co ntro ller asked me to rise s pread er lift sid e ( right -trim) and t o
Yes , 3 t imes . At the first time the cra ne sto pped trolley and aft er makin g re-s et the cra ne worked no rmally a nd after that I fo und t he sam e fa ult b ut at th e third time I asked for t he
expand t he twin mode op enin g, so I tried t o d o so but sud denly t he hoist breakdown . Aft er th at I tried to m ake a hoist d own but t here was n o resp ond s o I asked for th e Main ten ance
E ngineering a ssista nce a nd after m aking s ome checks I was in formed t hat th e crane was re ady and in the fou rth t ime th e incid ent ha ppen ed.
h elp.
What was yo ur exact tro
lleyatpowas
sit ion
n you
was hoisting
Wh
th ewhe
exact
p osition
o f th is tup
winthe
lift ?twin out from cell g uid e?
I was in bet ween th e 3rd & 4 th ro w of th e s easide.
It was a t the 3rd row of seas ide an d it was lo wer th an the 2 nd row by one cont ain er and t he 4t h row by 2 con tainers.
Operations : Moh amed H egaz y

E ngineerin g: Ah med Salaheldin
HSE : Moha med Atef & Mu stafa Fat hy
Open
Mohamed Elaraby
Open
Salah abd Elaziz
D o you have inst ructe d to make a t rolley backwa rd befo re bein g comple tely ou t of cell guide?
Did you make hois t up at h igh s pee d?
I do not h ave a clear in struction abou t tha t, b ut it d iffers from operator to anot her in how to ha ndle t he container wh ile d ischargin g from un der d eck, tha t I use d to make trolley back
No, it was just a s natch not a fu ll ho ist u p.
wh en th e con tain er be came a t the first qu art er of th e cell guide.
Did you check with deck con troller b efore you r hoisting up ?
Technical
Advise/Re
Yes , of
co urs e .port :
N ame: Ahmed S alah eldin ID: 3 41
D id you n otice whet her t he mid dle t wist locks was clo sed or not?
Dep art ment : E ngineering
Pos ition: S enior Elect . En gin eer
No, as I cant recogn ize th at from my vertical po sit ion an d it was a blind p oin t to me.
Immed iate caus es

Mid dle t wist locks of th e twin left g et close d while it was set tle d on the b elow twin con tain ers .
Underline ca use s
86
July,5,2013
23:00
Orange
QC
Wh ile QC Operato r was load in g Twin lift (in 45 sp read er mod e) in a blind p oin t on bay 26
d eck at s easide th e m idd le twin corn er cast ing s stu ck in b elow containers and t he
operator tried to sn atch th e s pre ader b y m aking a s lig ht hoisting re sulted in a d amage in
crane s s prea der ( SQ 1 1).
QC10 (SQ 11)
QC op erat or was lo adin g in a blind p oin t and was nt able t o recognize whet her t he mid dle t wist
locks were close d or no t.
Roo t Cause
Po or decis ion ma king:
QC op era tor d ecided to d eal wit h the problem with his own way dep ending on h is expe rie nce a nd
did nt wait for t he mainten ance help.
88
July,7,2013
10:30
White
RTG
RTG 23
N/A
during RTG 23 moving gantry from 04E higer to lower is deviated and hit
truck 68 effected damage in RTG diesel side ladder and TR 68 muffler
damage
Comm ent:
W hen you was hois tin g up h ave you got an y a larm for o verload?
No, the cra ne did n ot record a ny sig n for overload .
YES
NO
Y ES
NO

Y ES
NO
HSE:
NO
Y ES
Op erat ion s: M oham ed Ad el

E ngineering : Ahm ed Sha wky
M ohame d At ef & Moha med El ta beey
NO

I will s top t ryin g to do an ything and will as k for the mainten ance help at once.
No. I surprised by him showing to me from main drive way that I hit his TR.
Witne ss Pers on:
Name: Amro Moh eb
ID : 17 39
-While your gantry movement from bay 54 till 42 did you notice any deviation ?
Yes ,but I directly adjust my direction using steering joystick
.
Dep art ment
: Op erat ion s
Positio n: D &W Cont roller
-Where the RTG start deviation ?
At the turning plates between Higher & Lower and I stopped at the middle of bayE xperien
38.
ce:
3 years and ha lf
-Did you totally stopped before cross between H& L ?
operator
wamy
s load
ing a twin
lift on b ay 26 row 04 s easide and I was sta nding at th e right s ide, in th e firs t I not iced th at left side was no t sett ing p rop erly (a way from the corne r
No QC
I just
reduce
gantry
speed.
cas
tin g)block
so I t old
th e operator
to expand
the twin mode a little b it b ut not hin g has h appe ned afte r tha t I shift ed to th e rig ht s ide.
-What are SOP for crossing
two
or Higher
& lower
?
Stop at the end of the bay to check both direction before cross
and switch the spreader mode to 20 feet mode.
Wh at was your exact p osition wh en the S prea der s tuck?
-What
was
I was at
t heyour
right spreader
s ide t hen Imode
t old th?
e QC operato r that the right sid e is ok, b ut he to ld me th at he cant see an ything from t he left side as th ere was n o o ne waving to him s o I moved to
Ahmed Abo Rehab
was
tIthe
lift s40
idefeet.
an d foun d that t he containers corner cas tin g wa s far from th e con tainers b elow, so I as ked h im to expa nd th e t win mod e a nd to s hift th e spre aders left side to th e ya rd side
Amr ELshorbagy
Mustafa Fathy & Ahmed
-If the same situation repeated with you (significant deviation )how will
but you
t he cran
response
e was breakd
?
own.
Karawia
I will stop my RTG and call yard Supervisor for help or to contact ENG dept.
Immediate causes
RTG 23 Deviated and hit TR 68
Underline causes
Over confidence from RTG Operator (as he precept that he could re adjust that
significant deviation alone)
Root Cause
People cause
1-Poor decision making/judgment
Can you not ice from any side (righ t/left) wh ethe r mid dle twist locks were clos ed or n ot?
2- Lack of attention
No I can t n otice th at, a s it was a blind p oin t to me (twin con tainers load ed in b etween t wo 4 0 feet conta iners) .
3- Failure to obey safety systems as he was requested to stop gantry once he realize
he make that deviation
Note:
Wh at hap pene d after th e crane was b reakdo wn ?
After
accident
inspection
take
order
RTG
at 06I notice
F for repairing
purpose
,the
same problemt rying
appear again and one from ENG. team inform me that
I left the
cran e and
move d toI the
ot her
crato
ne parking
and wh ilethe
I t urn
ed back
that e:
QC wa
s workin
g and
Person :d Nam
Elsayed
E lab
oty o perator was
ID : 14 51 to se ttle t he right s ide a nd when I b ecame at th e rig ht side I
steering
defected
. or th e whole t win was setInvolved
fo und it joystick
wa s ok s owas
I told
the op erat
d and
he cauld
m eion
t hat
h e hop
asera
no tor
lande d sig nal on t he sp read er and h ence he wasn t a ble to ma de
Dtle
epa
rtm ent:
OPS lea ve it but h e toldPosit
: RTG
Witness: Name: Mohamed Ali Abd Elmoneim ID:
3380
unlock. So he as ked for the mainte
nance
ass is tance.
Exp
erience:
2 years
Minimum 1 * Likely 4 = 4
Add to TBT for all RTG operator

1- never handle severe deviation alone .
2-Report any abnormalities to avoid sudden failure in
equipment.
New
Department:
OPS
out
source(Camplle)
Driver
- I was h and lin g
reefer
con
tain er in 0 3G 46F4 .Position:TR
Wh en I mad e
t rolley, I n oticed t hat I h it ed ge of reefer con tain er in 0 3G 46B4 an d I tried to b ack tro lley to p reven t con tain er from fallin g
I was waiting in the middle of road between 04 D L/04 E L indown
frontbof
ut bay
un fo rtu
34nat
then
ely Ithe
noticed
accidenRTG
t hap23
pen
was
ed. coming from 04 E h to 04 D L ,when RTG reach turning
89
July,7,2013
7:10
Orange
RTG
19
N/A
D uring RTG 19 lo adin g reefer con tainer fro m 0 3G 46F4, it h it reefe r con tainer
N O.M WCU66 701 55 which loca ted in 0 3G 46B4 an d con tainer fall down
People Cause :
- Lack of att ention (RT G operato r wasn t b e a tten tio n that h e did nt hois t up t o s afe hoist leve l).
- Mis s ca lculat ion for the sa fe h ois t level.
People Cau se :
1- Did you hoist up t o safety h oist level?

- No , becau se the re is no 5 t ier in the b ay.
2 - What is the s afety pro ced ures during h and lin g con tainer in the ba y?
- I mus t ch eck ho ist level th roug h visu al in spection and RTG scree n.
3 - Was s creen working well?
- Ye s.
4 - Did yo u ch eck th e h ois t level in screen ?
D id you inform you r TR
sup
- No
, I ervisor
didnt. a bout t he chair iss ue?
No , I didnt.
5- Wh y you d idn t che ck the s creen?
Operations:
Ah med Es sam
Eng inee rin g:
Wae l Ab d Elfa tah
HS E: Moh amed El-Tabee y +
Mus tafa Arno s
Likely (4) * Severity (2) = 8
1 . Put inst ruction for sa fe h ois t level d uring trolley in RTG cabin to be
guide for all operators.
2. Ad d this case to TBT and h igh lig ht th at RTG o perators mus t be more
atte ntion du rin g makin g trolley and e nsu re tha t t he ho ist in safe leve l
be fo re makin g trolley.
1 3/07 /2 013
OPS
New
Salah Abd Elaziz
1 1/07 /2 013
- Beca use I was in hurry to fin ish m y work.

Your rig ht mirror was a dju sted a t the righ t pos ition or no t?
6- Wh at is t he safe ho ist level to pa ss 4 tier s afely?
No, Bu t I already ad jus t it after m aking h and over bu t the mirrors sta nd was moving wit h the TR moveme nt so I couldnt ab le to ad jus t it every t ime at my working h ours, b ut I didnt
- I don t kn ow.
t hin k in takin g the TR in to works hop in o rder to fix the mirror iss ue.
1.Lack of att ention:

TR 15 d river didnt not ice that h e migh t hit T R 48 wh ile h is man euver and th oug ht th at there is
enou gh sp ace for him to t ake th e movemen t.
2 . Inco rrect Follo wing of Procedures:
90
July 12, 2013
1:00
Orange
TRA
15&48
Tradmar
TR 1 5 with TT 38 h it TR 48 while man euvering b etween 0 2 B L & 03 B H res ult ing in

m any cracks in th e T R fron t glass an d some s cratches in TT38 .
why you didn t t ry to get ou t of the TR and t alk to th e RTG ope rato r or ju st p ress t he Eme rgen cy
Stop b utt on?
Becaus e, I t hin k t hat th e dis tance is q uie t enou gh to me to ma ke my moveme nt bu t unfortu nately the tail sligh tly sh ifted t oward righ t sid e and I d idn t n oticed t hat.
D id you at tend t oday s afety talk?
Ye s. It was abo ut res pecting safe ty roles ins ide th e term inal a nd follow s afety reg ulation s.
TR d rive r wasn t s topp ed on th e Stop m ark at th e e nd of the b ay, an d als o h e wasnt in the
righ t positio n away from RTG lane (TR right m irro r was on th e RTG lane).
3 . Poor d ecision makin g:
TR driver d ecided t o t ake t he wrong a ct ion (m aneu vering with in a very t igh t spa ce) altho ugh h e
was able t o g et out o f t he tru ck an d call for RTG o perator o r even to s top RTG movemen t through
pres sin g Emg -Stop b utt on.
Operatio ns:
Ade l Kh edr
En gin eering:
Ahmed
Sh awky
H SE:
Invo lved Pers on: Nam e:

De partmen t: OPS
Ris k= Likely (4) * S everity (1) = 4
Mo hamed Atef / Moham ed El- tabee y
Truck driver nee d to be se nt to th e tra ining secto r in order t o b e reass ess ed, and d uring th is pe rio d of t ime he s hou ld be ou t of working
rot atio n.
Ad d this case to TBT and h igh lig ht th at TR drivers m ust follow safe ty
reg ula tion s for traffic inside yard : t hey sho uld s top at t he St op sig n and
s tand a wa y fro m RTG la ne and d idn t t ake an y d ecision seem ed to be
hard to perform an d may lead t o a p oten tial of an accid ent.
Ops -training
Ops -ros ter
OPS
July 18, 2013
Salah Abd Elaziz
July 18, 2013
Salah Abd Elaziz
Abd E l-Alim Abd E l-Fat ah

ID :
3 295
Pos ition: T R D rive r (Tra demar)
Expe rie nce: Abo ut 2 years & 6 mon ths
TR 1 5 was st anding on b ay 78 and the TR head was aft er th e Stop s ign abou t m eter a nd th ere was RTG m oving from the le ft s ide of th e TR d rive r and also an othe r RTG was s top ped at
his rig ht side and i wa s waiting at t he sto p sig n bes ide TR 15. Wh en the TR driver s urprised b y t he co ming RTG he tried to make a revers e movemen t but u nfortun ately t here was
ano ther TR b ehin d it, when an oth er TR driver no ticed th e reversal mo ve ment of TR 15 h e u sed t he horn many times in o rder to sto p TR 1 5 driver.
From you r point of view, why the TRExperience:
15 driver did ntAbout
move alon
1 year
g un&
der6 tmonths
he sta nding RTG ?
I took a twin lift from a previous truck and stacked it, then returned back and waited for the coming truck, once it arrived I took the twin that was loaded on it.
During my lifting and once the twin became at a height about or meter I noticed that the twin mode wasnt activated so I hoisted twin move downward on
the truck.
People Cause :
91
July 11, 2013
8:50
Orange
RTG
At any time did this incident happen?

Incident happened at my 2nd hour.
Involved Perso
n: Name:
Abd on
E l-gh
any
8 68
While RTG 24 was discharging Twin move from TT 73 at 03 A 58,
Lack of attention:
Did
you check forMoh
theamed
twinAli
lamp
the
spreader?ID :
Dep art
ment
OPS illuminated, so i pressed
Positio
n: QC
op era tor
the RTG operator lift both containers in 40 feet spreader mode resulting in a
Yes,
it: was
the lock
button.
Exp erience: Ab out 1 yea r & 6 mon ths
damage in the spreaders Chain gearbox gear & Chain Lock.
As shown from the log file we found that RTG operator pressed the Twin up button by
youdown
storet illthe
mode of
after
move?
mistake when he was trying to press Twin-Telescopic store new position button for the I t ook t win move an d adju ste d the s pread er po sit ion an d sta rted Did
to hoist
t hetwin
1s t quarter
t he your
un der1st
d eck
th en i hoisted down in a full sp eed bu t sud den ly i found t he sp read er
2nd time (both buttons are so close on the left console), that lead to deactivating
Yes, I stacked the 1st twin move then
I stored
twin
mode
andidreturned
back to another twin move.
st uck
at t he the
mid dle
of th
e cell-gu
e.
twin mode without any attention from the operator which caused the incident.
Didincident
you not ice
ny old d amage
s ins
ide cell
g uidwho
e? informed you?
Did you notice the
byayourself
or the
truck
driver
No,
i didnt
foun d
any th get
ing wro
ng in
t he ce
e.
I noticed it myself, as I used to lift each twin move for about
a meter
before
a full
hoist
upll-g
souid
I noticed
the incident from the beginning and hence made a
hoist down.
Wa s it your 1st m ove ins ide th e bay?
How much time you waited till the next truck arrive?
Yes, it was my first mo ve a nd it was a t the be gin nin g of m y working h our.
I waited for about 3 or 4 minutes after the previous truck left.
24
Operations:
Adel Khedr
Engineering:
Moataz Howila
Likely (4) * Severity (1)= 4
Installing some sort of buzzer related to twin sensor on the

RTG spreader inside the operator cabin to alert the operator if
the twin mode wasnt activated before twin move get lifted on
40 feet spreader mode.
Add this case to TBT and highlight that RTG operators must be
more attention especially when trying to press twin-telescopic
store button so as not to press any other button instead like
twin-up button.
HSE: Mohamed Atef / Mohamed El-tabeey
Eng.
OPS
Did you not ice t he pre sen ce of the d eck controlle r on th e b ay?
attend
today
safety
No, t here was no deck o n the
baDid
y asyou
it was
th e t ime
of han
dovertalk?
and th e deck was a t the ga ngway.
No, because I came early today.
D o yo u have any feed back a bout t hat ves sel?

Yes, i have a feed back concern ing t hat ves sel b ut i was nt kn ow that it was the ves sel t hat i worke d on.
Peo ple Cau se :
Poor de cision m aking :
As QC op erat or to ok wro ng de cis ion wh en he ho ist ed down th e con tainer in the u nder deck wit h
fu ll sp eed & t ook t he decis ion withou t ch eck (es pecially it was h is first mo ve inside th e row, an d
92
July 11, 2013
11:00
Orange
QC
While crane 08 was loading twin move in bay 02 (M/V Mekong Spirit) he sho uld insp ect the st atus of t he ce ll gu ide or even ask if th ere is an ything ab norm al with in it ).
the cranes spreader suddenly stuck inside cell guide.
Organ iza tion cau se:
08 (SQ 10)
Ina dequ ate work p lann ing :

As t here was o nly one d eck controlle r for 2 working cra nes an d that con sid ers n ot eno ugh t o
main tain s afe operation proced ure s.
93
July 14, 2013
13:10
Blue
QC
W hile o perator q uay crane 1 4 dis ch arg ing on d eck ba y16 ves sel/crillon he info rmed
wh arf co ntro ller that crane b.d and aft er en g team comin g and insp ect ion fou nd da mage
in sp read er.
14( SQ 04)
Immed iat e caus e:

Spreader twin box dam aged
Roo t Cause :
Accumu lat ive roug h han dling
Immed iat e caus e:
94
July 14, 2013
10:20
Blue
RTG
W hile RTG 26 wa s making gant ry to park beside

RTG 22, it hits RTG 22
CR 26
- RTG 26 collid ed with RT G 22

Underlying Caus e:
- Poor d ecision makin g. ( When t he ope rat or dep end s on th e s ens or to s top him).
Roo t Cause :
People cau se:
1- Not followin g the work inst ru ct ions . (As h e did nt stop o n the s top sign be tween H & L when
cross ing t he main d rive wa y & d idn t use th e stan dard dis tan ce to do wn the sp eed) .
Imme diat e cau ses

W hile T R 47 g et man euvering , it h it th e X ray ga te by the s topp er ba rs which at tach on th e low
bed .
Und erline caus es
95
July 17, 2013
16:00
Red
TRA
Truck 47/ low bed 03
Trade mar
During turning to enter the x ray the low bed hit the X-ray door which fall down.
Stop per b ars wa s not st raight a nd th e d river did not check it before use th e low bed .
Root Caus e
People cau se:
- La ck of atten tio n of T R driver .
- Working u nd er in fluen ce of drugs .
Immed iate caus es

TR 6 2 hit T R 14 3 from be hin d.
96
July 19, 2013
11:00
Orange
TRA
62
Cambell
W hile TR 1 43 was d riving wit h low spe ed and give tra ffic light
dama ge as ph otos a ttach
TR 62 hit him caus in g
Underline ca use s
TR 62 d river wasn t at ten tion t o his road.
Roo t Cause
Peo ple Caus e:
- Lack of a tten tion ( The in volved T R 6 2 driver wasn t atten tio n to his road) .
Immediate causes
Imme diat e cau ses
RTG 40 OperatorTlifted
reefer
on 02G54-G4
R 79 ha
it connected
TT 98 o f TR 13
5
97
98
July 26, 2013
July 28, 2013
17:00
13:58
Red
Orange
TRA
RTG
TR 79 & TT 98 / TR 135
40
Sinai
N/A
Und erline caus es

No safe dist ance
kep t betwee
n TR 7 9 a nd TR 135
Underline
causes
Root Caus e
During TR135\TT98 turning to enter birth 04 TR79 came behind it and hit him from the back
People cau se:
Reefer container
was still connected.
- N ot following t he proced ure s (TR 79 driver) of faste n nor check the se at belt.
RTG
operator
wasnt
fully
during
process.
- Poo r decis ion
making
of TR 79
driver wh
o dconcentrated
ecide to ma neuve
r withlifting
out check
t he way ins tead o f
slow d own to ke ep a safe dista nce a nd to check t he right s ide b efore man euver.
- Im prop er us e of t he
Root
safet
Cause
y d evice of TR 1 35 driver.
D uring op era tion , RTG 40 ope rat or lift ed up a conn ect ed reefer unit No MWCU 67 220 53
located in Y 02G 54 G 4 wit hou t any not ification from ree fe r techn ician, which lea d to a
dama ge in th e reefer s ocket .
People Cause :
A. Lack of attention:
1. Fatigue: RTG operator slept only 3 hours the day before the incident.
2. Working under stress: there were many Trucks for loading so the operator was
Immedhurry.
iate caus es
RTG 36 h it th e left doo r of
wh ileProcedures:
ma king ga ntry b y its vertical ladde r.
B.Ops
Not-PU-20
following
use s
RTG Operator didnt check on the Underline
reefer logcasystem
whether the reefers are ready or
notwa
and
alsoing
didnt
toely
take
a confirmation
from
reefer
PU driver
s open
h is dowait
or wid
while
RTG was moving
an dthe
the d
oor po technician.
sit ion was clos e to
the RT G vert ical lad der.
Roo t Cause
99
July 30, 2013
18:48
Orange
Terminal Pickup
Ops-Pu-20
N/A
RTG 36 Vertical Ladd er hit the le ft d oor of Ops-PU -20 at 0 2 E 54, as PU driver was
op enin g th e d oor in the sa me time t he RTG was m oving leading to a h eavy dent in the
le ft d oor
Peo ple Caus e:

1. Lack o f at ten tion :
PU driver wa s hurry and d idn t p ay atten tio n to PU pos ition.
PU driver Op ened PU do or wide ly in th e same time RTG was m oving a nd didnt wait fo r RTG t o
s top an d then o pen th e door.
2 . Not Followin g Procedures:
PU driver didnt follow tra ffic SOP and left h is veh icle not far enou gh from t he RTG b ody.
D o you in formed b y d eck controller abo ut any old damag es in t he bay?

No, as it was my first mo ve a nd th e p revious op erat or ju st lo aded on ly one 2 0 feet co ntainer inside.
D id you a tten d tod ay s afety talk? Wha t wa s it ab out?
Yes, it was abo ut th e comp etition a nd we have to work h ard to ma ke a bet ter p rodu ct ivit y b ut th ere was no me ntion for th at vess el.
Is it normal op erat ion p rocedure t o make a fu ll hoist do wn wh ile d escend ing in a cell-g uid e?
Yes, the n ormal is des cen din g in a lo w s peed t ill p ass ing t he 1s t q uarter o f cell g uid e then h ois tin g in a full spe ed.
After s tuck happ ene d, d id you try to make a ny movemen t with t he sp reade r?
N o, i just s topp ed and informed th e d eck cont roller.
Operations: Mohamed Adel

Mahmoud Dorman
Engineering:
HSE: Mohamed Atef
If there wa s a deck wit h you on th e bay, do you th ink tha t the acciden t would h app en?
No, a s the de ck co ntro ller would fo r sure fo llow up with me at ea ch mo ve a nd would inform me abou t any old d amag es ins id e cell guide tha t I cou ldn t dis cove r.
Involved Pers on: N ame: Tamer Moham med abd elatif
ID : 14 7
I t hin k t hat th e main p roblems th at hap pen on the ves sels b oard was d ue to th e abse nce o f d eck controlle r, s o I think tha t providin g a d eck cont roller for ea ch op era tin g crane is a mu st .
De partmen t: OPS
Pos ition: QC o perator
Witn ess Person :
Nam e:
Islam Gab r
ID:
67 3
Exp erience : Po
9 years
D epartmen t: OPS
sit ion: Deck & Wharf con troller
I was discharg ing t win from me ntioned ves sel t hen I m oved to discharge anot her 2 2 0 cont aine
r on deck
raw sea side at ba y 1 6, I land ed my spreader on th e cont ain ers b ut th e
Experien
ce: 2nd
2 years
spreader wa s not lande d correctly as t he left side was la nded b ut righ t sid e is tilting to se a sid e I tried to ad jus t spreader positio n by lis t co mmand b ut I failed th en I tried to hois t up it
does n ot res pond I asked th e wh arf to give by-pas s the n he gave me thWehere
con trol
t-u p from
my ent
cab ine
t, on ce
wast oyohois
u when
th e incid
ha ppen
ed?i s tarted to h ois t up I no ticed th e midd le twin t wist locks wa s out an d Operatio ns Khaled Heg azy/Ahme d Fou ad (act SS I)
se emed
b e damag
I asked
him tIomade
call Eng
I was at th e gang way making m y h ando ver with my colleagu
e, a ndto
I knew
ab outedthth
e eincid
ent after
t he. han dover wh en the QC operator a sked for my ass is tance.
Have you felt some thin g abn ormal that ma y lead to th at dam age?
E ngineering : Ah med Sa lah elden
No, actually I fin ish ed my 1st t win very s mooth ly the n I hoist
upyou
a ndcolleag
it was ue
working
m oved
to old
2n ddamag
twin I es
tried
ist -up
D id
info rmthen
you Iabo
ut any
in tto
heho
vess
el? bu t I doe snt res pon d and I t hin k if s ometh ing was wrong
Safet y: Hish am Ism ail
ldn t a
h ois
t up fromre1port
st time.
Yes, he told me abo ut an old damag es in b ay 20 un der d eck an d asked me it
towou
prepare
d isclaimer
and s end it t o the chie f officer t o sig n but h e did nt tell m e a bout a ny thing for
Is it t he normal proce dure t o a sk the wha rf bay
for by-pa
02 . ss if you fin d som ething wron g with yo u ?
No its not t he correct pro ced ure bu t I have d one th is to s ave time as t here was not an y risks .
t was
your
hface
ois tin
g spe
ed
before
land
ing
2 0
cont
rs ?
Wha
W hen
reached
tany
he
bay
did
you
ny on
damag
in
th
e
cellaine
you
Did
you
prob
lems
infind
th e aRTG
du last
rin ge2this
period
?guide?
was
nbu
orma
l. t the cell g uid e was co nsisted into 2 long p ieces.
No, t here was nt any app aren t dama ge in th e cellIt guide
t jus
- No.
So,
you
didnt
feel
t
hat
you
ma
y
h
it
so
mething
?
W hen you b ecame close to RT G 22, did the sp eed b ecam e s low or n ot?
hin
D id th e operator made
anNot
y sme
uddg.
en move after bein g st uck?
- Beca
slow.
o, hba
e dys
idn
t made
an&y Lmo
vement
b y t he
spde
reade
When yo u cro sse dNthe
betwe
en H
d id
you n otice
any
fe ctr.s in th e g ant ry sto p?
- I d idn t n otice an y failures in t he function.
W hat was you r sp eed befo re crossing fro m H t o L?
- Fu ll sp eed.
D id you s topp ed on th e Stop S ign b etween H & L?
- No.
Why you didnt s top on th e sto p sig n?
- Be cau se th e stackin g of t he co ntainers was app rox empt y in this area & I che cked th e road which was t otally free from an y veh icles , so I d ecided t o con tin ue cross ing t he way with out
Operations Kh aled H egaz y
stop on Sto p sig n.
Eng inee rin g: Ahmed S alah eld in
H ow can you che ck the road while your s peed was the full spe ed?
Safet y: Hish am Ism ail
- I s low down th e spee d before t he main drive wa y.
Are you traine d fo r this beh avior?
- No.
Wh ats your ins tru ct ions wh en you cros sin g betwee n H & L?
- To st op on STOP sig n to check t he road t hen s tart movin g & the s prea der t o b e in 20 Ft mo de.
When you decide d to st op / re move your h and from gant ry joy st ick?
- Be fo re CR 22 a pprox ab out ha lf dis tance of 40 FT con tainer.
Wh at is th e stan dard dis tan ce req uired to rem ove your h and from t he joy st ick in the similar case?
- App rox o ne 40 ft conta iner.
W hy you us e the emergen cy st op?
- Beca use t he crane d idn t s top.
Why you d idn t follow the se in struction s of the s tand ard d ist ance?
Involved Pers on: N ame: Khaled Ib rah im Abd EL Aziz
1. Add this case to TBT regarding: all deck controllers have to

made a pre-inspection starting from the bays that within
operation process and then check for other bays with no
current operation.
2.Providing Deck
controller for each operating crane to maintain safe operation
process.
3.Refreshment / awareness
message sent by VSV for each working QC operator during
cargo operation (especially after each handover)regarding the
status & history of the vessel and also VSV have to monitor
deck position on board.
1/3. Ops
2. Management
4.Ops
1&3 :25/0 7/201 3
OPS -E xecut ion
1 6/08 /2 013
Open
Hatem Hosny
2&4 :wa iting
4.For such vessel: Cargo operation shouldnt be planned by

maximum cranes: by providing 2 operating cranes at most in
order to maintain vessel stability during operation and
decrease the potential of spreader stuck.
Probability (4) X Severity (2 ) = 8
Ad d to safet y b rie fing for QC operato rs

to p ay m ore att ention while dealing
with twin con tainers and
mo nit or th eir h oist s peed .
Add th is case to t he TBT in ord er to h igh lig ht th e impo rtan ce of be ing

more at tent ion while working clos e t o anot her RT G and d idn t d epen d
on th e s ens or
Open
OPS -E xecut ion
2 6/07 /2 013
OPS -Execution
August 1, 2013
1- HR
2 - OPS
3- HS SE
1 - 17/7/2 013
2 - 25/7/2 013
3-2 5/7/20 13
OPS
ops
Salah Abd Elaziz.
ID: 356 6
Dep art ment : OPS (Su b. Trade ma r Co.) Position : TR Driver

Involved Pers on: N ame: Bas sem Fayez ID : 364 1
Exp erience: 2 Ye ars
Dep art ment : OPS (Su b. Sin ai Co.) Position : TR Driver
While I was en tering t he X ray are a , th e a ttached low bed of my TR h it th e X ra y ent ry gat e by one of sto pper bars which was no t straig ht and I wa s not g ave atten tio n to it .
E xperien ce: 1.5 years
1 . D id you checke d the low b ed before yo u ente red th e X ra y area ?
- No b
,b
ut Idknow
th at
lot sto
of st
oppe
r bars
were
t straig
ht neuve
.
I was d rove my TR 7 9 from QC 0 7 to 06 F and while I was mo ving
ehin
TR 135
it a
was
pped
s ud
denly
s o Ino
tried
to ma
r to right s ide t o n ot crus h with it but t here was a noth er
T R in m y righ t sid e so I couldnt man euver s o I crus hed TR 79 in front of me.
1 - D id you g ive a safe dista nce b etween you and t he TR in front o f you ?
- Yes,
was
outamed
20 ft con tainer dID:
ist ance.
Ah
meditAnt
arab
Moh
3 745
of ition:
your TR
De part ment : OPS 2 - Was t he spe edPos
TRclose
14 3 ?driver (Cam bell)
- Yes th e spee d was
closed
.
Exp
erience:
One mont h
3- Was th ere an y p roblems in t he brake s?
No, it awas
fin h
e.igh er to en ter 0 6 D lowe r and t here was TR 62 b ehind me.
- I came fro m t he berth an d ent ered t he road b etween 0 6- lower
nd 07
4 - DIid
you fa OPS.bu
sten t hes.04
seawas
t beltcomin
?
- I slowed my sp eed an d gave left traffic lig ht to en ter 0 6 D lower b ut s udd enly
n oticed
g with h igh s peed from left side so I waited t he bus a nd su dde nly TR 62
- No , I d idn t
check
it befo
reind
starting
work.
hit
me from
beh
.
5 - Were
u rus
h or
you
r min d yo
busuyand
a way?
7- What
wasyo
the
dista
nce
b etween
TR 62 ?
- No,
bu sy.
- I Id wasnt
ont know.
D id you re ceive
a pyou
re-sst
hift
ty talk:
YES NO
8- Did
opsa
sufedden
ly?
- No, I jus t slo we d my spee d.
D idWitn
youess
rece
ive training
in h ow
to do
e t ask invo lved: IDY: ES
Person:
Name:
Wael
Ali th
Ahmed
15 9NO
D epartmen
Involved Person:
Name:t: OPS
Ali Mohamed Pos
Aliition:
IsmailOPS b us driver
ID:
Are yo u aware
t o t his wo
rk: YE
S NO
ExpPosition:
erience:
4RTG
years
Department:
OPS of the rule s / p rocedures related
operator
1475
Ope rations : Na der H elmy

Eng inee rin g: Am r ElS horbagy
HS E: Ra mzy Mah er
Moh amed Adel

Amr E lsh orb agy
Moha med El-Ta beey + Moha med Atef
Possible 3* Minimum1=3
Likely (4) * Severity (1) =4
1-Th e involved perso n wa s term inat ed from en tra nce t he termina l

again.
2-Ad d this cas e to th e T BT an d hig h lig ht th e impo rta nce o f
- Checkin g the lo w b ed sto pper bars before u sin g it an d the d efect o nes
must b e preve nted from use
- G ive more a tten tion wh ile en tering t he X-Ray area.
3 -Ra ndom s tuff (Su bcontractors & SCCT) s ampling for dru g tes t to be
don e con tin ually
2 Add th is case t o T BT an d hig hlight t hat TR drivers mus t be more

att ent ion to h is roa d and in form TR sup ervisor fo r any defe cte d seat
be lt. 26/07 /201 3 OPS
Open
Josh
July 26, 2013
New
Salah Abd Elaziz
1.Wa iting
2 . 3/8 /2 013
Open
Josh
1 . 1/8 /2 013
2 . 7/8 /2 013
Open
About
1: year
&6
months
requ
ired
, were
youExperience:
wea
thethe
correct
Ytra
ESffic
NO
- I ent ered t he road b etween 0 6 lower and 07 h igh er an d thereIfwa
s TR
1 43
in front
of
merinthgen
TR gaPPE
ve left
light t o e nter 06 D lower bu t I gave him alarm t o ask him if I can
pas s or no t.
I was working on bay 02G22- Th

then
i moved
54
the
block
and
took
a scontainer
for
discharge
from
and
put
it in the Bravo row, but I found a
Did
u receive
pervision
t he
las
t pas
1hr sin
of g,
yosur
work:
ESrear
NO
e TR
ga ve m eto
s igbay
n with
hon
isyo
han
d same
tha t I su
ca
n pass
. Win
hile
I wa
udd
enly tYhe
bus haittruck
TR 143
from
behind.
load instructions sent to me on the system in Gulf
How
&do
Fox
you
rows
t hin
k thtance
Iisstarted
inciden
twith
cou th
ldthe
G4
a voTR
ided
Container
in Tfutu
re?
but
9Wh
at
was
th
e so
dis
bet ween
eberear
and
R 14
3? while I was lifting it I found it still plugged in.
- give more at-tent
ion of
th e o thers faults.
I d ont
know.
Keep a10safe
d ist
ance
betwee
n
me
and
th
e front
id
you
know
th e rear
b us
sp
eed?
Did you check the- reefer
logD system
screen
before
lifting
the TR.
mentioned container?
- S low sp
No, i didnt because
ofeed.
lack of attention.
Direct Sup ervisor: Name: Moh amed Bra ia
ID: 1 364
Did you try making any

connection
with
reefer
Depa
rtm ent: OPS
Posthe
ition:
TR SVtechnician on the bay?
No. I didnt try to ask for anyone.
e/shefeel
g ivefatigue
a pre- shift
talk: YES
NO
Did
Didhyou
dues afety
to working
stress?
Yes, as there was a lot of trucks waiting for loading on bay 54 and also i didnt sleep well yesterday as i slept only for 3 hours.
W hen was t he las t time you s poke to or witnes sed t he invo lved pe rso ns work
How do you think this incident could be avoided in future?
Invo lved Pers on: Name: Ba leeg h Hamd y
ID: 3 516
I have to check for the reefers that ready for loading on the Log system or even check with the reefer technician before lifting.
Dep art ment: OPS ( Trad e m are Co.) Positio n: T R D river
Witness Person: Name:

Department: Engineering
Mohamed Elsayed Ahmed

ID:
Experien
ce : 5
Mo nth s
Position:
Reefer
Technician
Experience: About 1 year & 6 months
1921
Ope rations : Na der H elmy

Engineerin g: Ah med Sh awky
HS E: Ra mzy Mah er
Likely 4 * 4 = 16
1. S afety in struction s refreshm ent to b e d one for t he two drivers

2 .Add t his cas e t o the TBT and h igh ligh t the importan ce
1 - Fa sten t he sea t belt a ll drivin g tim e.
2 - Keep th e s afe dis tan ce be tween TRs .
1.Send the Involved RTG operator for refreshment about the

importance of using reefer log system.
Operatio ns: Ad el Kh edr
En gin eering: Azmy sh ata
HSE : Moh amed Atef
2.Add this case to TBT and highlight that RTG operators must
be more attention and check on the Reefer log system or
check with the reefer technician before lifting any reefer
container.
Ops-training
OPS
I was in my way from QC (m ain drive way qu ay s ide ) to ent er berth 0 4 then I slow my mot ion to p ass TRs in the op pos ite way and wh ile I was s tart to ent er Bert 0 4 I su rpris ed tha t TR 7 9
I t hin k th at if he le ft h is PU in t he mid dle of th e rout e t his incid ent wouldnt to h appe
n, sTR
o Ifrom
thinkbehind
PU driver
sh ould park his PU in th e midd le of the route or even away enou gh fro m t he
h it my
.
Kindly explain what
do
RTG
you
bodknow
y.
about
the incident?
lved 54
Pers and
on: once
Name:
E lsa yed Eidbay
Kashfound
kos h ID:
632 operator lifting the container.
There was a loading instruction Invo
on bay
the1RTG
1- D id you
fas ten thIereached
seat b elt the
while droIve
yo ur TR?
- Yes, bu t I was pu ll It forward b eca use it fixed my back wit h sea t and th is hu rt me .
D epartmen
t: the
Operation
: Ops Tra ffic
al
Is there any way
toDinform
RTG
ifPosition
the
containers
areMarsh
unplugged
or not?
id you re
ceive
a poperator
re-s hift sa fe
ty
talk:
YES NO
Yes, There are two ways to inform the RTG operator if the containers are readyExp
for lifting or1not,
these ways are either through Log system or through
yea rY ES NO
D id you rececommunication
ive training in h owwith
to dothe
th eerience:
t ask invo lved:
technician.

RTG 3 6 was st anding at t he beg inn ing o f 0 5 E Hig her an d sta
rte
How
d tomany
move containers
wit h me wh ile
onI wa
thes informin
bay have
g RTG
to be
op erat
unplugged?
or ab out 2 exte rnal t rucks wait ing o n bay 54 , after con firmat ion d one
I d irected t o my Pickup an d while IThere
wa s open
ing7t he
doo r i founfor
d the
do or ston
uckthis
wit hbay
the and
laddethe
r and
b eca me widely
o pene d
thenthe
t hefirst
RTG of
m oved
away and I fo und t he door became
were
containers
loading
mentioned
was
them.
If requ
ired , were
you wea
rin g the
correct
PPE : Ycontainer
ES NO
hea vily den ted .
Did
How
yo udo
receive
you think
su pervision
this incident
in t he lascould
t 1hr of
be
yoavoided
ur work: in
Y ES
future?
NO
do you t hin k th is inciden
t cou
ld be a voand
idedI in
futu re?
I believe that actions were taken are
enough
toHow
avoid
of such
think
thatr open
it was
because of human mistake.
Wh
en you was
ta lkingre-happening
t o the RTG operator,
d idincident
you leave
the Pickup
doo
o rhappened
not ?
No, for su re the d oor was clos ed.
Direct Sup ervisor: Name: Moh amed Bra ia ID: 1 364
Did yo u park th e PU in th e m idd le of the roa d?
N o, it was nt at th e midd le of the ro ad bu t also it wasnt clos e t o the RTG yello w line, the p roblem was tha t the do or was fully open ed while RTG was m oving a nd th at what makes t he
Depa rtm ent: OPS Pos ition: TR SV
RTG la dder hit t he door.
Op erat ion s: Ade l Khe dr

Ahmed Salah
HSE :
E ngineerin g:
Moha med At ef
Probability (3) X Severity (2) =6
Ad d this ca se to TBT rega rding: Sup ervisors sh ould fo llow Tra ffic SOP
con sid ering parking t heir PUs away eno ugh from the RTG yello w line
a nd from th e RTG bo dy in ord er n ot to get h it by an y p rotrude d parts
from the RT G bod y.
Operations
August 10, 2013
Hatem Hosney
1 Add th e ins pectio n of t he hoist s et point of the limit s witch th e P M.

2 To mod ify t he proces s of pre- task check of th e crane ope rat or, to be
t he 1s t move of every cran e the pre-tas k check by wo rkin g in th e safe
way & to check t he functions .
3 To ad d this accid ent t o t he TBT & to highligh t the importan ce of
following t he sa fe working p rocedu res & t o inform t he su perviso r & th e
colle ague s abou t any faults in t he equ ipm ents
E ng
Ops
Ops
August 10, 2013
Hatem Hosny
To add t his case t o t he TBT & to highligh t the importan ce of rep ort ing
a ny accid ent im mediately, in o rder to set th e root caus e & to ge t the
correct ive actio n to preve nt th e re-occu rren ce .
OPS
August 10, 2013
Hatem Hosney
ENG
1 - comp lete d.
2- 30 th Oct . 20 13.
3 -30t h Oct. 201 3.
Do you aware of t raffic SOP inside yard ?

Yes , I d o. I kno w th at i have t o p ark my vehicle in th e m idd le of the traffic route inside yard b ut i was in hurry becaus e it was th e fasting ho ur an d i wante d both ext ern al trucks fi nis hin g
Did h e/she g ive a pre- shift s afety talk: YES NO
th eir loading be fore fast ing .
Wh ere was th e exa ct p osit ion of you r PU when you was t alkin g to th e RTG Opera tor?
Wh y you d idn t che ck the wh ole functions ?
p edoor
wa check
s app roximat
ely
in be tween
th et he
RTG
(in fron
t he RTGtM
. y workin g.
We u sed t o mPicku
ake th
whole
wh en th
e crane
st art ing
1svertical
t move,ladde
b ut inrst his
cas et Iofreceived
heicroph
craneone)
a lread
Did you informed by th e previous colleagu e abou t any faults in t he limit switch?
No.
Immed iate caus es

Cont ain er hit the trailer by ro ugh h andling .
Are you train ed to dep end o n the sa fety devices n ot to take care while hand lin g the cont ain ers ?
N ot exact ly, b ut th is is the no rmal op era tin g procedu res , I st opp ed hoist do wn wh en th e s pre ader reachin g the cell b eam the it sup pos ed tha t the switch auto matically will s low down t he
sp eed, but in tod ays cas e t he limit was nt workin g at all.
YES
NO
Underline ca use s
100
July 31, 2013
22:30
Blue
QC
17
N/A
while CQ1 7 was dis ch arg ing o n TR137 /TT 124 , th e con tain er hit the t railer caus ing
dama ge in th e tru ck.
YE S
NO
Ineffective a dju stm ent ( Not a dju sted cen sors ).

Roo t Cause
Peop le caus e:
1- In a dequ ate pre-tas k check.
2 - N ot following t he proced ure s ( As t he 1s t crane op erat or didnt in form his co llea gue ab out th e
fau lts ).
YE S
NO
Op era tion s:Kh aled H egaz y

Eng inee rin g: Ah med Sa lah
HSE : Moh amed Abas s
Probability 1* Severity ( 2 ) = 2
NO
YE S
NO
H ow d o you think this incid ent could be avoided in fu ture?

1 - To ta ke care while workin g & didnt de pend o n the de vices.
2- To make a ll safe ty devices as a s tan dard a t all cran es, this to adjust a ll limits like the ot hers.
Involved Person II:
N ame: M ust afa M oham ed ID: 76 3
Involve d Perso
n: art
Nament
me: :Ahmed
Hamdy : QC Operator
ID :
11 94
Dep
Ops
Position
D epa rtme nt: Op s
Pos it ion: QC Op erat or
Expe rie nce:
One year & h alf.
Pleas e advis e how the inciden t hap pene d?
Immed iate caus es

Wire Cut .
101
July 29, 2013
14:00
Blue
QC
Durin g operation on M/V CRILLON N, t he deck con troller n oticed d amage in the h oist wire
rope .
17
Und erline caus es

U nrep ort ed dama ge.
Roo t Cause
Cran e operators didnt follow t he in structio ns of immed iate reportin g the d amage, which affect
the accide nt in vestigat ions .
- Durin g norm al operations & wh ile I wa s load ing o ne con tainer u nder deck, th e deck cont roller called me on th e radio & asked me to s top op era tion s imme diat ely du e t o some
d eformat ion s in th e hois t wire, I st oppe d operations t hen th e Eng t eam arrived to check the wire & informed us abou t the da mage.
The cont aine r was lan ded wh en the d eck asked you t o stop ?
Yes & I h ois t up after t his move.
How many ho urs you worked on QC 1 7 before t he acciden t?
Ap proxim ately 2 h our, it was the la st move th en Ill cha nge my rot atio n.
Durin g the la st two ho urs , did you no tice any pro blem in the cran e?
No.
The wha rf was with yo u during the la st two hou rs ?
No , when I need h im only.
Any wire s lack h app ened with you?
No.
D id you work b eside the s hip s crane?
No.
Operatio ns:
Khaled Heg azy
Eng inee rin g: Ahmed S alah
HS E:
M oham ed Ab bas
Did the cell g uid e wa s defected ?

No, it was in a g ood conditio n.
In yo ur po int of vie w, how th is in cident h app ened ?
I dont know, but d uring op era tion s, I can not n otice any st ran ge case.
102
103
August 10, 2013
August 4, 2013
8:15
1:30
Red
White
Truck/t ractor
driver
QC
Wh ile TR3 3 movin g in yard in 03 H the le ft wh eel was broke n byit s elf and s eparate from
TT51, as th e attache d showing.
TT51/TR33
QC 11
N/A
W hile QC11 d isc und er de ck. Lift t win left as 4 0 mode s prea der u nit which cau se st uck
t he un its in ce ll gu ide an d make d amag e t o one un it
Th ere are t wo t ypes of rims which are approved by WS t eam

1 ) German mad e
2) Turkish m ade (as a t emporarily solution in case of G erman t ype sh ort age)
Ot her t ypes of rims came wit h the ne w eq uip ment an d are chan ged afte r cracks appe ared in it
Th e broken rim wasnt G erman o r Turkish typ e
Immediate causes
QC11 spreader stuck in cell guide .
Underline causes
Absence of Dock controller
Root Cause
People cause
1- Lack of attention/due care.
2- Bypassed control
3- Not following/incorrect following of standards/proc
N/A
Probability 1 X Severity 3 =3
Minor (2) * Likely (4) =8
1- Inform ed all Tire WS abo ut su ch failure t o be aware of hidden cracks

places .
2 - Che ck all t rucks an d tra ilers with such rims and m onit oring it .
3- EPL Tea m is cu rre ntly cont act ing ALCOA Whee ls Co. for purcha sin g
and te sting new typ e of rims wh ich have bet ter m aterial q uality to
wit hst and h eavy loads .
New

Dep art ment: OPS
Immed iate caus es
The s prea der s tuck in vess el cell gu ide .
104
2013080414
August 4, 2013
12:00
Orange
QC
W hile QC 18 was loading twin con tainers on bay 12 o n M/V ME KON G SPIRIT, t he
cont aine rs s tuck in the ves sel cell g uide which lea d to ce ll gu ide cut to p icku p our
sp read er.H 119
18
Underline ca use s
There is abn ormal dent in the cell g uid e.
Roo t Cause
Techn olog y Cau se :
- Ina deq uate d esig n (th e vesse l cell gu ide de sig n is no t fitte d for ope rat ion which ma ke sp read er
st uck) .

Dep art ment: OPS
105
August 12, 2013
11:00
Orange
TR
131
Trade Mar
People Cau se :
- Lack of a tten tion .
D uring TR 13 1 maneu vering in 0 3G73 misca lculat e the dista nce a nd hit the re efer st and - Lack of exp erience.
make scrat ch an d den t in th e s tan d reefer
- Poo r decis ion making (T he invo lved pe rso n took wrong d ecision when h e tried to pas s th roug h
narrow dis tance) .
Abdu M ohame d Habib

ID: 1 271
Position : QC op erat or
- I was working on th is ves sel with deck con troller from the be gin nin g.
- When I we nt to th e involved bay for cha rgin g first 40 ft cont aine r, t he deck con troller d is covered dam aged on t his bay so he mad e dis claimer and wen t to ch ief officer to as sign th e
d ocu ment .
- W hile I was hoisting do wn the conta iner in th is row, the cont ain er didnt lan d well t hen I t rie d to hoist up t o re-adjus t the conta iner but u nfortun ately th e con tainer s tuck in th e cell
g uid e and I called th e wh arf controlle r imme diat ely to in form en gin eering.
1- W hat was you r hoist do wn s pee d?
- S low becaus e I was in fo rmed in TBT t hat I work s lowly an d ca refully on this vess el.
2 - Why th e con tain er st uck if you work s lowly?
- Becaus e t here is abn ormal t hin g in th e cell guide de sig n and th e con tainer s tuck in the b egin of t he row.
3- Why you d idn t wait the d eck controlle r before cha rging to be g uid e fo r you?
- Th is is the no rmal op era tion a nd als o the de ck co ntro ller will n ot help in th is case be cau se I was working s lowly as S Vs advis ed.
4 - In your opin ion , how can we avoid t his incide nt rep eated a gain ?
- this vess el ce ll gu ide d esig n mus t be rep aire d.
- I came from qu ay and directed t o 0 3 G 50 .

- When I wa s mane uvering to e nter 0 3G in opp osit e direct ion, the re is two TRs s topp ed in t he beg in of th e b ay at 03 G 7 3 and t wo PUs stop ped in the ro ad bet we en 03 G & 03 H so I
de cided to b ack reverse to t ake en oug h dis tance to man euver rig ht side of the t wo PU s but u nfortun ately I h it ree fe r st and du ring man euvering .
1- Wh at was you r mirror st atu s?
- G ood.
2 - Can yo u see th e TT t hrou gh mirror?
- No, t here is blind po int b eca use I h ad co ntainer.
3 - W hy you didnt ask for g uid e?
- Because I d idn t kn ow t hat I will hit the re efer st and .
4- Are you train ed abo ut traffic h azards in reefer s tand s?
- Ye s.
Involved Pers on: N ame: M ohame d Awad Abd ullah

D epartmen t: OPS
August 12, 2013
23:30
Red
QC
while QC1 7 wa s dis ch arg ed from below

d eck ce nter HC,Row 03 th e spreader
collid es with S P HC cau sed da mage to :
1 -On e hois t wire
2-he ad blo ck han d rail
QC 17 / SQ 07
Org anization:
- Ins ufficien t iden tifi cat ion o f ha zard ( Working in the blind p oin t with out gu ide ( Deck cont roller )
Likely ( 4 ) * Severity ( 1 ) = 4
1. Two cran es will work o n this vess el with t wo d eck cont roller bu t if
cran e will work in seas ide , th e o ther crane will work in la nds ide t o keep
equ ilibrium for t he vess el.
2. This cas e add to TBT an d hig hlight 1 st corre ctive for OPS SVs.
0 5/04/2 013
Ope rations :
Adel Khed En gineering :

Hewela
Moa taz
Likely ( 4 ) * Severity 2 = 8
1. Add th is case t o T BT an d hig hlight t hat all TR d rivers m ust b e m ore

att ent ion an d take the sa fe d ist ance durin g maneu vering in reefer
s tan ds are a a nd ask for g uid e in case of blind po int .
2. S ent t he invo lved driver to training de partmen t fo r reas ses smen t
OPS
New
Salah AbdElaziz
8/19/2013
OPS
New
Amr Rashwan
8/18/2013
OPS
New
Mohamed El Araby
1 5/08/2 013
ID : 26 3
Posit ion : Cra ne Op era tor

Experien ce :
106
Op erat ion s:
Adel Khed r + Salah Ab dElaziz
En gin eering :
Moh amed H adid i
Radwan Mo hamed Awad

ID: 3 201
Position : TR driver (Trade Ma r)
E xperien ce: 2 wee ks
7 years ( Since 200 6 )
I wa s workin g und er de ck on th e firs t row lan d sid e in the cent ral h atch, and th e land sid e h atch cover (p revio us row) was h ave 6 tie rs ab ove it , I dis ch arged 8 cont ain ers fro m u nde r
deck and I was m oving t o get th e las t o ne in t his row in fully b lin d point , I h ois t down an d I felt t hat th ere was a proble m a nd so I t rie d to hoist up b ut it d idn t , I switched off the
spre ader on 20 mod e but didnt res pon d so I mad e trolley forward to discover th e prob lem bu t I didnt sa w an ything and a ft er th at I calle d deck cont roller , wh ile t hat th e spreader
moved fo rward fo r 1 mete r app rox. an d after t hat I mad e trolley backward an d hoist up . I discovered t hat t here was a da mage on t he han dra il of head block then I made on e m ove and
st opp ed .
Ahmed Fawky Ahmed .
ID: 118 5
1 Wh at is t he reas on of this hit?
- May be th e spreader closed t o b e a litt le les s th an 40 ft mod e wh ich made th e spreader escaped from the cell g uid e and go u nde r the h atch cove r .
D epa rtm ent: OPS
Pos ition: QC Op era tor
2 Was the re a deck cont roller wit h you while you were working in t hat b lin d area ?
Experien ce: 1.5 yrs.
- No on e was with m e .
1 - Add to t he SOP t hat in cas e of workin g in a blind area the op erat or

mus t call the d eck controller as a gu ide .
Sh ift Man ger: M ohame d El Arab y

Invest iga tion comp lete d by:
Operatio ns: Hat em Hosn ey
En gin eering : Ahme d
Salah
HS E: Ramzy Mah er + Ali Ad el
2 - Add to th e TBT t he imp ort ance of t o be ca re while wo rkin g on blind
p oin t .
3 Did you as k for a d eck controlle r to help you ?

S umma
stat emen
ts:
- Nry
o ,ofI didnt
.
4 Did yo u wo rk with t he full s peed ?
I was loading cont aine r in 4t h raw se a s ide blind point- (1 st raw a ft er cente r hat ch cover) , su dde nly I su rp ris ed wit h spreader stu ck und er th e hatch cover, deck con troller was cro ssing
- No , wh ile working u nde r deck s pecially on blind p oin t .
from cran e t o crane by chan ce, he told me sto p there is so mething wron g with t he flipper then I stop ped an d ca lled the En g.
Imm edia te Cause :
107
August 7, 2013
15:10
Blue
QC
While crane 04 loading cont aine r in th e blind point in the ves sel M/V TUBUL t he
s pre ader s tuck in th e cell guide ca used damag e in th e fl ipp er mot or
- Flipp er mot or dam age du e t o hit b y cent er ha tch cover.

Root Caus e:
- Over confid ence/poor decis ion mad e from the op era tor who h as in struction to call Deck
cont roller for as sistan ce in cas e of a ny cas e ment ione d above.
Immed iate caus es

T R 82 h it TR 87 from b ehind.
108
109
August 13, 2013
August 21, 2013
8:00
11:30
Orange
Red
TRA
Terminal Pickup
TR 82
Campbell
W hile TR87 in t he qu ay s ide s low his spee d to wait TR which st opp ed in fro nt of him ,
there was TR 8 2 which was be hin d TR 8 7 and u nfort una tely 82 hit TR 8 7
wh ile MV/ Sea Land M eteor wa s berthing in t he north an d vess el su pervisor wa s going to
check th e b ow of t he vess el, vess el crew t hrowing th e ve sse l's rope on PIC- UP 9 0
Ops PU 90
Underline ca use s
TR 8 2 driver was d riving wit h hig h sp eed and n ot take safe d ist ance betwee n him an d the ot her
truck.
Roo t Cause
People Cause :
- Not followin g proced ures ( The in volved T R 82 d river was drivin g with h igh spee d and didn t t ake
s afe d is tance).
1- Wo rkin g with rush in a blind po int for the sa iling man

2- Not fo llowing th e p rocedu res (VS V didnt drive in t he sa fe p osition ).
Ahmed E laraby
Baher At tia
His ham Is mail
Was it you r first move ?

- N o it was my 3rd o r 4th one un der d eck.
Wa s there a d eck cont roller wit h you at th e t ime of in cid ent ?
- No , he was just cros sing by chance as he was a ssigne d with 4 cran es.
Wh at ,iswere
you ryou
priority
to g
call
deck cont
If required
wearin
thefor
correct
PPE :roller
YE S? NO
- Normally we call d eck controller in followin g ca ses .
Severity Moderate (2) * likely Possible (4) = 8
Ad d to QC op erat ors T BT t he imp ort ance of calling D eck cont roller in

case o f all sit uat ion th at may ca se vis ion difficulty, un bala nced or
inst ability du ring lo adin g/discharg ing .
9/1/2013
OPS
New
Mohamed Adel
1 Add th is case to TBT and h igh lig ht th at all TR d rivers mu st follow

s afety traffic rules .
2 Se nt th e involved driver t o t rainin g dep art ment for reass ess ment
OPS
OPS train ing
1 9/08 /2 013
1 8/08 /2 013
Opened
Salah Abd Elaziz
1- Claim t he vess el for t he ment ion ed dama ge

2- A cle ar in struction s to be writt en in th e SOP for takin g the s afe
p osition ( beh ind lane 3) wh ile be rth ing t he vess els e ven in driving
positio n & to pu blish it in the TBT.
1- claims
2- Op s
19 /8 /201 3
28 /8 /201 3
Opened
Amr Rashwan
Ops
August 28, 2013
Opened
Salah Abd El-Aziz
1- Ops t rain in g
2 - ops
1- waiting
2- 2 /9 /201 3
New
Amr Rashwan
.
Did yo u receive1-suLoading/dischargin
pervision in t he lasgt hatch
1hr of covers
you r work:
YE S NO
2 - Load ing /d ischa rging 20 foot cont ain ers .
3 - Load ing /d ischa rging blind p oint .
- I mu st in form my sup ervisor a bout a ny defected t hin gs.
Did yo u called D C ?
D ire ct S upervis or: N ame:
Has san Ab dela al
ID:
144 3
- No,
D epartmen t: OPS
Pos ition:
TR su perviso r
Why ?
- It was normal
ion,
I haave
d one
o r 4talk:
tim esYES
with out
D idop
h erat
e/she
g ive
pre-s
hiftits3
afety
NO calling h im.
Wh en was th e last t ime you s poke t o or wit ness ed th e involved person s work
Witn ess Person : Nam e:
De partmen t: OPS
o ne hou r
Operatio ns:
Ad el Kh edr
Ah med D oma
HSE :
Eng ine erin g:

Moham ed El-Ta beey
Likely ( 4 ) * Severity (3) = 12
El-Sayed Abd Alla Mo hamed

ID : 36 88
Pos ition: TR d rive r (Sinia )
Exp erience: one yea r
- I received my TR u nder QC 07 th en I d irected t o my a ddre ss in b ert h 08.

- When I wa s near to ent er berth 0 6, I n oticed T R which s topp ed an d wa s waiting an othe r TR t o ente r the yard so I s low down my sp eed bu t unfortu nate ly there was TR h it me from
beh ind .
9 - H ow long t ime you was working b efore th e accid ent ?
- Ap proximately 3 0 min utes .
1 0- Did you sto pped s udd enly?
- No, I did nt sto p sud den ly.
11- Wh at was you r spe ed?
E xperience:
Involved Pers on: N ame:
His ham Moh amed
You sse f 2.5 years
ID: 119 1
D epartmen t: OPS
Pos ition: QC operator
I was in m y PU in positio n toward t he bridg e of M V S ea Lan d Mete or Wh ich wa s berthing as an indExp
icator
for its capt
ain an d the n he asked me to check the bo w p osit ion , I while I was
erience:
2 years
driving t o the bo w I s urprised t hat on e o f t he vess el sailin g men d rop th e lin e rope from a blind p oin t wh ich crash ed my PU front g las s. T hen I informe d them o n the marin e cha nnel
abou
theskew
inciden
by Arabic
d Eng
lis hlylan
- Wh en I was ho ist ing d own to catch con tainer fro m T R, th e s prea der
mat de
seat side
and dan
own
st rong
onguag
the e.
cont ain er so th e left qu ay s ide fl ipp er hit the cont aine r from th e t op
which le ad to flipper damag e.
1 - D id you s ee
thesshois
ailing
ma nswitch
while hworkin
e dropgped
t he lin e rope ?
1- Wa
t limit
well?
- No, he
wasn t t here
eve naine
after
g et out
from
PUd. own strong ly on the cont ain er.
- Yes b ut at t he end d ist ance betwee
n spreader
and cont
r, sI omet
imes
s premy
ader
2 - W here d id exactly2-you
d rive
PUwere
90 wh
ileworking?
d irecting to th e vess el Bow?
How
lon g
you
- In t he mid dle- Tofhis
thwas
e q uay
wall
Bet ween
e igh
th conta
iner. lan e 2 and 3 .
3- Was3thThis
ere ahap
safe
po sit
ion for
yobuefore
wh iledu
b ert
hin
g the ves sels?
pene
d with
you
ring
working?
- Yes , in b ow dire ct ion an d back
ward a lit tle towa rd th e ya rd.
- No.
YES NO
D id you D
receive
ining ainphre-s
ow hift
t o do
the
ask invoYES
lved: NO
YE S
id you tra
re ceive
sa fe
ty ttalk:
Na der He lmy & Amr Rash wan

Ahme d Shawky
Ra mzy Mah er + Ali Ad el
Possible 3* minimum 1 = 3
NO
Are
yoyou
u aware
of the
rules in
/ proce
related
t his
work:Y ES
YES NONO
D id
rece ive
training
h ow dures
to do th
e t ask to
invo
lved:
If aware
required
were
you
g the related
correct tPPE
: wo
YE S
Are yo u
of, the
rule
s / wearin
p rocedures
o t his
rk: NO
YE S
NO
Did yo
receive
pervision
in trin
heg las
of you
r :work:
S NO
Ifurequ
ired , su
were
you wea
thet 1hr
correct
PPE
Y ES YENO
D irect
Nade r tHelmy
IDre?
: 565
HowS upervis
do you or:
t hinNk ame:
th is inciden
cou ld be a vo ided in futu
Dep art ment: OPS
110
August 23, 2013
3:00
Orange
Spraeder
W hile CQ 16 was catching a co ntainer from TR, th e fl ipp er hit the cont ain er from th e top
wh ich lead t o flip per mo tor d amage .F12 0
SQ 08
Peo ple Caus e:

- Rou gh ha ndling fro m t he QC op erat or.
Techn olog y caus e:
- Accu mula ted fatigue on t he flipper motor wh ich lead to flip per mo tor b roken easily.
Aym an Ta ha
ID :
11 49
OPS sup ervisor
Positio n:
Did h e/she g ive a pre- shift s afety talk: YES
NO
Wh en was th e last t ime you s poke to or wit ness ed th e involved person s work
o ne hou r
Ade l Khe dr
Ah med S hawky
Mo hamed E l-Tab eey
likely (4) * Severity (2)
Ayman H aikal
Moh amed El H adidy
Ram zy Maher
Possible 3* Sverity 2= 6

QC operators mus t be more at ten tion a nd mus t adjust t he sp read er on
th e con tainer well before d own th e fl ipp er to p revent collis ion be tween
flip per a nd conta iner.
In volved Person: Name:

Moh amed Ma hmou d Youss ef
ID : 17 171
D epartmen t: OPS
Pos it ion: D&W
Exp erience: one years
3- Was tha t happ ened in this ca se?
W hen
th e QC
operato
r was
do wn
to check
ca tch m
t he
iner, t heinflip
per
lip
ped
the cont
aine
from th eutpop.
- No, b ecause aft er the s preader
u nlock
I tho
ugh t that
t hehoisting
time I spe
nt to
y nconta
ext address
my
T Rs s
cre
en,atnd
hehit
sp read
er will
ber hoisted
in t he safe he igh t, s o I moved
1 - D id regardin
th e operator
use co
h igh
s peed
g to this
nclus
ion . h ois t?
- N o, h oist s pee d waDsidslo
w breceive
ut the saprea
der ift
masafe
de skew,
n he down
you
p re-sh
ty talk:wheYES
NO on the conta iner.
112
August 27, 2013
17:00
Red
TRA
TR 61 & RTG 31
Kotbey
Durin g hand lin g reefer con tainer M WCU567 913 7 truck 61 wa s moved b efore lift ing t he
sp read er of RTG 3 1
1 - Not followin g the proce dures.

2- Lack of exp erience.

YES NO
If requ
rin gt the
PPE
: in
Y ES
How
doired
you, were
th ink you
th is wea
in ciden
coucorrect
ld be avo
ided
futu NO
re?
Didctyo
u receive
in t he
t 1hr of yo ur work: Y ES
NO 4
D ire
S upervis
or:suNpervision
ame: Moham
edlas
Baraia
ID: 136
D epartmen t: OPS
Pos ition: TR SV
Aym an Ta ha
ID :
11 49
Dep art ment: OPS
Positio n:
OPS sup ervisor
D id h e/she g ive a pre-s hift s afety talk: YES NO
Did h e/she g ive a pre- shift s afety talk: YES NO
W hen was th e las t time you s poke to or wit nes sed t he invo lved pe rso ns work
Wh en was the last t ime you sp oke t o or witn ess ed th e involved person s work
Wetn ess : Name : Mo hamed Atef ElSayed E l Had idy
ID : 10 41
* Reassessment must be done for the TR driver about his safe

working instructions
- Add this case to the TBT and highlight the importance of
insuring that the spreader was in a safe height
D epartme
nt: OPS
Positio
rato
r
I was working u nde r deck on the first row land s ide, I discharg ed one cont
aine r from
un der
d eckn:1sRTG
t tierope
and
I was
m oving t o ch arge an oth er one in the s ame row and s ame tie r ( at
sa me positio n) in fu lly blind p oin t , I ho ist d own and I fe lt tha t there wa s a prob lem an d the cran e s top ped , so I calle d the En g. Dep artm ent who se ca me and switch on th e cra ne , an d so
I hois t up wit h the cont aine r and I saw the d amage .
113
August 29, 2013
2:00
Red
Spreader
SQ 08/QC 05
while QC05 was charged below deck ,Row 01 the spreader collides with SP HC
Peop le:
- Po or decis ion m aking
- Not follow SOP ( as the op era tor d idn t call t he deck con troller a s a guide)
1- Did you face a p roblem when you g et the fi rst con tain er on th is ro w ?
- N o , it was s moot h one .
2- H ave you any in structions ab out you r work in b lin d poin t area ?
- Yes , I have th at mus t deck cont roller be with me bu t I did n ot call him becaus e I know that h e has work with ano ther crane on th e same ves sel
3 - W here th e spreader are clear visib le for you ?
- Till th e tear n o. 3 un der d eck .
4- What a bout yo ur ho ist d own spe ed while you ch arg e t his con tain er ?
- It was no rmal b eca use I was working in blind p oint a rea .
YES NO
YE S
Hat em Hos ney

Moh amd Do ma
M ohame d Doma
Likely 4* severity 2 = 8
1- Risk Asse ssme nt to be issu ed for t his activity

2 - Add this cas e to the TBT an d hig hlight t he imp ort ance of following
th e s afe in struction s while workin g in th e blind po int wit h guide
ops
1- 6 /9 /201 3
2- 3 /9 /201 3
Probability (3) X Minimum (1)= 3
Ad d this ca se to TBT rega rding: all SV should pay more attention while
ma neuv ering, especially while driv ing aro und wo rking sites a nd pay more attentio n
for barriers places.
ops
September 10, 2013
Opened
Mohamed Adel
Add th is case to TBT regarding: a ll V.S.V should follo w their SOP dealing with
shifting QC during opera tio ns a nd they should check for the surro undings (gangwa y
position-Truck s on lanes-accommo da tion height-personnel passing-etc.) before
doing any mo vement by the crane.
ops
September 10, 2013
Opened
Mohamed Adel
ops
August 20, 2013
Opened
ops
September 5, 2013
closd
HSSE
9/18/2013
Mohamed El Araby
NO
NO

Involved Pers on:
N ame: Moha med Abo Bakr Kh alifa
ID: 2 96
How
do :you
th rat
ink ions
th is in ciden t cou ld be avo
ided n:
in futu
Dep art
ment
Ope
Positio
Yardre?
Sup ervisor
- T he truth , I sh ould call the de ck co ntro ller wh ile I wo rkin g in blind p oin t and I will st op movin g till be wit h me
Experien ce:
Immed iate caus es

OPS-PU-4 0 hit a s teel b arrier while PU driver was maneu vering aro und a working s ite in 02 M
Lower.
114
August 29, 2013
18:00
Orange
PU
while Y SV was m aneu vering by pick up 4 0, h e hit s teel b arrier which p laced by Elkot by
Su bcontractor t eam to se cure the rep air fo r HM0 2 which lea d to a damag e in th e PU
fron t left light an d cu t in pick up front bu mper.
OPS PU 40
Underline ca use s
The st eel ba rrier was s lig htly ou tside th e o ther barriers pat tern.
Roo t Cause
People:
Lack o f at ten tion : as th e PU driver didnt no tice the s teel b arrier while he was ma neuve rin g.
Immed iate caus es
QC 1 5 hit g ang wa y of M/V Romy Tra der wh ile making gan try.
Underline ca use s
1. G ang way Pos ition: was after the yellow lin e.
115
August 31, 2013
5:00
Orange
QC
W hile CQ 15 was s hifting from M V ROM Y TRADE R To M/V UAS C SH UWAIKH it hit t he first
ves sel ga ngway le ad to a heavy da mage in t he gan gway.
15
2. La ck of atten tio n: As V.S.V f did nt realize for the ves sel or e ven the g ang wa y p osit ion b efore
movin g the cran e.
Roo t Cause
People:
There were some workers belong t o E lkotby Su bcont ractor wo rkin g in th e m aint enan ce of HM 02 in 0 2M Lo wer and t hey su rrou nde d the working area by barriers bu t I not iced a barrier
placed toward t he Golf row ( in A Co ntainer b lock) which is s up pose d to be on th e RTG Lane in orde r to ena ble RTG operator to notice t he barrie rs an d not to m ake an y b reach close to
t he working site. S o I in fo rmed t hem abo ut th at barrie r but wh ile I was m aneu vering aro und t he pla stic barriers ( takin g a roun ded sh ape around t he working site) I s udd enly h it a st eel
ba rrier (n ot in t he same p atte rn like th e others) .
Invo lved Pers on:
Name: Mah moud H afez Nes eem
ID : 7 49
Why you d idn t n otice th e stee l barrier?
Dep
art ment
Opserat
ionsth an th e others so itPos
ition:in Vess
el rSup
ervisor
( Acting)
Becaus
e it: was
horter
wasnt
a clea
view
to me.
Experien
ce: was
6 dayou
ys still driving?
wh ile you was talking to th e Sub con tra ct
or workers,
N o, I s topp ed my ca r before startin g to talk t o them .
Immed iate caus es

SQ 20 flippe rs s tuck in the b ay d uring chargin g twin cont ain er.
116
August 13, 2013
15:00
Orange
QC
QC 10 was lo adin g twin cont ain er from th e tru ck to th e vesse l and whe n the op erat or
make lock, t he flip pers mus t be up b ut un fortu nat ely the fl ipp ers s till down an d the
ope rat or don 't no te so th e o perator loade d the cont aine r ins ide t he vess el un der with all
flipp ers d own which lea d to SQ20 all flip pers damag ed.I1 34
10
Underline ca use s
Flippe rs were s till down.
Roo t Cause
Peo ple Caus e:
- Not fo llowing proce dure s (Th e involved QC ope rato r didnt check th e flip pers if they u p or not )
Immed iate caus es

TR 43 hit TT 156 from behind.
117
September 5, 2013
4:50
White
TR
du ring TR 43 make a Maneu vering to en ter 0 3K . hit TT 1 56 att ached to TR 10 7 cau sed
d amag e in TR 4 3 bu mper a nd fron t glas s.
43
Und erline caus es

W hile maneu vering th e tra iler is no t appe ar in th e m irro r
Roo t Cause
Peo ple Caus e:
- Lack of a tten tion ( The in volved T R 4 3 driver wasn t atten tio n to his road) .
Op era tion s: Ad el Kh edr Eng ine ering: M ohame d

Hadidi
HS E: Moham ed At ef
I received a p hone call a skin g me to move QC 15 from outs id

M /V
myyour
Trader
to be
set tle dwhile
on M/V
UAS
C Sh
uwaikh
( toward
sou thern sid e), and afte r the Low-bed t ruck arrived an d
eWh
at Ro
was
exact
d irection
you
was
man
euvering
?
becaus e of t he trucks o vercrowding on lanes i was nt able t o noticeI was
t he vess
el pos
itiontowa
in regard
thehern
Crane.
I moved th e crane I fou nd truck d rivers u sin g the ir truck h orns
m aneu
vering
rd the to
s out
s ideAfter
.
inte nsively so I s topp ed imm edia tely an d moved to wa rd sea sid e to found that t he vess el gan gway get d amage d.
From you r point of view what was t he reas on beh ind that inciden t?
Did yo u Th
chat
ecked
ganned
gway
befoou
re tstarting
iftin
g the
cra ne?
incidfor
entt he
ha ppe
bepos
cauition
se I was
of my ash
tten
tion
.
No I didnt.
Wh y yo u was out of at tent ion ?
imagine
Why you th
d idn
t check?
Be cau se I th oug ht th at I pas sed a ll th e b arriers and d idn t
at there
will b e o ther barrier in fron t of m e like t he st eel ba rrier I hit.
Becaus e t he vis ibilit y was s o poor, as the cran e cell-bea m and
lanes t be
sid
t hea vo
Cra
ne HB
p laced
Howtrucks
do youscatte
t hin kred
th isoninciden
cou
ldebe
ided
in futu
re? on t he low-b ed were completely covering t he vess el bod y.
Did you
hea
r the s in
oun
of cra
cor,
llision
thteo gang
way? at tent ion wh ile man euverin g.
Su bcontractor workers sh ouldplace
th eir
b arriers
a dright
m ne
anne
a nd Iwith
ha ve
pay more
No, I did nt hear t he collisio n sou nd.
Did t he crane s top afte r co llision happ en?
N o, t he crane comp lete its movem ent.
Where was the cran e pos ition after you stop it?
It was at th e beg inn ing of th e vesse l accomm odat ion.
As you was QC operator, wha t did you d o before s hift ing fro m a ves sel t o anot her?
I had t o che ck for th e gang way positio n and also for th e accomm odation he igh t if it is ava ilab le to pa ss ab ove or not .
In such circums tances , I s hould get as sistan ce fro m s omeon e and if I was a lone I h ave to check for the ga ngway by mys elf before m oving t he crane .
Witne ss Pers on:
Name: Moat az Mah moud
ID : 18 66
D epartme nt:
Operations
1 .Lack o f exp erience : sin ce t he invo lved S.V wasnt well-experien ced in dea lin g with th e shifting
cra nes du ring ope rat ions , es pecially when th e crane is out of ord er for PM .
2 . Not following Procedu res: since from his exp erience as a QC op erat or he was respo nsible for
checking t he su rrou ndings ( vess el pos ition-g angwa y p osit ion ) before d ecidin g to make any
move ment b y t he crane.
8 years
Op era tion s: Ad el Kh edr Eng ine ering: M ohame d

Hadidi
HSE : Mo hamed Atef
Position : D eck & wha rf Controlle r

E xperien ce:
2 Years
Kin dly explain wha t did you see?

QC 15 while moving hit the ves sel g angway.
Wh ere was you wh ile collision hap pen ?
I was at the ves sel Quay side bu t there wa s a dis tance bet ween me and the ga ngway (ab out 2 0 meters) .
Wh at did you do when yo u notice t he crane mo ve ment ?
I expected th at th e crane was move d by theNves
ame:
sel S .V
M oham
so I tried
ed Els
t oayed
alertHe
him
lmy
on t he ra dio ID
chan
: 91nel
1 bu t I didnt ge t any res pons e from my S.V.
Dep art ment: OPS
Position : QC op erat or
D o you th ink tha t you had t he opp ort unity to alert th
e ve
ssel dut y
efore collisio n happ en?
Exp
erience:
2 byears
No, a s even if I informe d the du ty the re will b e not eno ugh t iming in order t o picku p the g ang wa y. As this type of gan gway is p icked u p manu ally fro m t he qu aysid e then lifted b y ve sse l
crane . By t-his
I was
wa y,
charg
since
ingt he
t win
cran
conta
e was
inerfaon
sterthe
theves
g angway
sel, I t ook
will
t he
beconta
hit before
iner from
g et co
the
mple
TR.tely lift ed.
Techn
- Inical
theAd
n ormal,
vise /Report:
when I make
Namelock,
: Ayma
flipnpers
Els ayed
up au
Taha
tomat
IDically
: 11.49
- Wh en I ho ist ed down t he co ntainer in the ves sel b ay, fl ipp ers was s till down an d slipp ers s tuck in the cell guide and d amage h appe ned for fo ur flippe rs.
1- How
Delon
partmen
g you t:were
Opeworking?
rations Position : Ves sel S .V
Comme
- Th is was
th irdnt:
con tain er.
2- D id you face any bre ak d own in th e flip pers durin g wo rkin g?
Involved Pers
on: Nexp
ame:
Ayman
Mohsh
amed
Mcrane
ahmud
Kindly
lain-the
No,
SOP
flip pers
for
were
ifting
working
s well.
durin g operations? ID: 339 5
partyo
ment
: OPS
Pos
TR
43 tin
d
r (Camp
bell)
If th e crane wasn t in operation i ha ve t o che ck with e ngineering
3De
- Did
ut eam
notice
whet
th ather
flippers
t he crane
weren
ist
available
upition:
before
o
rhois
und
errive
gPM,
down
after
in tthe
aking
ba ty?
he app roval fro m t he eng ine ering side i st art ed to check
Expe
rie
:was
years
,4 if
month
for th e gang way positio n even-by
No,mys
I didnt
elf orbe
witcau
h assist
se I was
ance
concen
o f t hetrat
deck
ed con
in t he
troller
QC on
scree
then ves
andsel
also
(if th
a vaila
e snce
un
ble)
,2an
reflectin
d also
g tin
hemy
crane
eyes
was
s o bvision
oom down
was no
i ht ave
cle ar.
to check t he availabilit y to p ass
ab ove vesse l accomm odat ion or n eed to b e b oom up .
- I wa s in my way from 03 j lower to 0 3 k highe r and t here is a TR 1 07 in front of me and wh ile man euverin g to ent er 03 k I was at tent ion t o p las tic barriers su dde nly th e T R 10 7 sto pped
and I hit
TT 156 in beh ind .
1 - What was yo ur s peed ?
- S low sp eed.
2- Wh at was th e d ist ance bet we en you and T R 1 07?
- Abo ut 3 m.
3- Why d id you hit the TR?
- I take m y ma neuve rin g nearby plastic ba rrier an d I give my at tent ion t o check my trailer t o avoid h it th e b arrier .
4 - Are t here an y p roblems in yo ur mirrors and g las s ?
- No, Mirror was in good cond ition, and th e gla ss give me a cle ar vis ion .
5- D id you wear the se at belt?
- yes .
- Ye s, a bout 6 h ours.
7 - W hat was t he in struction did you rece ived it in the t rainin g ?
Operatio ns:
Ad el Kh edr
Mo ataz H ewela
HS E:
Eng ine erin g:

Moh amed El-Tabee y
likely (4) * Severity (2) = 8
S hift Ma nger: a hmed h egaz ey

Inves tig ation com plet ed by:
Op erat ion s: ah med ab ou reha b
E ngineering : ah med bah a
HSE : a hmed karawia

QC op era tors must che ck flip pers sta tus b efore charg ing o r dis ch arg ing
on vess el.
1- Ad d this cas e to TBT and h igh lig ht th at TR d rivers mu st be m ore

att ention to his road and take save dista nce b etween t wo ve hicle
15/0 9/201 3 OP S
AHMED ABOU REHAB
2 - h old awa renes s ca mpaign ab out th e dang erou s of driving t o clo se to

vehicle in fron t
HSE
Fire
chief
Slo w do wn my s peed whDepartment:
ile ma neuve rin g,
a void pe ople e rror, keepPosition:
a save d ist
ance
betwee n me and an y T R .
8- In which h our in your rotat ion th e accid ent t ake place ?
I jus t receive th e t ruck before t he accident bExperience:
y 5 min after one
6 years
hou r res t.
9- Wha
is th e precaut
ion t hat
youthe
canold
take
it tstation
o a void it
ed aga
in? And when I started to move, the files and papers
- I was driving the Safety PU 01 from Ops PU parking
fort moving
our files
from
fire
torepeat
the new
one.
Ma kedown
a saveof
d ist
ance
betwee
n meI an
any truck
, more it
at tent
ionI. drove then I surprised that I hit a parking Ops bus.
which located beside me were dispersed and dropped
the
beside
seat.
started
to collect
while
118
September 11, 2013
16:00
Red
Safety PU 01
D uring Sa fety pickup 01 exit from parking h it th e parked OPS BUS 01 an d made d amage
in bot h of pick u p and b us.
People
Not following the traffic procedures that while driving, was busy with another thing
except his way.
1- In your opinion, why this accident happened?

- Because I was driving and I was busy with another thing except my way .
Name: Moh amed Abo Zaid
ID: 180 9
2were you fasten your seat
belt?
- Yes, I was. Position : ele ct ricia n engineer
Depa rtm ent: E ng WS
Did you receive a pre-shift
E xp erience:
safety talk:
2 ye ars
YES
, 3 mon
NO
th
I we nt to ad jus t the air pre ssu re of my PU t ire at th e work sho p, I entered by PU front face ,a ft er fin ish ed I direct ed to pa rk m y PU at t he work sh op parking , by us ing t he ra mp pat h at
fron t of t he work
sh op
, wh
ile mantraining
euverin g in
I did
nt see
t hethe
worksh
sh elt er su pport
I sud den ly hit it.
Did
you
receive
how
to do
taskopinvolved:
YES andNO
Did you see t he she lter sup port?
Are you aware of the rules / procedures

related to this work: YES
No , I d idn t
Immed iate caus es
E NG -PU-0 8 hit t he tire worksh op su ppo rt bea m wh ile PU driver was mane uvering t o g oin g
workshop parking.
Underline ca use s
119
September 12, 2013
3:30
Eng-Shift A
eng pu 08
120
September 12, 2013
13:00
Red
TRL
TR 9 8 / TT 1 57
& TR 58 / TT 5 7
Aft er EN G-PU-0 8 rear t ire air pre ssu re adjust ment , th e driver hit the tire works hop
su ppo rt be am.
Immed iate caus es

S potligh t over t he works hop light ing in his face an d did n't g ive him a clea r visibility.
Aft er TR 98 / TT 1 57 driver had charged a conta iner from QC 12 , he mad e a

mane uvering t o exit from crowded a rea which caus e h it of TR 58 / TT 5 7 ( tail to tail )
( TT 157 t o TT 5 7 )
- Area wa s very crowded

Lack of at ten tion : as t he PU driver d idn t s ee the worksho p shelter s upp ort wh ile ma neuve rin g.
- M iss calcu lating th e dis tance .
- TT 1 57 / TR 9 8 hit TT 5 7 / TR 47 while man euvering o n the Quay side .

Roo t Cause
Underline ca use s
People:
Trade Mar
Roo t Cause
People:
- Po or De cis ion M aking
- Did nt follow S OP
Immed iate caus es
- Op s bus 0 6 hit Ops PU 5 0 while he was reversing back.
121
September 15, 2013
14:10
Blue
Terminal Bus
Wh ile b us 06 revers in g back at t he parking a rea Sligh tly hit picku p 50 which located
beh ind h im which le ad s lig htly d amag e in bot h bus An d Pickup .
Ops Bus 06 / PU 50
Underline ca use s
- Lack o f at ten tion from Op s PU 5 0 driver.
Roo t Cause
Peo ple Caus e:
- N ot following t he proced ure s (As the b us driver did nt ch eck th e m irro rs while he re ve rs ing
back) .
Immed iate caus es
QC 0 7 pulley gu ard is collid ed du rin g discharg ing cont ain er un der d eck on ves sel.
122
September 13, 2013
11:30
Orange
QC
NA
While QC 07 Operator was dis charg ing from M/V CMA CGM BERLIOZ, he complaine d from
a no isy sou nd rais ed from th e h ois t so he as ked fo r the Ma int enan ce te am assist ance,
and while ch ecking th e sou rce of complain ing t hey dis co vered a dam age in t he gu ard of
th e left hoist wire p ulley.
Underline ca use s
In volved QC o perator was nt be att ent ion du ring discharg ing .
123
September 15, 2013
1:00
Orange
QC
NA
while CQ 08 d is harg e from the ves sel M V MS K KLEVEN th e crane op erat or no te some
sn eaked in t he wire , t he su pervsio r asked him to sto p operation imme diat ely to check
wire st atu s with en g team who m advice tha t there's d amage in hois t wire an d the cran e
get ou t of orde r.
UN Reported Damage
124
September 17, 2013
17:30
White
TRA
TR 111 TT 84
Sinai
while TR 1 11 att ached to TT 84 m ake ma neuve rin g to get o ut from QC 1 2 the re ar rim
collid e with th e edge of ha tch cover located a t back reach of QC 1 2
Roo t Cause
Peo ple Caus e:
La ck of a tten tio n.
Imme diat e cau ses

TR 1 11 att ach ed to TT 84 collid e with th e e dge of hat ch cover.
Und erline caus es
No warn ing cone s in fron t of hatch cover ed ge as ag reed be fore .
Root Caus e
1- Lack of experien ce .
2 - Lack of at tent ion /d ue care
Traile r evacuat ed to Worksh op for insp ect ion .
Amr Rashwan
Ahmed Shawky
Mohamed Abd El Rahman
+Ramzy Maher
Possible 3* Severity 1= 3
Add to the TBT that all drivers must stuck with the traffic roles
and give all attention and concentration on their way while
driving
Amr Rashwan
NO
If required, were
youdid
wearing
the
correct
PPE:
Wh y you
nt see th
e s helter
s upp
ort ? YES NO
BecauseInvolve
t here is
s pot lig
over
worksM
hop
ligh tin
g in my face a nd didn' t give
a clear visibility.
da
Person
: htNa
me:t he
Ibrahim
amdoh
Ibrahim
ID:me3 527
Did
you turn on
PU ligh
t while
move?
Did you receive
supervision
in your
the last
1hr
of your
work: YES NO
yes
How dot:you
think
this incident
could
in future?
D epartmen
Ops
( Su bcontractor
Trade
mar be
) avoided
Position
: TR Driver
W hy you did nt use
he reverse 2
poyea
sit ion?
Expterience:
rs, 4 mon ths
It wa s more eas y t o ente r by pick up fron t face .
Sh ift Man ager: M ohame d Ad el (Act ing )
I ha d ch arge d a con tain er on QC 1 2 and a ft er I fin ish ed , I cou ldn t m ove straig ht becau se the re were TRs in fro nt of me the n I decid ed to ra ise th e tra iler by the fifth wh eel to cros s the
Wh
was
while
you were
man euvering
sign cone an d sta rted to move with out Wh arf Con troller, howeve
r ,at
t he
lanyour
es onexact
berthd irection
was ve ry
crowded
an d after
I m oved ?from th e crane area , I sa w t hat all lane s from 1 to 4 and a lso Operatio ns: Moh amed s aiff
I was
mane
tire5worksho
area ed
to to
workshop
PUarea
p arkin
g. while I was en tering , th ere was TRs wait ing in my rig ht
la ne No. 6 wa s very crowded a nd I sa w an e mpty sp ace wh ich
cou ld
ge tuvering
me freefro
in m
lane
and so Ipdecid
en ter t his
and
E ngineering : Es sayed Abo E lene en
and left sid es, so du rin g mane uvering b etween t hem I h it the t railer 5 7 by my TR t railer 1 57 which was s topp ed on t he right s ide from me a nd I didnt st op imm edia tely be cau se th eir
HSE : Ahme d karawia
Is t his
as at
a sth
hortcut?
oth which
er word
s, is
it aarea
llowed
t onois
move
in Ith
is area
byr the
PU?h it so und .
wa s dis ch arging
frocon
m tsid
he ered
cran es
e s ameIn
time
get
t he
very
y so
didnt
hea
No it isnt a sh ort cu t, ye s it allowed to mo ve in this area an d SOP d idn t m ention any th ing abou t that be cau se som e t ime whe n we n eed to g et our e quipmen t like welding machine or
the mo bile G ene rato r we use th is access t o e nter.
W hat
you r sp
D id th erewas
an ywas
p roblem
oneed?
your mirrors ?
It was slow.
No , it was in a go od co ndition a nd I mad e pre-t ask ch eck on it before I b eginning my work .
D id th e way yo u decide t o p ath fro m it was wid e a nd su itab le for you ?
D o you have an inte rnal d riving license ?
No , but I wa s going to ta ke th e a tten tio n of t he TR driver on my le ft h and to m ove fo rward t o get me mo re space are a b ut I d idn t reach to him
Yes
Do you h ave
D id any
you in
receive
struction
a psre-sh
abo ut
ift what
safe ty
you
talk:
d o in YES
like thNO
is s itu ation s ?
Ye s , I mu st st op and call TR s upe rvis or
D id you wea r your s eatb elt?
D id you receive tra
W hy
ining
youindid
h ow
nt tca
o do
ll TR
the
sup
t ask
ervisor
invo?lved: YE S NO
Yes rie nce t o do tha t alon e .
I think that I have an expe
Whe re
was your
b reakto? t his work: YES NO
Are yo u aware of the rules
/ proce
dureslast
related
sleep
It was Are
fromyou
12 :0
0 amwell?
to 01 :0 0 pm
,Hwere
ow myou
anywearin
hou rsYes
d toda
If required
gyou
theworke
correct
PPE :y ? YE S NO
5 h ours
Did
In
From
volved
you
Person:
r point
view
Name
:suffering
Amr
H assa
tfrom
he
reas
onyou
beh
that
ID
inciden
:S 69NO
8 t?
yo u
receive
D idsuof
you
pervision
wa swhat
in twas
he
las
t nin
1hr
any
of
pro
blem
r ind
work:
? YE
T hat in ciden t happ enedNo
b ecause
I wa
, I was nt
. s out of my att ention.
D epartmen t: Operation s
From
youdo
r point
ofink
view
wast tcou
he ld
reas
beh
indinthat
t?
How
you th
th iswhat
in ciden
beon
avo
ided
futuinciden
re?
in cident
app ened
eca
use
t ook
d ecision
.
- ToTh
letisall
drivershpay
more bat
tent
ionI wh
ilepoor
re vers
ing b ack.
Experien ce:
3 years
- To p ark th e picku p in th e rig ht po sit ion.
Op erat ion s: Nader Helm y

Eng ine ering: Ah med Salaheldeen
Ad el
H SE: Ali
Operations : Ahme d Hega zy.

Eng in eering: Moham ed Ali.
HS E: M ohame d Ab d Elrahm an & Moh amed Aba ss.
Add t his cas e to TBT regardin g: all En g. & operator sho uld b e m ore
atten tio n while m aneu vering. All pick up while adjust able t ire air
pressu re ent ering in revers e pos ition with a g uid e t o avoid an y impact.
Probability (3) X Severity (1) =3
Probability (4) X Severity (1)
Probability ( 3 ) X Severity ( 1 ) =3
I wa s dis ch arging from t he un der d eck and a s soon a s I lowered the cont ain er on th e tru ck and s tarted t o h ois t up th e spre ader I heard a h ig h soun d tha t even th e p eople on the q uay
Involved Person II:
h eard t he sam e s oun d at the s ame time, s o I told the wharf to call the m aint enan ce te am in ord er to ma ke th eir regular check b ut th e resp ons ible e ngineer t old u s tha t soun d ca me from
Nam e: E lsaye d Mahm oud Ha ssan
ID : 11 17
t he left trolle y whe el which was loose an d they alread y kno w ab out it a nd I can continue my work wit hou t any pro blem .
Put tin g some re flective ta pe on th e worksh op she lter sup port.

Rep osition t he sp otlight b y coordin ation with T S
Add ing T R move ment in tire s worksh op area in SOP
Ad d th is case to TBT reg arding: all T R d rivers mu st be followed th eir

S OP reg arding t o inform t heir direct s upe rvis or when fa cing any
ch alle nge which m ay a ffect on t he operations / safet y p erfo rman ce.
1 To put a p las tic b arriers in th e parking s lots front of Mu ster room &
resta ura nt st airs .
2 Add th is case to TBT and hig hlight ed the importan ce of pay more
a tten tio n wh ile you driving & to pan t he ent ran ce by an y veh icle
beyond the ne w ba rriers .
eng
01/10/2013 , 25/09/2013
OPS
September 20, 2013
CLOSED
mohamed saiff
Amr Rashwan
Ops
HS E
September 25, 2013
Salah Abd Elaziz
OPS
September 20, 2013
Amr Rashwan
OPS
September 25, 2013
New
Salah Abd Elaziz
Ops
September 27, 2013
New
Amr Rashwan
D epa rtm ent: Operations

Po sit ion: Bu s Driver
At which time this situat ion h appe ned?
It hap pen ed after I spen t abou t 45 minut es on th e crane.
Expe rie nce:
5 Mo nths (As bus d river) Truck driver before .
why
did yo
ask for
th ethe
m aint
enan
cerst eam
again?
- I was drive th e bus from the yard to the mu ste r room pa rkin
g area,
droupped
d own
p ass
enge
th enhelp
takeonce
my mane
uvering t o p ark th e b us in the pa rkin g area, ch ecked t he left
As a ft er I d ischarged 3 cont ain ers fro m t he las t situat ion I h eard a noth er no isy sou nd while I was h oist ing u p, so I st oppe d the trolley a nd continue d my h ois tin g up in o rder make s ure.
m irror and it was clear t hen u sed th e rig ht on e t o adju st t he bus & to avoid the st airs of the res tau ran t; s ud denly I hear t he voice of the cras h, stop ped t hen in formed my s upe rvis or .
D id you n oticed th e pickup befo re reversin g back ?
Is th ere an y on e stan din g with yo u on the b ay?
- No, t he are a was totally free from an y ve hicles .
No, t here was nt.
While you was working , did you hit the s prea der in any pos ition at th e ve sse l?
No, I did nt hit t he sp read er while workin g.
D id you r form er QC op erat or in form you ab out an ything wron g in th e crane?
No, he didnt tell me abou t anyt hin g.

Eng inee rin g: Ahm ed Salah
H SE: Moha med Atef & Moh amed El-Tabee y
D id you o bserve any frict ion in the ho ist wire while h ois tin g up?
N o, I did nt obse rve any frict ion or any abn ormal movemen t of t he wire on t he pu lley.
Witne ss Pers on:
Name: Moh amed Ha ssa n Morad
ID: 9 46
D epartmen t:
Operation s
Add t his cas e t o TBT a nd highligh ted th at QC op erat ors m ust b e more
at tent ion an d avoid roug h hand ling du rin g dis ch arg ing or ch arging
con tainers und er deck.
Likley (4) X Severity (3) = 12
E xperien ce:
4 Years
S agie e Sale m S alem ID : 379 9
Kin dly explain what d o you know abou t tha t incid ent?
I know not hin
and t here
is not
hinsource
g happ(S
ened
ringTR
my
working hou rs .
Dg
epartmen
t: OPS
Out
ina i with
CO.) me
Pos du
ition:
D river
Was you th e fi rs t one who op erat e the cran e o r it was working from the previou s shift?
N o, th e crane was working from
Experien
the night
ce : s1hift
.5 .mo nth
How many ho urs d id you s pen d on the cra ne?
Aft er QC 12 load my conta iner I moved t o t ake my man euverin g behind
I spe
QCnt
1 2my
but1st
I miscalcu
2 h ours late
fromthmy
e dis
working
tan ce be
datween
y.
My TR and t he hat ch cover an d my Trailer re ar whee l collid e with
Did yo u make
th e haatch
ny move
coverwith
ed ge
t he
. sp reade r?
Yes, aft er I op era te the cran e, I shift ed to M/V CM A CGM BERLIOZ a nd op ened h atch cove rs th en I ad jus ted t he crane on b ay 46 in order t o start discharg ing and I fin is hed dischargin g till
2ndwhile
t ier. mane uvering ?
-W hat was you r th
speeed
Very s low .
-Did you se e t he hat ch cover before d ecide to take your maneu vering ?
Yes , I did
-D o yo u think t hat t he area b etween you r TR and ha tch cover sufficie nt for s afe maneu vering ?
It was e noug h but I found T R comin g in my way so I d ecide to make sha rp man euverin g
-D o yo u have any problems affect your at ten tion wh ile d riving ?
No.
-in Wh ich hou r of your rotation th e a ccid ent ta ke place ?
2nd h r in my la st 3 working ho urs fo r this day.
Ehab Zah ran

Am r ELsho rba gy
Mu sta fa Fa thy
1 -Add to all TR d rive r TBT to a void sh arp m aneu vering nea r hat ch
covers
2- Add to D & W controlle r TBT to secure all hat ch cover with cones
once ope ned
3 -TR Driver will directed t o OPS-Trainin g for reas ses sme nt
Exp erience:
2 ye ars , 3 mon th
1s t I was cha rging from MV. Th ermiakos and th e M/V in a list p osition becaus e t here was a noth er two cran es charg ing a nd discharg ing on it ,due t o chargin g from the s ea sid e the list
was h igh , my SV asked me to moved t o b ay 3 to discharg ing , after dis ch arging five cont ain ers I lifted t he sixth container from the 2 nd row 3rd t ier at t he sea s ide an d sta rte d to move
trolley wh ile I was m ove I h it th e 1st row 2 nd tie r and fallen in the s ea in-b etween t he M/V a nd qu ay s id e.
People:
125
September 20, 2013
2:30
White
QC
QC 14
While QC14 was dischargin g on ment ion ed vess el , Two empt y con tain ers were fa llen
in to water due to t he spreader hit fi rst row.
-incorre ct followin g of stan dards an d procedu res : didnt ta ke his safe dista nce wh ich he receive d
it in h is t rain in g.
-Poor d ecision makin g: h ois t down be fore get ou t of the ves sel.
W hat was yo ur sp eed while moving tro lley ?

Slow ,be cau se I was d ischarge in lane 2
wh at is t he safe dista nce wh ich you received it in you r train ing p rogram?
Abou t one conta iner (2.3 m)
And what was yo ur dista nce wh en th e incide nt hap pen ed ?
About 0 .5 m
Did yo u made ho ist d own while moving trolley?
No
Is the limit switch working p roperly?
ye s
Name : Waleed S aad Eldeen Ras hwan
ID: 1 71
Prevent ive meas ures and im proved procedu res:

1 -Op era tor s hould have h is work histo ry sho uld b e looked at, and h is
s taff card as well. Look a t past practice s, an d the n re evalu ate
corre ctive act ion s.
2 -Test ing t ech nical s olut ion s (AAL is t esting an ti collision syst em on
QCs)
Op era tion s: Ehab z ahraan
Eng ine ering: amr el shorbag y
HSE : Ahme d karawia.
Probability (2) X Severity (2)=4
Operations: Nad er He lmy

E ngineering : Mot az Hewlah
HS E: Ali Ade l
W here was t he dock con troller wh en th e incide nt hap pen ed?

Dep art ment
Ops13 b ecau se th e crane op erat or nee Po
sit ion:
Operato r
Wit:h QC
d his
h elp Crane
.
when th e incid ent ha ppen ed th e work wa s seq uences or Non-s equ ence?
Experien
ce :
7 Years
It was se quen ces
mann er
Is th e vision was clear in your cab in?
I was Loading twin con tainers in row 05 from the la nd side , I Load ed two moves in this row Yes
with out an y p rob lem and wh ile I was Load ing t he th ird mo ve , I us ed ce ll gu ide t o b e sure t hat
the cont aine r ent er the row a nd I be gan to h oist d own and a t deep ness (10 meters
ly) , I stop ped b y force be cau se I hit some thing and aft er th at I sa w th e oil s prea d
Are approximate
you sleep well?
Leakin g, I p res sed on s prea der oil Pump off and call Yes
d eck controlle r , En gin eering t eam to fix th e p rob lem .
Corrective actions:
1-Re fresh er train ing for QC ope rato r.
2-Ad d th is case to TBT: all CQ o perators sh ould p ay more att ent ion an d
follow S OP while ch arging an d dis ch arg ing cont ain ers ( take a s afe
dis tance ,ask the d ock co ntrolle r for a help if need ed)
3- Ad d this cas e to TBT rega rding: all lash ers t o che ck t hem workp lace
o n the ves sel an d rep orte d any abn ormal s it uation to th e sup ervisor,
and follow SOP.
in W hich ho ur of your rotat ion t he accid ent t ake p lace ?

In a 1 st h r after 2nd
rest In t his d ay.
Organ izat ion :
126
September 20, 2013
18:10
Red
Spreader
20
Remain on board uns eate d twin left wh ich Lea d to be hit by the lo adin g twin .
, Lead in g to the s ubject d amag e.
- Lack of s upervis ion du e to sho rta ge in th e deck cont roller n umbe r

En viron ment :
- Obs truct ion
- D id you faced an y p roblem while yo u makin g the first an d second m ove ?

No , th ere didnt .
- D id you r sp eed move in t he th ird on e was like th e 1 st an d 2nd m ove ?
Ye s , us ually I get t he co ntainer inside th e cell guide and a ft er th at I get d own .
- Do you h ave a limited do wn spee d wh ile chargin g (Loading) con tainer as S OP ?
No , I h avent .
- Did yo u note d any move ( Trim Lis t ) on th e vesse l while yo ur work ?
Yes , I in fo rmed t he VSV t hat th ere was list mo ve fo r the ves sel an d I he ard him on the chan nel inform
t he deck con troller t o report th at with t he ch ief officer .
- D id th e deck cont roller in form you ab out an ything wron g after h e che cked th e b ay ?
N o , he didn t .
- D id you as k for the D eck controlle r for an y p roblem before ?
No , I d idn t .
- Are you wa s suffering from any pro blem b efore or wh ile you working ?
N o , I was in a g ood conditio n .
- D o you took your slee pin g hou rs yes terd ay ?
Yes , I do .
1.Provid e d eck cont roller for ea ch Quay Cra ne

2.Add th is case to TBT an d inform operators ( De ck Controlle rs , Crane
operators and lash er
Amr Rashwan
Th en we co ntinue working wit h 40 ft mod e t ill s pre ader s tuck again in th e same ba y row 0 3 quay s ide. and I t ried to hoist u p but I fa iled s o I asked the wh arf co ntro ller callin g the en g
ten
was
your
peed
wh ile
d ischargin
D epa rtm
agent:
ain .Wha
The
Operations
g ca
me sand
th ey
enab
le Pos
meition:
thg?
e h ois
Ya rd
t. Su pervisor
It was
n ormal.
Did you see t he-deck
con
troller o n the ves sel ?
Have
r expos
to
similar
situat ion
?ce ll gu ide
Experien
5t he
years
Yes , an d he
wasyou
moneve
ito rin
g theed
s prea
der ence:
tering
- Yes, b ut th is is my 1 st time I had an a ccid ent/d amage on s imilar case s.
127
September 22, 2013
9:00
Orange
TRL
TT 135
Kotby
wh ile TR 134 wit h TT13 5 movin g to crane 1 7 and cros s crane rail t railer le g den ted
becaus e o f h avey wiegh t of t win continers
Peo ple Caus e:

- N ot following p rocedu res (* Involved TR d river didnt check t he leg s upp ort level be fo re drivin g,
* In volved TR driver d idn t inform T R s upervis or th at TT 135 fi ft h-whee l plat e down after load ing
Imm edia te Cause :
- Flipp er mot or dam age du e to hit b y a noth er conta iner.
Un derlyin g Caus es:
128
September 23, 2013
15:30
Blue
Spreader
durin g QC 06 d ischarge CT R in six tier with jammed twist lock, sp reade r hit t he ano ther
CTR cau sin g dama ge in flippe r moto r
SQ 08
131
September 23, 2013
19:15
Orange
PU
20
Wh ile Yard Sup ervisor in dut y was che ckin g for yard operatio ns, the Pick-Up fron t hood
sud den ly open ed in an u nexpecte d way a nd pre sse d the PU win dscreen wipers res ult ed
in a cra ck in t he PU front g lass .
129
September 28, 2013
7:00
White
Spreader
SQ 17
Eng Team received a spreader BD N on QC17 ,after in sp ect ion th ey found d amag e in
SQ17 te nsion rod .
130
September 28, 2013
9:00
Red
QC
CQ14 s nag fau lt. After ins pection fo r the h oist wire rop es, we fou nd th e sea side hoist
wire rope n eed to be repla ced .
QC 14
- Abse nce o f D &W cont roller.

Root Caus e:
Lift ing with de fe ct ed twis t lock.
1 . People cau se: In adeq uate p re-ta sk che ckin g:
Since the in volved Y SV d idn t pCorrective
erform even
a fastt aken
check Live.
on the PU p rior to drivin g, h ence he
actions
wasn
t able
t oced
reco
gnize iate
the ly
opb
ened
hood
.
- S pre
ader
repla
immed
y E ng.
Te am.
2 . PU hoo d s afety lock inap pro priate adjus tmen t: a s the sa fety lock was nt in its app rop ria te
pos ition in order t o hold t he hoo d rin g to prohib it it s open ing .
Imme diat e cau ses
- SQ 1 7 stu ck ins id e cell guide
Und erline caus es
- Po or vess el cell gu ide cons truction .
Root Caus e
-H and lin g spreader stu ck before arrival of ENG Tea m .
- Inade quat e comm unicat ion .as t he wharf d idn t me ntion sp reade r stu ck in h is call t o E NG te am
Peop le caus e:
1. Poor decision makin g (working in blind po int wit hou t guidance) .
2 . Failure t o act wh en the cont aine r st uck.
Roo t Cause
People:
134
September 29, 2013
7:00
White
RTG
15
wh ile RTG 15 disha rge conta iner in 05 A2 1 E2 , it hit anot her cont aine r in 0 5A23 B4 which
lead to cont aine r fall d own and caus ed dam age in t hree cont aine r more
-Lack of experien ce/train ing : t his was t he 4t h day in h is rot atio n after fi nis hin g the RTG tra ining.
-Lake of atten tio n: RTG pos ition in correct.
-Poor decision makin g: use d fu ll s peed .
Corrective actions t aken Live
-RTG operator sent t o make a d rug t est .
-The cont ain er dam age was move d in ano ther place.
136
September 23, 2013
7:00
Red
QC
13
Wh ile CQ 1 3 dis ch arg e from the s ubject ves sel h e note t hat th e hois t wire ge t outs id e
th e pulley.
137
October 2, 2013
1:00
Orange
QC
14
W hile QC 14 was dischargin g twin mo ve s from below deck of M/V YM INRE MENT ( bay 14row 05 ) the QC o pera tor comp lain ed th at he wasn t a ble to ma ke lo ck on th e con tain ers
an d after e ngineering t eam in specte d the sp read er th ey fo und a d amage in the two twist
lock p in s and also a big crack in t he right t win gea rbox.
Due to unreported damage to the hoist wire
Immed iate caus es

D amag es in th e SQ 1 3 twis t lock p ins & rig ht twin gearbox while d is cha rging un der d eck.
Und erline caus es
Working e nviro nmen t:
138
October 7, 2013
18:00
Orange
RTG
While RTG 4 3 operator wa s lifting twin move in 0 5 A 54 from TR 1 15, he lift ed it on 4 0

fee t spreader mode caus ing s prea der ( SR 2 5) chain cu t and da mage in 40 feet s ide twist
locks.
43
Impro per s tacking for the twin con tainers und er deck cau sed t he twis t lock p ins to hit t he side
edge s of the conta iners (corn er cast ing s) and a lso re sulted in cracking th e rig ht twin gearbox.
Immed iate caus es
Root Caus e
RTG 43 op era tor lifted twin move on 40 fe et spreader mode.
People cau se:
Und erline caus es
Incorrect fo llowing of pro ced ures :
People Cause :
QC ope rato r was hoisting d own in full spe ed und er de ck res ult ed in a st rong collis ion wit h the
A. Lack o f con
at tent
tainion
ers
: RTG
cornoperator
er castings
wa s
& hurry
co ntainers
in h andling
b ody tfra
heme
twin
from
move
theand
middle.
d idn t rea liz e
wheth er th e twin mod e was really act ivat ed or no t depe nding only on the b lin king of th e con sole
twin b utto n.
B. Te chn ical cause : afte r ins pecting th e t win activa tion b utt on lam b on the cons ole it wa s found
irresp ons ive to pu shing an d appe ars t o be activat ed all t he tim e witho ut trying t o act ivate it.
Root Caus e
People Cause :
N ot following Proce dure s:
RTG Op erat or didnt check fo r the twin activat ion on t he sp reade r vis ually o r even on t he
spreader/ca bin lambs b ut dep end o nly on th e twin activatio n but ton on t he co nsole.
Immediate causes
TR 78 reversing back and hit ENG PU 04.
Underline causes
139
October 12, 2013
17:30
White
TRA
78
Tradmar
While Eng PU04 maneuvering behind CQ03 TR78 reversed back and hit it
causing dent in PU.
Th
I wa
ens we
patco
rolling
ntinue
at th
0 1e co
wontainer
rk and b
load
locks
two
betmoves
ween Higher
andInvolved
I wen
& lower
t toPers
close
yard
range
e ame:
hatch
s, b cover
utMat
th
ine 20
cont
ft mode
aine
rat
blo
tsan
his
ck tthe
imePU
onpeasse
from
d Eng
over
a379
lan
s top
onllap
t he
sehat
anch
d I cover
foun dtthe
o ins
PU
pect
hoothe
d sud
s pread
den ly
eropen
an d ed
he
on:th
N
ahmu
dF Mohs
en Has
ID .: to
3d co
Was
d
r ass
ist ing
yo
u ?sel S V
and PU was d irected tcon
oward
firmtth
heatlan
the
dmark
s preaader
nd Iin
wasn
good
tDcond
able
tition
o s ee
and
anyt
asked
hin gt here
me
in fron
toa continue
t eck
of mcontrolle
e, snoormally
I took
my
but
left
m
direction
ves
a nd
s witch
presse
thed cra
thene
b rakes
off a nd
th en
make
remo
ah
veand
my
over.
foot from the brakes and
epa rtme
nt:
OPS
Posit
ion
: yTR
d river (Kot
bey)
Yes , bu
t he was
sy ort
with
aExpe
noth
er nce:
or.
left th e PU t o -move
forward
forbu
a sh
t ime
th en
Iop
userat
ed3the
h and
rie
mont
hs b rake.
-IN wh ich hou r the accide nt take pla ce ?
you
receive
safet
tr alk:
YE
S sp
NO ineel
At
any
t his
nt hap
penIn
sa03
and
hlas
ow
mu
tyime
end
drivin
tpre-sh
helower
tifttwo
hou
. did
- I took twin
cont
aintim
ersefro
m incide
tDid
he yard
in
berth
an
dch
I knew
th atyou
TR
Fifth-Wh
Plag
tethis
wasPU?
down s lowly.
- The twin con tain er was h eavy so fifth -wh eel p late s tarted to d own.
you
receive
tyou
rainin
g in
ho
w 1tefore
od
o the
sk
NO my colleag ue Tamer.
In cident- h
a t Did
abou
7:15
d controlle
after
ab
out
our
&me
qta
uarter
ince
ok
it from
-PM
did
slept
well
comin
g involved:
this
shift
?toYES
Wapp
henened
I reached
to tQC
1 1,
whan
arf
r inb
foh
rmed
t hat
I smu
st Iman
euver
and b ack aga in.
Yes
I did
- While I was ma neuve rin g, TT leg su pport hit
the
groun d and caus ed right leg su pport bro ken .
Are you awa
re of
t he ru
les s/ peed
pro ced
relat
ed to th
is work:
YES N O
Wha
t was
your
whures
t his
inciden
t hap
1 - D idyou
inform
yo
ur su perviso
riletha
t TT
fi fth-whe
elpens
was ?down ?
-Do you h ave any proble ms
affect
yo ur at tent ion wh ile working ?
- No
, I didnt.
uired,
were
you
wearing
he
PPE:
YES
NO
MIfy req
s peed
was
within
No
the
, every
ntormal
tthin
rang
gcorrect
is
e ok
(arou
nd 25
-35 KM/H).
2Wh
y you
d
idn
inform
yo
ur
su pervis
or?
- I wou ld in form him b ut afte r I will fi nis h work un der QC 1 7 and I did nt expect tha t TT leg su pport will hit t he grou nd.
Did yo u -Does
receive
su pervision
in tclea
he las
1hr of yo
ur work:
Y ES NO
your
Cab
in training
glass
n t&provid
e cle
vis ion?
3 - W hat d id
you ta
ke in
t he
whe
n you not
icear
p roblem
in t he TR?
Do you
knst
ow
ur s afety
Yes
reg
, ulat
I had
iona
re
clea
gard
r iate
vision
inglys peed
.
idepro
th eblem
term
- I mu
inoform
my sup
ervisor
immed
abou
tins
any
. inal?
4- Did you check TT le g sup port level b efore you d rove the TR?
-wh ereYes,
was
mth
ye
s peed
D ockscont
wit
at thin
he 2tim
5-3e0oKM/H.
f acciden t ?
-hou
No ld
,roller
I be
didnt.
there
s a Deck
cont
roller
witahcut
me,inhtehewould
h elp
y callinme
g me
rad
io to my
st op.
Yes, Ifand
h e wa
informed
me
th ere
was
ca ll gu
ide me
an dbasked
to son
low
down
sp eed.
From you r point of view what was t he main reas on beh ind t hat inciden t?
1s t Witn ess :
N ame: Ahmed Ma nso ur
ID: 153 2
-amed Abou
I d idn t kno w. I b elieve that t he lan d collap se wasn tWitnes
t he main
reas
on; also
I was
a t a hEigh
s peedd and
th861
e front h ood was clos ed this in cident was nt to ha ppen .
s: 1Name:
Mos if
tafa
Mohdriving
l Hame
ID : 1
De partmen t: Op erat ion s
Pos ition: D &W Con troller
- t ryt: to
De
D id
partmen
you
OPS
op en
Po the
sit ion:
h ood
D&W
even b y mista
E X:2 years
ke?
cedit
: ion
6 an
years.
Befo re we wo rk on this vess el we have bee n informed th at we have to ma ke full survey forExperien
bays con
d make d iscla imer report to th e line ,an d alrea dy we m ade th is rep ort wh ich
No, I didnt.
in clude
As wede
opfect
en th
s in
e front
ba y 2ho
0 cell
od only
guide
t oRo
fillwth02
e wind
sea side
screen
& wip
03 Quay
ers spray
side wa
. ter t ank.
was working
s tan din gdbetwee
n QC 06
&07QC
a t midship,
I was intwin
differe
nt ch
ann
then
constroller
asske
d me
move
to QC06
becaus
e s omet
hin
g wrong
e t wist
, th
en I
II was
eck controlle
r with
17 and
whan
iledloading
move
ins
ideel,row
0 2Amr
s eaWharf
sid e the
pread er
tuck
anto
d th
e Operato
r tried
to h oist
u p bu
t he
failed with
Our th
Vess
el SV
came
I fou
nditEng
thpeossible
Up on checking t he invo lved PU we dis co verand
th atins
the
g as-ta
waition
s almos
t full,
sth
o en
is
tcame
hat you
p ulled
th ehois
h ood
bu tto, n by mist ake inst ead of the g as-t ank but ton?
pect
the nk
cond
oncame
boa
rd
. accid
Teament.
and
e nable
t again
W hy do you th ink tha t happ ened ?
-Wha t wa s the h oist d own sp eed in sid e cell guide ?
- Th at
sh ip
ha PU
s a as
ve ry
bad itt wist
lock,
t .offront
its twist
jam med.
Ma y b e, bu t it was nt me how
fuel
t hat
I t ook
from
It was
thselow
pand
arking
spmos
eed(in
o f t helock
Op sare
office)
and d irected toward t he yard .
D id you hear t he mes sage ( call) from t he wharf cont roller to t he ENG ?
D id you make
N o. I awas
pre-otask
n myinve
spection
sse l radon
io th
cheann
PUelb efore
(16 ) d riving it ?
2
nd
Witn
ess
Moh
amed
t harwa
tby Co.?
-D
id an
y on
e :fromName:
the E NG
tea
m came
t o tt he dock for in Ko
spection
- ( betwee n shift s) no t with in th e working shift .
No , as we mad e that insp ection aft er han d over
No.
D epartmen t: Op era tion s
Pos ition: d owel man

Eng inee rin g: Ahm ed Sha wky
HSE: Moh amed E ltab eey
Ope rations : Kha led He gazy

E ngineerin g:
Ah med Salahd en
Safet y: H ish am Ism ail

Eng ine ering: M oham ed El-H adidy
H SE: Moh amed Atef
Moh amed Se if
Ahm ed Salah
Ahmed Kara wia/Mus tafa Fat hy
Risk= Severity (2) * likely Possible (3) = 6
(2 )* Likely (3) =6
- g with
SoWe
if tcont
hereinu
was
e wo
anrkin
y prob
lem 4in0 tFt
hemPU
ode
how
till would
we reach
youRo
bewable
03 Qua
to dis
y Sco
ide
ver
, it ?
2 years
An d the sp read er st uck ag ain ,we con tin ue lo adin g 2 units th en we have to clos e the haExp
tch erience:
cove r a t this
time. on e from Eng team as k him to sto p on the h atch co ver to in spe ct t he
If th ere was any
sp read
problem,
er th enmy
theformer
y ad vice
colle
that
ague
we s
can
houcontinue
ld in formnme
ormally
abo ut
. it t hats all.
Whrow
en the
opside
era tor
lande
d on
the cont
ainter
and
hoisthig
upher
,s pread
lift row
s ea by
sid 2
e. tiers, and th e 3rd row land s ide was 1 tier (t he
I was cha rging 40 ft. co ntainer o n MV d eck in 2 nd
la nd
and
it was
1 tier,
the 1s
row
lant ried
d sidto
e was
t han er
t hehit
2nd
An
d the
was
ap bet
we
en rce
ntera hatch
cover
an d iner.
sea ha
tch cover.
sam e a s the 2n d row) bu t it was h igh er th an the 2 nd row be
cau
se th
e 1a
stgtier
cont
aine
was
hig h cu
be conta
I reached
t he 2n d row and while I ho ist ed down th e con tainer, it s right
id you
ceive
a p re-s
sa fe tyt o
talk:
YESto ad
NO
sea s ide twist lo ck stu ck with t he right land s ide of th e 3rd ro w h ighDcub
es re
cas
t corner,
s ohift
I started
hois t up
jus t it b ut th e s pre ader d idn t a nswer then I tried to give it an order
How didMon
youir nMo
oticed
t he acciden
t ? ID : 09 55
ss:e spre
2 -Name:
hamed
esoky
ag ainWitne
th en th
ader s ud denly
jump anEdLdgave
th e sna
g fault a larm.
- I was on th e cat walk prep aring forDtid
heyou
5threce
t ier ive
contraining
tain ers , in
I nhoticed
he th
spreade
hit lved:
t he container
in 6t h tier wh ich I already prepare d.
ow to tdo
e t ask rinvo
Y ES NO
D epartmen
Position
: Dthe
& Ws ame
controlle
1-t:DOPS
id you
work in
row rbefore? EX: 2 yea rs
I re ceive the Cra ne which continue t he work normally
Area-yo
ftYes
er
u ,aware
release
ofs tuck
the
t2n
hen
s
we
p rocedures
work
loading
related
wit
o tside
hhis
40wo
Ftrk:
mod
YEeSt ill 6
NO
:40 am th e spreader stu ck again and I call the En g ,
I s tacked
therule
d /row
& th efor
3 rd
ro w la tnd
conta
iners.
Direct S upe-Wh
rvis or:
N
ame:
had
y pSoin
olim
an
at2-the
meitssa
ge /call
for
ENyou?
G Team ? ID : 1 258
Was
aSblind
t to
If requ
irede, were
you
wea
rin
the
correct
ES
halan
ve
ois
t fault
. PPE
- Yes,
becaus
the 1s
tWe
row
dhgsid
e
wa
s abou
t 4: orYth
ree NO
tiers .
Dep
ent:
Pos ition:
Vess
SV.
-Dartm
idcon
you
meOPS
ntion
r stu
ck ha
?el ndled
3- Was th ere a deck
troller
withspreade
you while
you
tha t row?
enwith
Did
th ey
yo
came
u receive
th eQC,
su
QCpervision
t he
rm
the
t 1hr
m am
of
nd
yo
he
uras
work:
k t o stan
e nable
Y ES
NO
to hleft
oistside.
up .
-No,
No but
, he wh
was
the
o ther
aoperato
nd th ererininfo
was
alas
dowel
an
but
was
din ghim
at my
Suany
mmary
of wh
st ateme
4- Did t he Ves sel make
move
ile younts
h andled th e con tain er?
*th en we load 2 m oves and t he bay was fu ll so we have t o clo
How
se the
do h
you
atch
t hin
coIkver
th is
,the
inciden
spiced
read
t cou
er tu
ldmove
rned
be a vo
to ided
20 .Ftinsu
futu
ccess
re?fully an d before we catch the h atch co ver one fro m E NG as k
- No,
didnt
not
any
ment
op erat or to s top over the ha tch fo r ins pection the n he coInvo
nfirm
lved
t5o Pers
con
on:
working
Name:
Yass
norkin
rmally
ergMo
b
hamed
ut
outh
rAb
shincid
d
iftelhave
all
to make
ID : 79
han
2 dover and th e Next sh ift (Da y s hift ) will close th e hatch
whtin
atue
was
your wo
hou
r in
e
ent time?
I think t hat all lan d collap ses in the yard sho uld b e fi xe d, an d
als
o all
s2nd
hould
make
a rand
om
chion.
eck on
PUs even wit hin t he working da y ( during h and lin g PUs amon g
Wit
nes
s: su
3-N
Mahm
oud
Moinhamed
hin
ID:t heir
1 523
- pervis
It ame:
wasors
my
h our
my
1stLas
rotat
artm
ent:
ition: rRTG
Operator
6- Did you pu sh a Dep
by pas
s bu
ttonOPS
a ftshift
er thse sfiup
rs tervis
timeors).
t hePos
spreade
did nt
ans wer your orde r?
: OPS order
Pos ition:
con trollerjump
EX: ed
2 Years
- N o, I gDep
aveart
it ment
th e second
t henD&W
th e spreader
su dde nly.
It was m y last working h our fro m 5 to 6 am and QC o perator a sk m e to call Eng t o enab le hoist
the s pread
Expafter
erience:
4 dayer st uck on ve sse l cell guide ,I ca lled t hem to s olve th e prob lem .
t wa s the
mes
sag
/calltyfor
Eng team
D id-Wha
you receive
ap
re-sh
iftesafe
talk:
YES ? NO
I was d ischa rge a container in bay 21 Fox 5th t ier, th en I receive d an ord er to discharge
We h ave
a anot
hoist
herfault
cont ain er in t he same b ay but in Eco 2 nd tier after I lifte d it from TR and s tart to move
trolle y t o p ut it in place s udd enly I h it th e a noth er conta
iner
Did
inyo
ba
u yment
2tra
3 Bravo
ion an
4th
yht ow
hin
tier
g
y
ted
htto
s prea
of
co
der
ntainer
s tuck
?S d saw
D id you
receive
ining
in
t obrela
dorig
the
tside
ask
invo
lved:
YEan
NO it fallen . I s topp ed moving and call my s up ervis or.
No. but wh en the y arrive I told t hem an d they as k is there is any problems if th ey e nable hois t so I as k t he QC ope rat or who in form me th at the re is no p roblem .
essin
: a4-Na
Hition
any Moh
amed
Elbos
tany
Are the RTWitn
G was
righme:
t pos
when
you s
tarted
to dID:
ischa156
rge7on t his b ay?
Yes,If and
th e proof
ischa rge
oncorrect
e cont ain
er: befo
th is ba y.
required
, werei was
you d
wearin
g the
PPE
YEre
S inNO
D id you
Depamove
rtm ent:
gan
OPS
try after
Position
1st cont
: OPS
ain
SV
er?
He confirm a/m
No s tate ment s
Witnes s: 5-N
Areame:
you put
Moha
t he
med
1s tElsayed
con tainer
E l Shafe
correct
eyly? ID : 0 933
Yes
Dep
W hat
art ment
was you
: ENrGsp Pos
eedition:
whenFirst
the Elect
acciden
ric ttechnician
happ ed?
Full spe ed
W hy you use d the EXP:
full spe
7 years
ed and yo u still beg in ner?
-in the fi rst BD N ,I have bee n informed by ra
I tho
dio ugh
ab out
t after
landing
th e 1st
la mp
con
istain
always
er th ON
at the
a ndb ay
in twa
hissBD
clear
N we
to me
arran
ange
d I with
was tst
he
and
operato
in a rig
r ifhtthe
po sit
lamp
ion (indicat
an d
or) in his cab in working to d epen d on
following trainin
itgtill
in struction
repair th eabout
lamp hois
b oard
t safe
on tdista
he hea
nce.
d block .
W hat was you r height wh
-Did
en you lift
make
ed th
s itee1insp
st cont
ection
aine?r? And t he 2n d con tain er?
No ,I
Full
hoist
answe
up rinon
the
th e
1 st
radio
conta
only
iner,
anan
d they
d abou
agtree
11 and
m incon
t hetin
2n
ue
dconta
workin
iner.
g.
In the se con d BD N I ha ve b een in forme d that t he crane d idn t resp
D id
ond
you
honist
otice
comma
any nd
conta
so iner
I d irected
on bayto23
the
incorre
cran ect&pwent
osit ion
t o?E -room an d before e nter the E-room I check t he pos ition of the
sp read er and fo und
No,
it free
I didnt
away from th e h atch .
Aft er checking t he fault from the PLC I found it Unb alan ce fau lt and t he diffe
Are you
rence
h ave
bet we
a clear
en the
visload
ibilit on
y inb your
oth wire
RTG?
s ide was s mall and it was safe to make bypa ss to h andle it so I a ctivate
bypa
Yes
ss, b
till
utth
theeoperator
front glass
land
es ed
neethdeto
con
clean.
tain er .
In volved Person
:
Na
me:
T
arek
M
ohame
d
Shab
ana
593
-W
hat
was
t
he
Are
exact
you
ha
p
osit
ving
ion
an
of
y
p
th
rob
e
con
lem
tain
in
you
er
whe
r
RTG
n
?
you
ch
N ame: M ohame d Ah med Abd El-gh any
ID : 11eck?
90 ID :
Dep
art
ment
: OPS
Positio
QC
opst
era
tor
Th
Ye
e s,
lower
t he
deviatio
4 corn
ernof
in th
theiscont
RTGain
was
er were
hig h so
free
Iu
awa
sually
y n:
fro
usm
e tthe
he
cell
eering.
gu ide .
Experien
ce: bPo
2efore
years
-Did a ny one in form
ab out
y s tuck
Did
oryou
abnin
ormalities
form your
take
sup place
ervisor?
th e Crane
fa ult ( Operato
hois t notr re spo nding) ?
Depyou
art ment
: an
Ops
sit ion:
N O. t hey did nt and if I h ave been informed abo ut any st uck I h ave to call for a ssistan
ce t eam to check t he spreade r (on e o n board to co nfirm with me while Im at E-ro om)
No
Pe
rsoE-room
n:
N ame:
d
ID:Technica
- aft er you dInvolve
escendd
fro
From
m
you
r point
,Did of
you
view
asMoh
kwhat
th eamed
operator
was Awa
t he
reas
toMoha
lower
oncemed
beh
tread
hat accide
er for
nt? 12 30
l ins pectio n ?
Experien
:t heind
2sp
Years
I d idn t kn ow wh at hap pen ed Ma
with
reade
r, i in
wa
st dis
Dep
chpos
arging
artm
twin
OPS
m below
ck
ofthbay
Position
14
on
M
: /V
RTG
YM
operator
INreade
CRE
from
quof
ayside
y btIhe
eask
I sp
was
th
esta
operator
nd
correct
o lower
tition
heent:
sp
on
read
thmoves
iserba
asy,fro
I and
s aw
wh
s omet
en Ide
hin
lifted
g sus
pen
e 1st
ded
cont
from
ain
er
t he
with
sp
a fuMEN
llrhoist
,itTwas
u paI the
pie
didce
nt
not
raice
gs tand
. hat.wh ile i was t ryin g to ha ndle t he
twin
move atgrow
05
i foun
d iner
the lofrom
ck function
working
onbthe
pread
er b
ut
ju rst
ealand
Experien
ing
stake
ign
ce:
alplace
app
2 years
eared
thement
s pread
h ead block
b, s ller
o i asked
for me
th e an
engineerin
g
In which
hou
ccid
? at thon
I was
dischargin
a s in
gle
conta
un der dwasn
eck , t
b ut
it was a
lin ds
point
for
me
an
dthth
I ehad
nt ent
d eck
cont
roller
is mo
s oer
I called
wh arflam
co ntro
to guide
d he res pond
as sis tance, after
enginee
g team
arrive
d they
as ked
main
e ter
o try
er twin
but
thaultin
t hespsam
e pr rob
lem
hap
pen
b ut in
t here
were
o con
on the
e last
in
my
.t i found
immediately
, Aftethr eI had
h oisrin
t down
sa fely
and
g et the
cont
andag
hain
ois ton
upan
,Th
Ioth
found
ah our
b ig
smafte
okershift
res
g from
reade
right
s ea
sid
e wire,
soaIddition
st opp ed
imme
diatn
ely
andtrol
called
th e
I spreader
was liftin g
and
twin
also
move
thesreinwas
05 A
no54
hotist
hen
u p,
YSsVoin
the
formed
en ginme
eering
to shift
te am
t oward
took the
b aycont
78 ma
on
rol th
aneenan
dsame
made
a am.
byp
aine
ass
r blo
to b
ckring
in order
po we tr oagain
lift two
to 40
sp read
fee ter
con
and
tainers,
a skedbme
ut th
toere
bring
wast he
a pro
sp read
blemerwith
to th
thee
int
ce cont
te
s pre ader a s it wasn t fu lly op ened
q uays
on ide
40 feet
in orde
mod
r to
e so
in spect
i presse
it . d
Ththe
en 2
the
0 fe
wh
etarf
mode
co ntro
an d
ller
mad
told
e ame
reset
thatfor
t hey
t hehad
sp read
t o replace
er fun ctions
t he spreade
a nd presse
r with
d an
theoth
40erfeone
et mode
.
b utt on again after t hat th e
sp read er was working well, afte r finish liftin g both con tain ers i m oved ba ck to bay54
a nd
st sleep
art t o well?
h and le the 1 st twin move and aft er lift ing t he move for met er I s tarted to ad jus t the
Did
you
cont ain ers s tack p osition o n the sys tem s cre en. After i n oticed wh at hap pene d i found bYes
oth 2 0*2 an d 40 lam bs on th e con sole blinking inte rch ang eably t ill t he twin lamb st opp ed
b lin king an d 40 mode lamb persisted .
At an y t ime th is fau lt hap pen s?
Be fo re lifting thIt
e wa
twin
s at
momy
ve was
second
thehtwin
our on
lamb
theon
cran
thee.cons ole blinkin g?
I cant rem ember, b ut i am su re th at i pres sed o n somet hin g on th e con sole b ut what wa s it I cant reme mber.
D id you complain from any previous fau lts on the cra ne before t his fa ult ?
W hen you were
N o,lifting
it watwin
s themoves
fi rst fau
inltt he
th at
first
haptime,
pen ed
wadu
s the
rin gtwin
my wo
lamb
rkinognhou
thers.
cons ole working?
Ye s, I am sure it was working.
Do
Didyou
yourrem
colleag
ember
ueifinfo
you
rmpres
you
s abo
th e ut
t win
any
buproble
tton on
m the
withcons
th eole
spreader?
or n ot?
I am not s ure t hat if i press ed No,
the he
t win
bu tton
not,
bu
i rememb
at i th
presse
d the 4 0
ft ernotice
sh iftinan
g toward
feet ab
bay,
bu t laft
er iit.
fin ish ed han dling b oth 40 feet
didnt
tellor
me
abo
utt any
probleer
mth
with
e spreader,
anfeet
d alsmode
o i didant
y t hin g 40
looking
norma
with
con tain ers a nd moved b ack to ward twin bay i foun d the twin lamb o n the cons ole blinking bu t I ca nt rememb er if I p ress ed on it o r not .
How many moves yo u made be fore the last on e you was trying t o hand le?
Firstly, i st art edtoDid
discharg
yo u cheeck
on th
deck
e t win
then
la mb
o pene
on dththe
e s pre
ha tch
adercovers
o r ins an
idedyou
dis ch
r cabin
arge db abou
eforetliftin
2 tiers
g the
& htwin
alf till
move?
the fau lt ha ppen ed.
No i didnt, as i was h urry a nd dep end ed only o n the twin lamb on the cons ole.
Tell m e abou t the way you work in sid e the un der d eck?
I mad e a t rolley toward cell guide and lowering my sp eed th en se
ttle
Did
d the
yousnot
pread
iceerthe
s easide
twin sta
ontus
th eb cell-gu
y you rside
elf p
orad
what
and? ma de a hois ted d own, before ap proa ch ing t he co ntainer i s tarted
No, tru ck driver wh o informed me, that i h eart h
o islower
yellint he
g from
hoistbelow
sp eed.
a s i was co ncentrating on th e syst em screen .
Did you mad e any sud den move
What
withdth
id eyou
spreader
d o a ft er
o ethven
at? hit it at any pa rt of the ves sel?
N o, iI was
s tartfollowing
ed hoist ing
th ed n
own
orma
stel operational
p by step o npthe
rocedures
truck aand
nd i ifoun
d idndtsp
hit
reade
an y rpwide
art from
ly open
theed.
ves sel.
W hat are t he st
anda
Is t here
rd proce
was adure
d eck
s con
controller
ce rning with
han dling
yo u on
cont
the
aine
b ay?
rs for d is cha rging?
Firs tly, I too k th e tru ck nu mber a nd place dNo,
it on
i did
th ent
syst
notem
icescreen
a ny one
, anand
d then
alsoi isd
tarted
idn t at o
skhfo
and
r any
le the
help
cont
asain
th e
erbay
by lift
con
ingditition
forloaoked
little gdood.
ist ance from th e t ruck and ad jus t the cont ain er
s tack p ositio n on the s ystem s creen and con firm st acking th en mad e a fu ll hoist up and directed t oward th e bay.
Kindly d escribe th e way you ap ply to g et out from und er deck?
I was lift ing o verload twin moves soHow
t hatdo
i ha
you
d tot hin
hoist
k thitisuinciden
p till the
t cou
cell-gu
ld be
ide
a vo
paided
d then
in futu
i s tarted
re? t o m ade trolle y to ward qu ayside.
Amr Sh orb agy

Hat em Hos ney
Ramz y Ma her
Ali Adel
Op erat ion s: Ade l Kha dr

E ngineering : Ahmed S alah
H SE: Ahmed Karawia
Operatio ns: Hat em Hosn y

Eng inee rin g: Mo taz H ewlah
H SE: Ram zy Mahe r & Ali Adel
possible 3* sevirity 3 = 9
Possible (3) X Severity (4) = 12

TR drivers mus t ch eck TT leg s upp ort b efore driving and inform T R
s upervis or abo ut any de fect in the TR.
Provide additional D&W controllers to be with each QC operator.

Add th is case to TBT reg ard ing : All S upervis ors s hou ld follow t he traffic
rule s ins ide t erminal re gard ing d riving s peed n ot to exce ed: 25 KM /H.
Add t his cas e t o TBT regardin g: All Sup ervisors have to make a pre -task
ch eck at each time the y h ande d over Ops- PUs amon g them selve s
wit hin t he working sh ift in ad dit ion t o t he normal in sp ect ion be tween
s hifts in ord er to discover s ources of ha zard b efore it b ecomes risky.
1 Ad d to all D &W con troller TBT to inform t he ENG t eam full deta ils
ab out an y circum stan ce s take place before s tart hand lin g any fault .
2 Add to all QC ope rato r TBT never h and le any sp read er st uck be fore
arriva l of E NG te am.
Ad d to th e T BT t hat call th e deck cont roller if an y a bnormalities

hap pene d
wh ile ha ndling t he containers sp ecially in the blind areas .
Add t his cas e to TBT a nd highligh t tha t RTG op erat ors m ust b e m ore
at ten tion d uring working o n bays an d make s ure t hat th e RTG po sit ion
is right b efore st art ing work ( che ck & dou ble check) als o wh ile making
trolle y an d ens ure th at th e h ois t in sa fe level be fo re makin g trolley.
Sen t the involve d operator to training de partmen t fo r reas ses smen t.
Ch eck list for t he crit ical points o n the sp read er/ head block to be
formed by ENG & OP S depa rtm ents t o ch eck the s prea der eve ry hot
seat chan ge for th e wh arf controlle r
Possible (3) X Severity (3 ) = 9
Op era tion s: Moha med Adel

E ngineering : Ahmed S alah
Likely (4) X Severity (2 ) = 8
Ops
OPS
October 4, 2013
Opened
Salah Abd Elaziz
wating
closed
mohamed el araby
October 2, 2013
Opened
Salah Abd Elaziz
10/15/2013
New
mohamed el araby
October 4, 2013
Opened
Amr Rashwan
07/10//2013
CLOSED
Amr Rashwan
Ops
Ops
EN G & OPS
Amr Rashwan
Closed
Salah A. El-Aziz
Opened
Ehab Zahran
20/10/2013
27/10/2013
New
Amr Rashwan
1- Op s
2- Op s
3- EN G
1- 21 /1 0/20 13
2- 21 /1 0/20 13
3 - Waiting
New
Amr Rashwan
*Rea sses sme nt to be d one to th e RTG

operato r spe cially on t he reefer con tainers hand lin g in struction s
*Ad d this ca se to th e TBT an d highligh t the im portance of follo wing t he
pro ced ure s and mu st check t he unp lu g syst em firs t
*A s urvey on the p hone s of a ll RTG s mus t be don e and s elect the d efect
ones t o repo rt it t o t he TPM s ystem for repairing.
1- ops t rain ing

2 - ops
ops +engineerin g
1- waiting
2- 21 /1 0/20 13
3 - Waiting
New
Moahemd ElAraby
Add this case to TBT: highlighting the necessity of reporting

any accident happens immediately, in order to define the root
causes and to get the required corrective actions to prevent its
re-occurrence.
OPS
10/25/2013
New
Ehab Zahran (Acting)
Ops -Training
2 3-1 0-20 13
Ops -Training
2 3-1 0-20 13
Add th is case to TBT an d hig hlight t hat: QC op erat ors h avent to

increas e their ho ist s peed wh ile dischargin g und er deck and p ay m ore
att ent ion in cas e o f cont ain ers fou nd to b e improperly sta cked and
arrang e the ha ndling p rocess with deck con troller.
1.Send the In volved RTG ope rat or for re asse ssm ent.
2. Repair defe cte d Twin act ivat ion bu tton on the cons ole.
3 . Add th is case t o T BT an d hig hlight t hat : RTG operators mus t pay
more atten tio n while a ctivating sp read er twin mode by vis ual
in sp ect ion on t he sp reade r and b y n oticin g twin a ct ivation lamb on the
s pread er or in th e o perator cabin.
E NG
1 2.10 .2 013
Opened
Su rvey to be d one for th e safe gu ard of th e p ulley of t he hoist wire

Add t his cas e to TBT and in form our operators ( Cran e operator , D eck
and wh arf controlle r )to report any hit or abn ormalities to EN G tea m
Op era tion s: Moha med Adel

Eng inee rin g: Wa lled E l-fou ly- E l Zohery H ass anHany Mag ed
Ops
Mng.
0 3.10 .2 013
OPS
1 0.10 .2 013
OPS
October 15, 2013
Ops Train ing
1 2.10 .2 013
E NG
1 1.10 .2 013
OPS
1 5.10 .2 013
1-OPS/ENG
2-OPS Training
moving I found ENG PU 04 coming in same lane so I reduce my TR speed till PU Driver deviate into main drive way and let me continue ,I continue forward then I
After p res
sin g twin
i haveint oorder
che ckto
wheth
er thmy
e spreader
twin mod
e was
act ivat ed on th ethe
s pre
ader
o r behind
not b y visual
ins pection
before
ma king an
y moIvement
stopped
to comman
reversedback
adjust
trailer inside
the
lanereally
but unfortunately
PU
was
me and
I stopped
reversing
after
noticeaitnd. not t o
de pend on the cons ole la mb alon e.
you
mirror
back ?378 3
Witne-Did
ss Pers
on:check
Name :your both
Amin
Atefbefore
Amin you reverseID:
es I did and it was clear
before
I moved
Dep artm ent: Y
OPS
Position
: TR
Driver ( T.rade mar)
-Did you have guide
while
reversing?
Exp
erience:
6 mon ths
No,
Kin dly explain

whatwas
d o you
know
t what
-what
your
TR abou
speed
? h appe ned?
I was han dling twin move from QC 0 8 and directin g toward yard in 05 A 5 4, a ft er enIt
tering
e ranslow.
ge i st art ed to adjust t ru ck pos ition on th e rang e and fou nd RTG 43 app roaching comin g
was th
very
fro m t he sam e b lock, afte r RTG s topp ed, the op era tor ho ist-Do
ed down
he sp reade
r and ma
a lock o back
n the conta
iners,
while?hois tin g up i was t urn ing my ba ck and m y h and was on t he
you thave
instruction
todereverse
without
guide
whee l i found a s tra nge th ing that t ruck was movin g forward and b ackward so i presse d the ha nd brakes and yelling and t here was a noth er truck d river beh ind m e fo und h im yelling t oo.
Reversing with guide Only under QCs.
Aft er th at i rele ased m y s eat belt b uckle and jump ed from th e cab in th en I foun d RTG op era tor h oist ing d own th e t win move s tep by st ep and a sked my frie nd to in form my Tru ck SV.
-if the same scenario repeated with you again ,what will be your response ?
I will
reverse
without
guideiner
. from the t railer?
At any time you sho
uldnot
m ove
aft er lifting
the conta
-What suwas
your
schedule
time
When I became
re that
conrotation
tain er was
lifted for at
1 othe
r 1 and
of
meaccident
ter i b egan? t o m ove.
Last two working hours in my first day shift.
N/A
Root Cause
Mohamed Seif
Moataz Hewella
Mustafa Fathy
Possible 3* Severity 1 = 3
1-Prohibition for all SCCT PUs to wait in standby lane & use
designated parking( at M-Block) .
only in case of heavy tools required they should confirm with
wharf controller before discharge their tools then wait in MBlock
2-OPS Training to Issue RA for vehicles reversing back
W hat was th e height of th e twin move wh en you were preparing t o leave?

It was at ab out 2 or 1 and met ers h eig ht.
TR Reversing back without clear vision (PU was at blind point while TR adjusting his
position )
Wh en th e t win was lifted did you not ice anyth ing lookin g abn ormal?
Person:
Alifrom
ID:th e0085
Yes,Involved
I found t he
twin lifted b ut2-Name:
it wa s still Antar
se ttledAhmed
on trailer
midd le.
Department: ENG
Involved Person:
I was loading on deck of M/V
140
October 13, 2013
16:00
Red
TRA
TR 26
Trademar
Du rin g TR26 lo cat ing u nde r RTG 21 for RTG glass was hing equ ipm ent to clea n RTG2 1
cab in glass , the was hin g equ ipme nt hit the ree fer st and an d the re lated cab les .
People cause:
Lack of attention as the TR driver though that the TR was loaded by reefer container
not the glass washing equipment.
Position: Forman Electric Tech.
Experience: 9 Years
Name:reeferAhmed
s tan d. Khalil El-Sayed ID: 804
1- From whe
re did you enter to 05
G Lower?QC Operator
Department:
Operations
Position:
In drivin
volvedg Person
Nam e: 0
Diaa
Mohr amed
mel
- I was
my TR :b etween
5 Lowe
and 0 Ka
5 Hig
her ID
an: d20
0505
Lower.
2- So why did you en ter th e 05 G Lower
wit h the op pos6ite
directio n?
Experience:
years
Opain
s er, and I forgot
Pos
ition:
RTG g
opthe
era
tor hin g equ ipme nt.
- I t houg ht th at I haDdepartme
a reefernt:
cont
I was
carryin
was
3 - D id you work with th e RTG cabin s g las s wash ing eq uip ment b efore?
Maersk Kentucky then
i noticed something
like grease on the
left/land side hoist wire rope, after
- No, it was th e firsEt xperien
time . ce: 19 d ays
that i asked the wharf controller in
inform
team or
toan
check
wire status.
4 - Did yo uorder
workedtowith
OOGEng.
co ntainers
y e quipmen
ts with prominen ce?
I went to 0 2G3 0 as it a ppea red in t he tower screen an d when I reach ed th ere,
the
ree fer
techn
wasind M
own
- Yes,
many
times
buician
t it was
ike.the re, a nd while I wrote t he num ber of th e TR t o con firm it , he s hout t o me
an d wave that t he reefe r co ntainers in 02 G3 0B1,2 were ok and wave
to5 me
t oward
th eeyou
reefer
con
tain
ersned
of 0
2G5
4 were ok. An d there wa s TR 1 14 was waitin g in th at add ress , s o wh en I
When
- How
exactly
did you
did
nter notice
the
men
the
tio
wires
block?
defect?
fi nis hed a t 02G 30, I went t o 0 2G 54
d whIt
ile
I hea
hois
e mirrors
reefer con
tain
er from
0 2G5
4G 1hour
,t
he reefer
with
his back
with h
orn
formed
me to sto p, t hen I s topp ed bu t
- Ian
adjust
t he
dt up
by
the
asof
I carry
a ree
fer conta
iner
,on
forg
ottech.
tha
tcame
I was
carrying
th e washing
eq
uipin
ment
.
was
at
theth
beginning
my
1st
working
the
crane
(after
loading
2u pmoves).
after
cu tting
th e cab
le. el Kh alek ID: 12 35
Involved Person
: Nam
e: mind
Abd
el
Razik
Abd
6- Wa
s your
b usy
with
a ny
thing?
- No,block
it wasinto
cleaany
r.
Did
you in
hitlothe
spreader/
head
froma vessel
structure?
1- D id you
checked
ad
(u
.) that
tition:
her ree
feer part
co
ntainer
t 02G 54G
1 was un plu gge d?
7- sys
Whtem
at
Dep
was
artnplug
your
ment wo
:sys
OPS
rkin
Pos
g hou
in th
RTG
incid
ope
rat
entortime?
No,
absolutely,
i was as
loading
onth
and
there
werent
any
to me
(as
i was
loading
by
sequence).
- No, I didnt check t he syst em
becaus
myworking
training
p eriod
on
e
RTG,
they
to ldisme
t he
but drivers,
to be
more
s ure
check
with
e reefer
-eI in
was
a TR hea
ddeck
driver
as
t here
no check
rota tion
fosyst
rblind
theem
hpoints
ead
they
are
working
b y th
reque
sts . t ech , s o t he ch ecking wit h the reefer
t ech. was e noug h to
me.rie nce: 2 yea rs
Expe
2 - Was
tthe
he receive
reefer
unp
s at
ys.
Work
erly
in
RTG
11 ?2 nd
Did
your
previous
colleague
inform
you
about
defect
inTT
the
spreader/
head
block
wire?
I took an order t o loading fro m 0 5
A7
5 Sin
gle twin
as normally
we
tyou
1s
t single
winany
e end
of
69
an
d NO
the
single
twin or
at thoist
he head
of TT, I lift ed th e 1 st s ing le twin from
Dpu
id
a ptlug
re-sh
ift th
safe
ty prop
talk:
YES
- Yes
,tell
b Iutwait
I didnt
eanything
it, I co nfirmed
with
reeTR
ferdriver
tech.
fox 2 nd tier an d sta r to hoist do wn it on th e end of TT No,
69 be
fore
lan
ded
abouus
t3
second
toconcerning
ch eck
witthe
h the
t he block.
con tainer p osition b ut he d idn t mo ve s o I pu t it th ough t the
he
didnt
me
about
wires
or
head
D
idntyou
re ceive
phre-s
hift
sa fe
ty d
YES
NO
cont ain er in righ t pos ition,
then
to brin
g theainan
othe
an
putinvo
it in
th e head
r this TR leave th e bay .
D id
youI we
receive
tra
ining
ow
t or one
do
the
ttalk:
ask
lved:
YE Safte
NO
Did you receive a pre-shift safety talk:
YES
1- Add to th e TBT t he imp ort ance of

giving m ore att ention while drivin g the
equ ip ments with promin ence.
N ader Helmy
Moh amed El H adidy
Ramz y Ma her
Possible( 3)* Severity( 2)= 3
2- In struct all Ops S Vs t o avoid Was hin g the RTG s cabin s glas s in t he
reefer st and s blo cks
3- Put tin g a reflective tabs & paint the RTG ca bin s g las s wash ing
equ ip ment b y s hin ing colo rs (ye llow & Bla ck)
NO
D id
rece ive
training
h ow dures
to do th
e t ask to
invo
lved:
Are
yoyou
u aware
of the
rules in
/ proce
related
t his
work:Y ES
YES NONO
Did
you
in
how
to
do
the
task
yo
u
aware
oftraining
rule
s
p
rocedures
related
tPPE
ogtinvolved:
his
rk:
YEYES
S
NONO
-Are
Are
t he
TR was
in
th e
rig
ht/ wearin
po
sit ion
while
loa
din
the
1 stS
conta
iner?
Ifreceive
required
, the
were
you
g the
correct
: wo
YE
NO
Yes, I tho ugh t that .
If requof
ired
, were
you
wea rin g the correct
Y ES
NO YES
Are you aware
the
rules
/ procedures
relatedPPE
to: this
work:
141
October 16, 2013
4:22
Red
RTG
RTG 11
RTG 11 lifted u p co nnecte d reefer u nit PONU4 815 98 5 from 02G 54 G 1 wit hou t any
n otice to ou r side tha t cau sed t o d amag e o n ment ion ed socke t.
141
October 16, 2013
14:00
Orange
QC
while CQ 05 was loading on MV MSK KENTUCKY, the crane operator note

some sneaked in the wire , vessel supervisor asked him to stop operation
immediately to check wire status with eng team whom advice that there's
damage in hoist wire and the crane get out of order.
People cau se:

Lack of experien ce.
Immediate
causes
No t fo llowing th e procedu res fro m
t he ope rat or
side who didnt check the un plu g sys tem.
Mis com munica tion b etween t he reefe r tech. and th e RTG op erat or.
Left/Land side hoist wire rope damage, dent in the guard of left/land side pulley.
Underline causes
Unreported damage.
Root Cause
People cause:
Rough handling procedures during normal operations.
Immed iate caus es
20 cont ain er no. MRKU 91 446 82 fell d own after b ein g hit b y an oth er conta iner wh ile t rainin g.
Underline ca use s
October 16, 2013
15:00
Orange
RTG
57
During training with RTG 57 the trainee hit the unit at E4 and the unit was fall
down causing damage as dent in the right side, dent rear bottom rail, dent
rear top rail
Peop le ca use:
RTG ope rat or mis s-calculated t he safe h eigh t while t rolley backward.
Roo t Cause
Lack o f expe rie nce:

RTG operator s till in h is train ing p eriod (s pend o nly 5 days in train ing ).
Immediate caus es:
144
October 21, 2013
21:30
WHITE
RTG
20
Wh ile loading th e sub ject co ntainer on the TT6 9

An d due t o t he truck wro ng pos itioning un der t he RTG 2 0.
And t he RTG op era tor p oor decis ion .
The co ntainer s eate d on th e t railer s harp edg e cau sin g small hole in the p ipe .
D amage in con tain er p ipe an d cargo lea king.
Und erline caus es: -T he TR wa s incorrect p osition

-miscalculated t he right d ist ance on TT from RTG o pera tor cabin.
-Truck TT s harp edge was a b lin d point to RTG o perator wh en he ge t more
clo ser,
(BOSCER TT is sh ort ).
Root Caus e
From RT G operato r:
1 -lake off a tten tion becaus e h e heard a h orn an d didnt st op.
2 - Incorre ct followin g of stan dards abo ut han dling cont aine r tan k: he didn t wait till TR d rive r
ad jus t his T R po sit ion, and d idn t s top t he TR d river when h e saw him s poke on the cell p hon e.
Moham ed Hamd y ( Act as S SI)

Mo taz He we la
Ram zy Maher

De partmen t: Ops
Pos ition: Y S V
Direct Supervisor:
Name:
Abdalla Khaleil
ID: 290
- D id th e tru ck driver
a lert you to st op before
p ut th eVessel
con tainer?
Department:
Operations
Position:
Supervisor
NO
I heard a horn b ut afte r I pu t the conta iner and I t houg ht th at it coming from ot hers TR m oved arou nd th e bay bu t I sto pped a bout 3 sec a nd I didnt s ee anyth ing a bnormal conta in
Did he/she W
give
pre-shift
talk:
NO
henawas
t he las
tsafety
time
s poketotoAym
or witnes
sed
t heaine
invo
rso ns
work
Involved
Pers
on: you
ame:
Moha
med
Awad
ID pe
: 850
9YES
movin
gNtrolley
get
aan
noth
er
cont
r. lved
Adel Khedr
Ahmed Shawky
Mohamed Atef
Wet
nes
s: not
N ame:
Mahmo
ud
Moh
amed
IDor
:1
840
De
partmen
t: t hat
Op era
tion
sZahran
Pos
ition:
RT
Opsharp
erat
(AS
ST)
- Are
you
ice
you
p ut
th e con
tainer
on Isaa
t ru
ckGTT
edg
e?
Witness Person:
Name:
Mahmoud Hafez Nessem ID: 749
epartme
ition: the
Reefe
rTrain
Tewa
chee
.s leave
Exp
Fresh
(5 days
At the t ime which I p ut th e con tainer on t ru ck D
TT
I did ntnt:
notReefe
ice
it,rerience:
bPos
ut after
truck
I s)aw t he container a long sharp edg e.
Department: Operations
141
NO
-D id you n otice th e T R ne ed to move to ad jus tmen t the cont ain er?

yo uTT
receive
su pervision
in t heth
las
1hr
of yo
Y ES to
NO
No, the cont aine r from my ca bin was in right p osition a boveDid
alsowere
when
I h oiswearing
t down
e tTT
b eco
meur
awork:
blind YES
point
me so I wait the TR driver t o move reverse bu t he didnt so I
Iftruck
required,
you
the
correct
PPE:
NO
Ho w d o yo
think
t hisI incid
betavoid
edn.in fu ture ?
thouugh
t that
wa s ent
put could
it in righ
positio
- To check o n the ree fer un plu g sys., a nd ge t a cle ar co nfirmation with t he reefer tech.
Did you receive supervision in the last 1hr of your work: YES NO
-Dos e the me gaph one work p roperly? And wh y yo u did nt use t he mega phon e to make the TR driver ad jus tmen t the TR pos ition?
D irect
Suvery
perviso
r: so
Na Ime:
S addKam
eleElTR
Ash
ry r to not ice m e if ID
8 83 s to adjust h is TR pos ition.
I didnt nee d it, becaus e the ga
p wa s
sm all
d epen
on th
d rive
h e: need
Position: QC Operator
Expe
rietnce:
2 th
years
We were tra ined o n 4 tiers bay s tyle, and t here were
cont
erswhich
in each
row
(initEwh
, F ile
and
G ) then
i took
the lin
4
tierk con
err?fro m F row and load it on the t ruck and th e rest 3
-wh at4 is
th eain
sop
rece
ived
t rainin
g
abou
hand
g
tan
conttain
aine
We
req uest ed
un plu
g three
0 2t hen
G 30i &
0 2eHa50
& 0 2G
I u nplugg
ed 02
3 0 B14,2
I confi rmed
th einu ord
np lug
s ystem
d tafter
t hat ,RT
G 11
relcu
ach
ed,
tried
to call
t he
co ntainers
gottot ran
sferred
int olocations
the A row,
mad
trolley
to. do
th e same
by G
t aking
th and
container
in th eitGinrow
er to
load itan
on
he truck
but
i mwas
iss -ca
lat
edI so
i didnt
h oist
Experience:
8ing
oenou
perator
y t he
psu
hon
b ut
was
defect,
s out
I and
sh
toco
him
an dica
waved
h imTRtha
02 the
G
B1
were
ocast
kst
to
hyears
and
I wen
tisttodwith
02
Ht 50
B
1ro
tough
un plu
gcast
it , th
requ
d toi
gh hbeigh
t (iRTG
imIn
agin
ede
th
at
i hoisted
up abo
oute
mete
an
d made
trolle
ytobt ack,
sodriver
ithit
per
o fle,
tition,
het hen
E4slow
conta
he
lower
corner
ing
f t he
coneste
tainer
re
the
TRit
in
righ
t pos
ition
if ndotr)
mmun
te with
he
an30
dupwa
it,2corner
tile
adju
his
pos
hoiner
own,
a void
h andling
.enowe
n ew location s to discharge,
I went
t o ttly
he ifirst
henconta
a neiner
w locat
ion for
ch arging
was ap
Grn
54thGe 1con
(a ccid
entb lo
catand
ion)t,os o
whrn
ileto
I was
g oin
g toition.
tha t location I su rpris ed
held, ansdoco
nseq uen
sa won
theetE4
falling.
Then
m y t rainer
as peared
ke d me at
to 02
retu
tainer
ack
retu
pa rkin
g pos
t-Wh
hat
During
RTare
G working
11
ed
on
the
QC
re05
anddid
s se
tart
you
han
the
dle
itspreader
witho
ut cohead
nfirmation
block
into
cut
t he
ca
ble.
at
thre
e ach
sig ns
which
you
u
it to
t ohit
adju
st th
e con tainer
while
hanand
dling
sany
ing
leobject?
twin
?
No,The
at lock
all Iin
didnt
hitdle
the
block.
t he mid
of head
truck TT
.
1- In the first ad dres s 02 G30
, did
youy wave
to thha
e ve
RTG
op erat
or th at
the
reefer
cont
rs g?
in 02G 54 were u nplugg ed?
How
man
d ays you
p ass
ed since
t he
beg
inn ing
o f taine
rainin
--In
No,wh
I Itwaved
for
only
30
add
resdeck?
s.
isworking
m
y ok
forth
da
y
in0 2G
tra
ining.
ich
hour
the
acciden
t or
take
place?
Were
you
on
deck
under
2- Was th e damag ed reefe r con tainer b e requ este d in th e t ower s cre en when you a t 02G 30 ad dres s?
No,
I was
working
under70
deck.
- No, it was apKind
peared
in me
th ewh
tower
sIn
creen
when
I train
wa
at 03H
(a
ft er
m in. cont
fromain
lea
ving
ly tell
at you
ha
bheen
ed
to
wh
ha10
ndling
ers
? 0 2G3 0).
t heve3t
hour
insmy
rotdo
atio
n.ile
I ho ist ed up t he co ntainer i h eld an d in ad dit ion i t ake a sa fe h eig ht of anot her cont ain er, but wh at really happ ened wa s that : I h ois ted up a nd th e trolley was slower th an hoist, so I
uld
Didbyou
face
while
working
under
deck
like
blind
points
for
example?
as sume d that t he conta iner wo
e hois
ted uany
p forproblem
more
han
1 an
meter
away
from
E4
con
er, but
u nfortun
ately my as sum ption was in valid .
- did tyo
u
sle
pt d
well
b efore
comin
g to the
this
sh
ift? tain
No, the bay was opened anyYes
there
were no blind points to me.
, I d id
At any time this in cid ent h appe ns?
e incid
entan
hay ppen
s afteraffect
a boutyour
haour
s tio
ince
my last
rest . ?
-DTh
o you
have
p roblems
tten
n while
working
No, everythin g is ok
Technical Advise/Report:
How man y h ours do you sp end in tra ining tod ay?
I s pen
t abou
t 1 Cab
hourinsin
ce t he
inn ing of
myartrain
ing d ay.
-Does
your
glass
cleabeg
nAhmed
&provid
e
cle
vis ion?
Name:
Shawky
ID: 484
Yes, I had a clea r vis ion.
Department:
Engineering
Position: Senior Mechanical Eng.
Are
you
t rained
t onche
ckened
below
wh ile
y b ack?
- Is
th is
s itu atio
happ
with
youtrolle
b efore?
Ye s of cou rse , I was checkin g from below wh ile h oist ing u p and
N o m aking t rolley b ackwa rd bu t I mis s-calcula ted th e heig ht.
Comment:
Op erat ion s: Walid Aly

E ngineerin g: Ah med
Sha wky
HS E: Moh amed Atef
Provid e refres hmen t ses sion fo r the involve d tra inee concern in g
con tainers s afe han dling proced ure s.
No one of train ers is allo wed to st and clos ely while hand lin g pro ces s
and t o stan d in a sa fe p lace away from the cont ain ers h andled. 2 3-10 2 013
Ehab Zahran
After inspecting
head
& hoist
rope, we found the following:
-In your othe
pin ion
whyblock
th e accid
ent s wire
happ ene
There was an unreported damage in the guard of the left/land side pulley that might be resulted from a collision between HB and vessel structure.
About the wire cut, we think that it might be as a result from scratching process between wire & containers or vessel structure and it might be accumulative.
Hoist wire life span: wire spend only 60 % of its assumed working period (hoist wire recently changed at 30-08-2013).
New
Ahmed Hegazy (Act As)
From TR driver:
1- Lack of atte ntion: becaus e h e was sp eaking in the cell p hon e wh ile loading conta iner and
didnt re turn back.
2- Lack of experien ce : when h e took th e 1 st cont aine r in a wron g positio n he moved t o take t he
2n d one wit hout comm unicat e with RTG operator by using meg aph one or call h is s upervis or. And
when h e call sup ervisor a ft er obs erve d the leak h e did nt give a clear mess age to him.
3- Incorrect followin g of s tan dard s: spe aking in the cell p hon e wh ile work u nder RTG.
145
October 21, 2013
11:30
Red
RTG
41
Likely ( 4 ) * Severity (2 )= 8
146
October 23, 2013
15:45
Orange
QC
13
147
October 24, 2013
22:00
Red
QC
148
October 25, 2013
6:00
Red
RTG
41
149
October 25, 2013
6:45
Red
RTG
36 & TR 02
probability (3) * Severity (1) = 3
OPS
150
October 29, 2013
16:00
Red
RTG
42
OPS,HR
152
October 28, 2013
9:00
White
QC
153
October 30, 2013
4:00
White
QC
14
154
October 31, 2013
18:20
Red
QC
156
November 1, 2013
15:00
Orange
Spreader
15
Likely (3 ) *severity ( 3) = 9
Unreported damage I161
Likely ( 4 ) * Severity ( 2 ) = 8
Hatem Hosny ( Act as OSM )
OPS
Open
Salah Abd El-Aziz
06.11.2013
closed
Ehab Zahran ( Act as OSM)
November 10, 2013
New
Amr rashwan
13.11.2013
Amr Rashwan
Ehab Zahran ( Act as OSM )
11/10/2013
Ops
CLOSE
ABO REHAB
11/14/2013
Ops
CLOSE
MOHAMED EL HAMAMSSY
20.11.2013
Ops
CLOSE
Amr Rashwan
OPS
November 7, 2013
Closed
Hatem Hosny
Y ES
NO
Y ES
NO

D irect Su pervisor:
Dep art ment :
Na me: Ah med Es sam

Op era tion s
ID: 881
Posit ion : Yard S V
Did he/sh e give a pre -shift safety ta lk:
157
November 1, 2013
RS
during RS05 handling a container in 03L 63 F1 the unit was Sliding to hit the
wheel gird make a small dent in it
RS 05
YE S
NO
Not defi ned

Involved Pers on: 2nd
Nam e:
D epartmen t:
Moha med Anta r Ab du - Alla h
OPS - Red S hift
ID: 828
Positio n: RS & EH Ope rato r
S hift Man ager: Hate m H osn ey

Operations: Adel Khedr Eng inee rin g: Ahm ed Kh atab
HSE : Mo hamed Ate f ( Orang e Shift )
Sh ift Mana ger: Amr Ras hwan
Op erat ion s: N ader Hlmy
En gin eering: Els ayed
AboE lene en
HSE: Ali Adel ( Red Shift )
d
Probability ( 1 ) x Severity ( 2 ) = 2
As no root cause defi ned- No recommended / Corrective action
E xperien ce: 5 years

I wen t to WS for che ckin g the RS0 5 before delivered it and I s aw t hat t he left whee l rear was nt fixed , I told W S team t o fi x it with b olts a nd th ey d o so , I t ook my 1st order from the YS V
to lo ad a con tainer 2 0 feet from 02 J and aft er I h ad finishe d this move , I wen t to 03 K 42 G for lo adin g a con tainer 4 5 feet . Aft er I checked the area , th e only way to lo ad it was b y
get ting spre ader a ngle 90 bu t during t his I informed by ga te operation th at the RT G was comin g to han dle th e same cont aine r , s o I get my sp read er back norma l but wh en I tried t o
clos e it again on mod e 20 feet , it didnt res pon d .
158
November 8, 2013
20:00
Red
QC
159
November 10, 2013
2:00
Red
TRL
TR75 / TT34
Did you make any moves m ore tha n the two move s you men tion ed ?
N o , it was t he 1s t and 2n d moves in my shift .
During Q.C 02 loaded twin lift on the deck the dowell man observed that the
wire braids suddenly snatched and cut then he inform the deck controller to
stop the crane.
Sinai
Probability ( 4 ) x Severity ( 3 ) = 12
Did you face a ny prob lem while swit ch ing s pre ader from 20 feet to 4 0 feet ?
No , the sp read er was working well .
Imme diat e cau ses

- TR75 hit the cont ain er
Und erline caus es
- TR driver revers e back withou t guide .
- H eavy tra ffic .
Root Caus e
Peop le :
- Not fo llowing proce dure .
- Lake of atte ntion .
While TR75 making reversing in 07A to moving from the block, he hit
container No TTNU8038401 which caused damage in the container
D id you lo adin g the 2 nd conta iner ( 45 feet ) b efore th e RTG comin g ?

No , I cat ch t he co ntainer b y 2 corner cast ing o nly and I was trying t o cat ch th e anot her corn er cast ing b ut I didnt load it fro m t he lan d becaus e the s pread er po sit ion was nt read y t ill
m oment
.
Name : Ayoub Ibrahim tShis
alma
n
ID: 3 706 ( Sinai )
D epartmen t: OPS
Position : TR driver
D id you h oist u p the cont ain
er from
th e land
Expe
rie nce:
7 m?
onth s
No , b eca use du ring I was s etting th e spreader lock p osition with th e con tain er corne r ca sting ( didnt ho ist u p the cont aine r from th e land ) , one of th e g ate op erat ion informe d me that
RTG will came to lo ad this co ntainer s o I left th e area wit hout h and lin g the cont aine r .
I was drivin g in t he yard at 0 7A L and t here were t wo RTG ( on e o f th em on th e rig ht side and the oth er in the le ft s ide fro m m e ) a nd als o the re were the fu el TR b ehind th e RTG right
pre-sh
y tIalk:
s ide an d I was tryin g to mane uver an d pat h away betwee n the RTG Did
left you
side receive
and t heafuel
TR ift
busafet
t after
d irecteYE
d Smy NO
T R , I notice d that t he distan ce will be critical , s o I reverse ba ck again
and t ook my way after I was meas ure d the dista nce care fully .
Did you receive t rainin g in ho w t o d o the ta sk involved: YES NO
Nad er Helmy
Els ayed AboE len een

Ali Adel
Likely (3) * Severity ( 1 ) = 3
1 Add th is case t o T BT an d inform our TR drivers th at they mu st be

reverse back with gu ide .
Ops
16.11.2013
Closed
Salah Abd Elaziz
Closed
Salah Abd Elaziz
20/11/2013
New
Ehab Zahran
CLOSED
Ehab Zahran
Opened
Ahmed Hegazy
new
Mohamed Elaraby
1 - Did yo u notice an y s oun d durin g the TR hit t he conta iner ?

Are you awa re of- tNo
he ,ruTles
/ pro
ureswas
relat
edrytohig
thhis. work: YES N O
R mot
orced
so und
ve
2- Did you close you r cabin g las ses ?
If req uired,
you
wearing
NO
- Yeswere
, I was
closing
th et he
cabcorrect
in fromPPE:
all sid eYES
.
3 - D id you h ave the awarenes s abou t the p rohibit ion of reve rsing b ack with out g uid e?
Did yo u receive su pervision in t-he
las t 1hr of yo ur work: Y ES NO
No.
160
November 10, 2013
2:00
Red
QC
Imme diat e cau ses

- Damag e in th e spreader
Und erline caus es
- Sa iling wit h full s peed for the M/V ARCHIM ID IS .
Root Caus e
Org anization :
- N egligen ce 3rd party
- T he mooring ropes autom atic syst em of the s hifted s hip .
During MV/ ARCHIMIDIS was sailing with full speed from the quay side in
berth02 to be on time with the convoy , which made the (MV/CMA CGM LYRA)
moved forward and backward lead to damage in QC12 spreader while it was
working in the hatch cover land side ( under deck ).
12
In volved Person : Nam e:Moham ed Gom aa Has san Ali ID : 11 58

Direct Sup ervisor:
Name
Sa adPosition
Ashry : QC Ope rato r
ID : 88 3
D epartmen
t: :OPS
Dep art ment :
Operatio n
Exp erience:Position
2 Ye ars
: Yard SV
D id he /s he give a p re-s hift sa fe ty talk:
YES
I was lo adin g twin cont ain ers in bay 38 row 0 3 in th e hatch cover la nd side ( Und er de ck ) , an d sud den ly the (M V/CMA CGM LYRA) move d forward and fou nd my crane cabin above b ay
Operation s:Na der He lmy
Ad
/Report:
Name
amed
lham
ed Abdel
S ode
alamfromID:
36 an d the s prea der s till in ba y 3 8 , so I h ois ted up Techn
t he spical
read
ervise
from
th e und
er an: dMoh
aft er
it waAbde
s free
, I chan
ged m
40 3fe43
et to 20 fee t and switched off twin mo de in t he same
Eng ine ering:Elsayed Abo Elen een
Dep art ment: EN G - WS
Positio
st Me
chely
anical
gin eer rTh
cu rvat
ure sh
inip
t he
time
b ut n:
un1fort
unat
, t heEnspreade
hitere
in was
the baody
of the
. boo m cylinde r and t his curvatu re sto pped s pre ader s witch
H SE:Ali Adel
m ode from 4 5 feet to 20 fee t which in dicate th at th is curva ture was h app ened b efore th is move .
1- Did you not ice a ny abno rmalities or move ( Trim or list ) fro m ( MV/CM A CG M LYRA) d uring work ?
Com ment : According to t he operato r sta temen t for th e red sh ift , th ere- were
No , nt
everyt
anyhin
abn
g ormalities
was in a go
orod
inciden
co ndition
t hap. pene d with op era tor du ring his work ( he mad e only on e m ove and t he
p roblem happ ened in th e 2 nd move wh en he was tryin g to ch
2 ange
- D id you
s prea
fader
ce an
moyde
p roblem
from 45
durin
fe etg mode
your work?
to 2 0 feet mod e and after that h e repo rted t he case to WS t eam )
- No , QC was work well .
Likely(4) *
Severity ( 1 ) = 4
1.Ad d this ca se to TBT and inform ou r VSV t o repo rt to all VSV on th e

b ert h abou t any vess el makes moo rin g or s ailing du ring th e o peratio n .
2 .M ake risk ass ess ment fo r the mo orin g and s ailing p rocess for ships
Ops
In volved Person : Name : Els ayed Ha ssa n Elma sry ID: 1 049
Dep art ment : OPS Po sit ion: QC Op era tor
Imme diat e cau ses

Sp read er collide wit h con tain er
Und erline caus es
161
November 14, 2013
1:00
White
Spreader
during load on dock a twin move in blind point cause damage in flipper's
motor.
QC 12 / SQ 19
H and lin g in blind p oin t

Root Caus e
Peop le ca use
Lack of a tten tion
Exp erience: 1 .5 ye ar
I was lo adin g twin m oves us ing fl ipp ers t hen we moved t o anot her b ay t o dis ch arge 3 s ing le moves ,b ut th ey were b etwee n two rows bo th of them was 7 t ier ,afte r finish dischargin g we
moved to cont inu e load ing ,when I give flippe r down comman d one fl ipp er didnt res pon d so I in form my Vess el su perviso r and E NG te am fo r ins pection.
-la st time you us ed the fl ipp er ,Did yo u notice an y a bnormalitie s in its p erfo rmance ?
No, it was all in go od co ndition
-What wa s your h ois t down sp eed ?
It was s lowly
-Whe re was the D ock cont roller ?
H e wa s workin g with m e .
-while yo u ente r bet we en the t wo 7 t ier rows ,d id you collide with any cont aine r or you r spreader made an y s way ?
Just litt le sway while ent erin g bet ween th e t wo row with 7 tier.
-acc.to you r rota tion s ch edu le, in which ho ur did th e d amag e t ake p lace ?
Aft er 5 working ho urs .
Mo hamed H egaz y
Ahm ed Salah
M ust afa Fath y
Prob ability (4 ) X Se verity ( 1) =
N ader H elmy
Ahm ed Salah
Ra mzy Mah er
Ad d to all QC operator TBT t o give extra care wh ile en tering b etwee n

hig her t iers on dock
OPS

Ho w do you thin k t his incide nt could b e avoid ed in fut ure ?
- All T R drivers mu st follow t he in structio ns by wait ing t he RS/EH op erat or signa l to ent er un der t he sp reade r.
Direct S upe rvis or: N ame: Han y S amir
D epartme nt: Op s
162
2013112270
22/11/2013
15:30
Red
TRA
TR 47 & RS 05
Trade mar
While RS05 were going to handling an OOG container with OHF TR47 moved
froward and hit the cargo caused a damage in the cargo outer wooden cage.
Imme diat e cau ses

- Th e cargo wood en box of a n OOG conta iner wh ich was loa ded to TR 47 h it th e OHF which was
att ach ed to RS 05
Und erline caus es
- The dista nce b etween t he OHF a nd th e cargos out er box wa snt th e s afe distan ce, th e T R
d rive r ent ered u nder the RS earlie r.
Root Caus e
- People cau se:
1- The TR 47 d river didnt follow h is inst ructions b y n ot ent ering un der t he RS till the op erat or
g ive him a p ermission.
Immed iate caus es

- RTG 56 hit the g ate fence door.
163
19/11/2013
20:00
Orange
RTG
Unde rline cause s

- Gat e fen ce d oor was in wrong p osition .
- New RTG s like as RT G 56 ha s lad der b igg er in wide tha n old RTG s.
While RTG Operator make normal gantry in 05k hit opened fence door
fortunately no damage occur to RTG but door damaged
56
Ro ot Cause
Tech nology Cause :
- Inade quat e design for g ate do ors in 03 & 0 5 K.
Environme nt Caus e:
- Obst ruction.
ID : 512
Po sit ion: Op s SV
D id h e/she g ive a pre-s hift s afety talk: YES
NO
W hen was th e las t time you s poke to or wit nes sed t he invo lved pe rso ns work
Involved Pe rs on: N ame: Ash raf Abd El Az eem Akl ID: 335 5
D epa rtme nt: Op s (Camp bell)
Po sit ion: TR driver
Ad d this ca se to th e TBT an d highligh t that a ll drives follow his

in structio ns by no t enterin g und er th e RS t ill
th e o perator g ive him a p ermission by han d signal, RS horn or
microp hon e
Ops
30/11/2013
OPS & G ate se rvices
2 9/11 /2 013
E xperience: 2.5 years

I went t o 06 M to discharge an OOG con tain er, the RS was th ere an d after it attach th e OH F, it was s topp ed as s tand by pos ition, then I started t o m ove with TR to ge t und er OHF a nd I
was lo oking t o t he RS operato r and h e d idn t alarm me b y a ny horn , signa l or micro phon e and while I was en tering u nde r OH F, I he ard a sou nd of cras h I looked b ack, I saw th e d amag e.
1- Wh at is yo ur in structio n for sa fe en trance und er RS ?
- Th e RS op era tor mu st give a s ig nal by ha nd, RS horn , or m icroph one.
2 - W hy you did nt follow t hes e inst ru ctions ?
- Becaus e I saw him s top moving as a s tand by pos ition.
3- Did tha t wh at you train a bout e nterin g und er RS?
- No , I train ed th at I didnt ent er till th e RS o perator g ave me a perm iss ion .
4- D id he g ive you an y alarm even a ft er you st art t o ente r und er th e RS ?
Involve d Perso n: Na me: Ibrahim Abd El-Rahma n
ID: 19 86
D epartme nt: OPS
Position : RTG operato r.
Expe rie nce: 6 mon ths
- I was working in 05 K 64 then I made ga ntry t o 05 K 38 .
- Du ring ga ntry, I faced problem in gan try an d I calle d the EN G the n the g antry wo rked well.
- I co ntinued g ant ry again but I heard horn from sup ervisor t o stop g ant ry. H e t old me t hat I h it gat e door.
1- Can you se e t he doo r du rin g gan try?
- No, this was blind p oint .
2- Did yo u work with t his kind of new RTG s in th is p lace before ?
- Ye s.
3 - D id you fa ce an y p roblem abou t this cas e before?
- No, I worked n ormal a nd not hin g hap pene d before .
* New RTGs (from 53 t o 58) will not work in 05 K a nd ad d this cas e to

TBT fo r Gat e services, Ya rd SVs an d RTG op erat ors .
Ope rat ions : M ohame d Ade l Eng ine ering: Moh amed
H assa n HSE : Mo hamed E l-Tab eey + M ohame d At ef
Unlikely (02) * Severity ( 01 ) =2
* Make ins pection fo r all g ate fence doo rs every day to be su re th at all
doors ope ned well and s afe fo r RTG s operation.
- G ate s ervices will make this in spection in d ay s hift .
- OPS S Vs will make this ins pection in nigh t shift .
* Acco rding to ad vice from term inal s ervice s manag er th at all s uch
uns uit able g ates shou ld be redes ign ed and cons tructed sa fely to
elimina te the acciden ts.
OPS & G ate se rvices
2 5/11 /2 013
Waiting feed back from

pro ject
Wa iting
February 12, 2013
Mohamed Hamed Mohamed ID: 1285

Immediate causes
Twin container collide with cell guide
Underline causes
164
28/11/2013
9:00
White
QC
While QC 13 loading twin containers on M/V HUMBER BRIDGE location 61/63

11 10, the quay crane operator seated it on head cell guide
QC 13
Handling heavy containers

Root Cause
People cause
- Not following/incorrect following of standards/procedures
As the operator didnt stop hoist down before reach the cell guide by safe distance .
Department: OPS
Experience: 2 Years
I was loading heavy twin moves inside sea side hatch and the middle hatch was closed and loaded with 4 tiers so I have to hoist up to exceed these tiers then
enter the hatch ,while hoist down suddenly the hoist stopped and the wires make spring movement and the container collide with cell guide .which make the
damage
-What was the weight of the twin?
About 69 ton & we used to work slowly in this case.
-What was your hoist down speed?
It was slowly due to heavy load of the twin.
-after the hoist stopped ,What was your reaction ?
I switch the crane off then on and hoist up again then adjust my position using trolley and enter the cell guide.
-If you stopped the hoist before the hatch by safe distance ,does this damage will took place ?
May be yes & may be no.
-When this accident take place ?
In my second working hour
Mohamed Seif
Moataz Hewela
Mustafa Fathy
Add to All QC operators to stop the hoist before enter the cell
guide by safe distance to adjust the position
Ops
EN G De pt. to stu dy pos sib ility of ins talling addition al gu ard t o p rote ct
wire fro m g et out o f p ulley
ENG
15/12/2014
New
Mohamed Elaraby
Ad d this case to TBT and h igh lig ht th at all T R drivers mus t be more
att ention and take e noug h res t before working h ours.
OPS
August 12, 2013
OPened
Ahmed Hegazy
M ohame d Mus tafa Moh amed ID : 84 6

D epartmen t: OPS Position :QC Ope rato r
Imme diat e cau ses

Ho ist wire get ou t form pu lle y an d sna tched
165
28/11/2013
0:30
White
QC
Und erline caus es
During QC 04 discharge single unit from location 33 09 02 the wire get out
pulley and snatched
QC 04
N/A
Root Caus e
gu ard of hoist pu lle y b roke due cumulative roug h hand lin g du rin g normal ope ration
Immed iate caus es

- TR 4 3 hit T R 95 from back.
28/11/2013
166
30/11/2013
6:30
15:00
Orange
Red
Terminal Bus
QC
TR 43
El-kotby
Ro ot Cause
Peo ple Caus e:
- Fa tig ue.
During loading by Q.C 05 - SQ10 in the hold the twin box was clashed with
star board tank edge
QC 05
30/11/2013
13:30
Red
RTG
RTG 30
During RTG 30 loading a twin containers in TR 98, it stuck with the TT tails
back edge and after this the same RTG while loading another twin containers
on TR 110, the same was happened on the TT back edge
168
2013120829
December 2, 2013
2:00
White
Terminal Pickup
PU 20 & PU 21
While PU20 returned behind and PU21 is coming forward between 04 F and
05 F lead to damage in both of them
169
2013120712
December 6, 2013
14:30
White
RTG
50
On 03H 62 while RTG 50 discharging one container from truck to row F , the
RTG operator hit a container in row E lead to damage at some containers also
reefer stand.
170
201312097
December 8, 2013
4:40
White
RTG
50
: RTG (50 ) handled plugged reefer no (MWCU6922745) with no previous

confirmation from reefer tech. Which caused damage to the reefer socket at
( 02H 66 A 4 )
171
201312189
December 17, 2013
23:30
White
RTG
32
During handling reefer container TRIU8840812 to be gated out, RTG 32

operator put it on the guide of ex-truck which caused a hole in the floor of
a/m container, the hole is penetrated into the reefer unit as shown as the
attached pics.
167
Unde rline cause s

- TR 4 3 hit T R 95 from back.
While TR43 go out from inside the yard between Higher and lower, it hit
TR95\TT157 on back tailer during TR95 stopping in stop sing.
Imme diat e cau ses

- RT G 30 lande d the twin con tainers on the b ack ed ge of the TT /TR 9 8 & TR 110
Und erline caus es
- Lake of atten tio n & not following th e S OP from t he RTG op era tor
Root Caus e
- People cau se:
1- Workin g und er in flue nce o f d rug s.
Immed iate caus es

OPS PU 2 0 tru nk h it an othe r OPS PU 2 1 tru nk while d riving revers e.
172
2013121674
December 16, 2013
19:00
Red
RTG
47
173
2013122468
December 22, 2013
7:45
White
TRA
TR 54
RTG 47 handled reefer MWMU6364860 with no previous confirmation from

reefer Tech , which causes a damage to the related socket, and cut to the
reefer cabel
Und erline caus es

Wh ile man euverin g the driver did nt look at to t he ca r mirror.
He d idn t h eard t he horn due t o t he ca r wind ows was clos ed.
2-EX TR guide was small and sharp.
Imme
e cau ses
Rootdiat
Cause
D amag e to the re late d socke t, an d cu t to th e reefer cable
People cause
Und erline caus es
1-wh
Incorrect
onctEX
T he reefe r con tainer was lifted
ile it wa sloading
still conne
ed, TR.
Reefer p lug syst em did nt work
Root Caus e
People:
- D idn t followin g pro ced ure by :
1. D idn t report tha t the re efer plug sys tem was nt wo rk.
2. M ade a co nfirmatio n to the me ntioned cont ain er befo re act ually load ing it to the TR.
Immediate causes
TR54 when going out of QC11,it hit TT84 from the back side(attached to
TR141) causing damage in the front mirror of TR54 and metal broken in the
TT84
Underline causes
Lack of experience of TR 54 Driver (10 months )
Root Cause
Lack of attention/due careImmediate
of TR 54 Driver
(looking at VMT while Driving)
causes
RTG 26 operator hit the right-side reefer stands handrail while discharging 40 feet
container in 05 G 18.
174
December 19, 2013
13:20
Orange
RTG
26
After handling reefer container for discharge from an ext. truck; RTG operator
directed to load the reefer unit into the E row inside 05 G 18, but while
hoisting down the operator hit the right side (last tier) catwalks handrail
leaving a big dent in the handrail with no damage in the reefer socket.
175
28/12/2013
2:24
Red
RTG
18
During RTG 18 discharging lift twin containers as 40 ft. mood which led to
container fall down on the TR cabin
Mohamed Seif
Moataz Hewela
Mustafa Fathy
Operations: Walid Ali (Act OPS SSI)

Engineering: Elsayed AboEleneen HSE:
Mohamed El-Tabeey
H atem Ho sney
Moh amed El H adidy
M aher
Ramz y
Underline causes
RTG Wasnt correctly adjusted on the working reefer containers bay.
Root Cause
People cause:
Lack of attention: since RTG operator didnt correctly recognize his position on the
bay after making spreader side-shift from right to left side.
People cause:
Lack of attention & negligence from the RTG operator side as he did'nt turn on the
twin mood before starting to handle the twin containers.
1- HR
2- Op s
3- Ops & W S
1- ----2 - 8/12/2 013

3 - Waiting
Opened
Mohamed Elaraby
Ad d this ca se to TBT and h igh lig ht th at all PU d rive rs mu st be more

a tten tio n to his road an d t ake s ave dis tance bet ween th e ve hicle also
wh ile re vers e b ack wit h maneu vering .
OPS
25/12/2013
Opened
Mohamed Elaraby
30.000 L.E container damage 2 * likely 4 = 8
Ad d to All RTG o perator t o hois t max and g ive more at tent ion wh en
han dling in reefer range s
OPS
15/12/2013
New
Nader Helmy
Possible 4* severity (1) =4
1 Add to t he TBT the im portance to following SOP ab out h andling reefer

to all RTG op erat or an d did nt take any decis ion ne ed aut horize fro m
t hem su perviso r with out kno wledg e. Always return to your sup ervisor.
21 /12/20 13 Ops
OPS
21/12/2013
New
MOHAMED EL ARABY
Add to TBT: all RTG operators to take extra care and to be

more attention while handling the reefer container.
OPS
31/12/2013
New
Amr Rashwan
Involved
-What
was
your
hoist
down
Yasser
speed?
Salama
3708
-why
dPerson:
idnof
t work,
call tName:
he
reeh
fe
tech
us
ing
he
onbehind
th e RTG?
S tres s, and
heyou
adache
and
e rdHassan
idn
t by
n otice
thtat
thmeg
ere apho
wasID:
anePU
h im.
Are
you a wa
re of
t he rudown
les / pro
ures
relat
ed to
th is it
work:
YESTR.
NO
Normal
and
I slow
my
speed
when
I put
on the
Itced
did
nt work
-How many containers
did you
before
accident
happened
specially
Department:
-D
OPS
iddone
you
Out
inform
Source
ed the
your
(Sinai
s upe
Co.)
rvis or
Position
ab out it?
: TR
Driver on EX TRs?
If re quired, were you wearing t he correct PPE: YES N O
No and 1 reefer.
About 10 containers
- When t he reefe r tech was lat e why you did nt ca Experience:
ll your sup ervisor
y u sin g the p hone cell?
10bYE
month
D id you rece ive sup
ervisio
in th
e last
1 hr of
work:
S NO
Myslept
ph onencell
was
b roken
in you
ththis
isrtime
did
you
before
shift?
I was waiting under QC 11 then the wharf controller inform
me
to
move
for
discharging
QC
13
How- do
you
t hin
k th iswell
coucoming
ld betby
a
vo
ided
inwhich
futu re?have no TRs .I moved forward but QC 13 was going to
-In
which
hinciden
our t het acciden
take
p lace?
Yes
did
open hatch
1 . I covers
will reposo
rt an
I start
y ab normalities
moving
but
oer las
failure
unfortunately
in Itaft
he
I 2nd
hitent
the
im trailer
mediately
of the
to E NG
TR te
inam
front
. of me
In th
t hour
erequ
th eipm
b reak.
2. I will n-In
ever
maopin
de-Did
co
nfirmation
-In
before
hour
che
the
ckin
accident
g with
reefer
take
place?
ch
. aand
cont
youwhich
know
about
TR
moving
in front
youloade
?d it dinthe
your
ion
why
th
e accid
ent
t ake
place
?
and
hote
w
toof
voide
t he
futuaine
re r .
Involved
Person:
Name:
Mohamed
Ahmed
el-sodany
1263
Witnes
s:
Nasaw
me: my
M
oham
ed Ah
med
Eltawel
ID: 34ID:
10
the
Yes I2nd
,I
after
college
1st
break.
I was h arry to d one th e wo In
rk and
d idnhour
t fo llow
th ethe
insBassem
tru
ct ion
,we can a voide d it by follow t he so p.
Dep
art ment
: OPS while handling
n: this
( Elkotb
y)
-Are you
was
attention
reefer
container?
-Why you Pos
hit itio
him
?TR d river
Department:
Operations
RTG Operator
ExperienPosition:
ce: 3 Years
Yes
I was
looking
VMTther
screen
I ente red th e area 02 H18 d uring t he RTG 47 was lo adin g one of th e con tain ers
o n the
trailer at
of ano
tru ck and I stop ped u nder the cran e fo r a few m inu tes, he calle d me to ch eck th e
-Are
period
was
enough
you?
-Do you have anys instruction
your
or
OPS
trainers
tofor
monitor
VMT screen
while driving ?
ocket b efore from
lo adin
g itthe
ansupervisors
dtraining
I foun d that
t he
socket
was dam
aged
an dthe
I in formed
h im.
Experience:
2 years
No, but It is my habit to check
Yes the screen while drive .
-In
your
opinion
-What
why
was
the
your
accidents
TR
speed?
take
1 - W hen
you
a rrived
to RTG
47,
what
was
t he
opplace?
era tor
oing ?
I handed over RTG 26 on bay 18, then i started to handle
1st
reefer
container
(according
to RTG
my
work)
bydadjusting
the spreader using side-shift in both directions
He
waslow
loading
anoI ther
tain
erEX
to an
er distance
TR.
The
EXright
TR guide
small
and sharp,
mayon
bean
when
I -adjusted
the
container
on
the
TRoth
the
which
I itook
the TTand
guide
and the
container
It was
very
speed
justcon
start
moving
from
QC
13.
(left&
sides)was
as the
container
wasand
loaded
external
truck
and
the
truck
wasnt
adjusted
on
the
bay,
then
tookbetween
the container
directed
toward
the
2 - Wyour
hat ab
out
th e time
tnot
aken
t o load
you
r conta
iner? ?
was
right.
-Did
TR
front
glass
provide
clear
vision
reefer bay but while i was hoisting down- Ii wait
felt
something
haseshappened,
sooperator
iyou
stopped
for 7 or 8 minut
and t hen RTG
conimmediately
tact with m e and phoned my direct yard supervisor.
Yes .
3- Did you not ice an ything d uring you r waiting time und er th e RTG?
Acc tomovement
you rotation
,when
thehandling
accident the
takecontainer
place? from the Ext. truck?
Did you apply any gantry
before/after
- No , I didnt.
In myNo,
1sti working
at (07:45side-shift
am) in my
first day shift .
just use hour
the spreader
mechanism.
-HowPers
many
hours
you
slepttayesterday
Involved
on: N
ame: did
S had
y S haha
ID: ?
114 0
Involve
d Pe rso
n:DeNa
partmen
me:
Mot:hamed
Ebay,
Only
NG Posit
As
4 which
hours.
aad
ion Moh
: Redirection
efer
amed
te Al
chnSh
ician
ahin
e truck
ID : 11was
14 shifted?
According
to your
position
on the
to
the
ext.
ce: 8 years
-Why able
? E xperien
Ext. truck was shifted toward my right hand-side
(forward),
the
first
i wasnt
to etake
the
container
according
to my position, for that i use side-shift to
D
epa
rtm
ent:
Opas
sthin
Posmore
ition:
RTG
op
tor ou
I went t o 02H 18E 2 to rele ase th e electric wire for two
conta
iners
from
eir
s ocketprevent
s and I fou
ndfrom
t hat th
con tain
er
elect
ric wire
was
have
some
family
reason
my
sleeping
than
4era
hours
. tside conta iner bag an d after I che cked it an d the
the right side (instead of making gantryI movement)
thens ocket,
hoisted
up dand
spreader
I foun
tha tre-adjusting
the s ocket was
da mage side-shift to the left-side before hoisting down in the bay.
Was the RTG megaphone working
properly?
Experien ce:
2.5 year
1- Did you see t he RTG op era tor d uringYes.
he was loading th e ment ione d con tainer?
I went t o my a ddress on 0 1 E 46, and I fo und TR 77 was wa iting th ere, I- N

took
o, hmy
e wa
pos
s free
itionfrom
and it
s tarted
( Stan dby
to hpoist
ositdion
own
) on th e twin cont aine rs, after t he sp read er lan ded I s tarted t o h ois t up
Witness:
Bassem
Mahfouz
ID:tainer
3641
t he co ntainers and wh ile I d o s o I was confirmin g them on
2 -So,
tDhe
id
sys
youtem
tyou
akescree
aName:
lo ng
n but
time
it sud
to
den
tofayez
lythstop
e of
ment
ped
ione
an ddI was
con
making
p lace?
refreshm ent to it, a nd while that I heard a s trange s oun ds, I
why
didnt
use
it go
instead
making
the
side-shift?
looked
down a nd
I fou
nd th
e conimmed
tain
ersiately.
dCo.)
ropp ed
on t he TR
in.
Department:
OPS
- Outsource
No,
I went
(Sinai
Position:
TRcab
Driver
As the Ext. truck drivers in general are not rapidly responding to our requests.
Experience : 2 years
- D id to
youyard
n oticed
t hat th e at
conthe
tainers
wouldreach
hand le was
a twin
con tainTR
erscoming
?
I get out from QC 13 with container
and
in my1 way
,I stopped
endyou
of
back
another
,once
I stopped I surprised by TR 54 hit
Did you
recognize
the side-shift
direction (whether
itkno
was
on the to
leftwait
or right-side)
while hoisting
down?
- Yesmy
, I was
wing
trailer
. .
No i2-didnt,
it was
soe difficult
tobrecognize
while
down.
Did yoas
u turn
on th
t win mood
efore h andling
t hehoisting
containers?
Ahmed Karawia
Ha tem Hos ny
Ahmed S hawky
Ali Ad el
Mohamed Hegazy
Mohamed Hassan
Mustafa Fathy
Mohamed Adel
Wael Abd El-fattah
Mohamed El-tabeey
Mohamed Atef
QC
14
During crane operator QC14 made his pre use check before starting work , he
noticed that hoist wire land side defected
Y ES
H atem Ho sney + Nad er He lmy

Amr Ha mza + M oham ed El Ha did y
Ramz y Ma her
QC
During berth maneuver MV ARCHIMIDIS. the vessel collied with QC06 leading
to get. The crane out of rail
D irect Su perviso r: Na me: S aad Ka mel Ashry
issue date: 01/07/2011
Po sit ion : Op s SV
1-Date: will be in the form (January 1, 2009).

2-Deadline: Must identify the exact day ex. (January 7, 2009).
3-Time Of Incident: Must identify the exact time by code ex. (12:00 AM/PM)
4-Equipment Type:to be according to the standard appreviation.
Issue #: 02
ID: 8 83
NO
Last update to the sheet 05-01-2014 (please don't update any further
data)
QHSE (Wael. Haggag)
For Any update - please contact QHSE section
Notes:
New
Amr Rashwan
Amr Rashwan
OPS
29/12/2013
Open
Mohamed El araby
Ops
E NG +OPS
1 - 1/1/20 14
2 - u nde r stu dy
New
Nader Helmy
1 -Recomme nd to inst all TTD S (Twin twen ty det ect ion s ystem ), as t he
sp read er can det ect t he twin con tain ers and ne ver move till tu rning on
th e twin moo d.
Possible 3* waiting 4 = 12
NO
NO
- To provide the RT G spreade rs wit h TTDS ( Twin Twen ty Det ect ion S ystem ).
Unreported accident
D epa rtm ent: Op s
December 28, 2013
02.01.2014
30/12/2013
4- Were you b usy or d ist urb ed min d?
Did you feel any fatigue or even a partial loss of consciousness

Ho w d o yo u think
while
t hishandling
incid ent could
this container
be avoid ed (as
in fuwe
tureknow
?
that you had previous high pressure problems)?
- To give more atten tio n and look t o the
mood
in dicat
ion la mp before hand lin g the cont ain ers .
No,twin
i was
feeling
good.
6:00
Add this case within daily shifts TBT: regarding that all RTG
operators before handling their 1st move inside bays, they
should adjust their position firstly by taking the first snapshot
using empty spreader inside the bay.
Ops
OPS
- Yes, I turned it on, b ut it d idn t wo rk.
D id you
you made
rece iveany
training
in h ow
to do th e tto
askput
invo
lved:
Y ES NO
After the incident was happened, did
gantry
movement
the
container
in another location in the same bay?
Yes, i made left gantry movement as the RTG wasnt positioned properly.
December 12, 2013
Ad d this cas e to th e T BT an d informed all RTG op erat ors that t hey mus t
follow our SOP d uring ha ndling reefer cont aine rs an d they mu st
reported a ny abno rmalities and failu re in th e e quipmen t to ENG team.
1 Add to TR Drivers TBT ,Give more attention while driving and

never concentrate with anything while driving
2 Reassessment for TR 54 Driver
3-monitor
Was th erethe
an yright
d evice
show(last
th e stier
tat uscatwalk
of the t win
mood if it
work hoisting
or n ot? down?
Did you
reefer
handrail)
while
- Yes , No,
th ere
was a twin
mood
in dicat ion la mp,
ut I d
idn t
look at it.
because
i was
concentrating
onbthe
left
side.
- Yes , I was b usy on t he sys tem screen as I was tryin g to con firm t he co ntainers and it did nt work pro perly, an d I didnt give atten tio n to the t win mood indica tion lamp.
Why you5-didnt
activate spreaders zero position before hoisting down?
wha t was your rotat ion ho ur in the time of the acciden t?
I used to handle containers using side-shift option in the spreader
ofurmaking
gantry
- It was instead
my 3rd ho
on my 2n
d hot smovements,
eat chang e. and i already adjusted my position taking reefer container
in the Row-Alfa as a reference
re-adjust
position
within the bay boundary.
D idthen
you re
ceive a pmy
re-s hift
sa fe ty again
talk: while
YES being
NO
Did your previous

colleague inform you about any problem with the RTG/spreader?
No.
176
1-Follo wing u p the op erat or case as p ositive drug te st.

2-Add th is case to t he TBT and highlig ht the importan ce of:
-The importan ce of working with fu ll concent rat ion an d following t he
SOP of h and lin g the twin co ntainers.
-The cons equ ences of working un der influ ence of d ru gs.
3 -Review t he pro gres s of the project of makin g a visua l marks o n the
trailers t o be clear for the RTG operators while sta ckin g the cont aine rs
o n the TTs
Did yo u receive su pervision

- D id in
you
t hewear
las t the
1hr se
of at
yobelt?
ur work: Y ES NO
Ho w d o yo u think t his incid ent could
yes. be avoid ed in fu ture ?
-what a bout t he illuminat ion in t his place?
Direct Sup ervisor: Name
It was
: Moh
n amed
o goodH. amdy
ID: 1 298
Operations: Moha med siff

D epa rtm ent: Op
-Did
s yo u sle ep well? Po sit ion : Op s SV
En gin eering : ahm ed sha wkiy
Su mmary o fYes
s tate ment s
HSE : a hmed karawia
-Are you have anDid
y phe/sh
roblem
e give
effect
a ed
preto
-shift
you rsafety
performan
ta lk: ce
YES
while
NOdrivin g?
In vo lved Person:
Name:
Ali
Sh ahat
ass
anen
ID: 1 264
Roo t Cause
NoEl Ahm
Ah med
Abd ELaal
ed hID
: 172
5
Imme
cau ses
Peodiat
pleeCaus
e:
W hen was
-Wh at
t hewas
las tthtime
e insyou
tru ctsion
poke
which
to oryo
witnes
u received
sed t heit invo
in the
lved
t rainin
pe rsogns
? work
Dep
art
ment
: Ops
ion
:dRTG
op
- La ck of atten tio n The in volved d river wasn t a tten tion t o his road) .
S low down my sp eed while man euvering s pecially Reverse
dD
rive
, avoid
peop
le erro r, keep
a s afe
istOp
ance
betwe
epartmen
t: OPS
PosPosit
ition:
RT
G
eraera
tortor en me and an y T R u se the car mirror to ch eck th e road.
RT G 50 Operator hit cont ain er in 0 3 H 62 E 5 an d make it fall do wn and collide wit h reefer u nit s
Wetn ess
Hamed
: N/A
El Tamimey
N ame: ID: 8545
ID:
in row F
ce:it re2
2peat
years
-What is the p recaution th at you can take EE
itxperien
to avo id
ed again?
Years
N ame: Ah med Mo hamed N ageb Experience:
lgh areb ID: 132
3
ke ep
more atin
tent
eck
an
d doub le
Dep
check
art62
ment
tPosition:
he
:road
Pos
ition:
efore
move,
usring
ca rTR
mirror
allt up
thean
t ime.
I was dis ch arg ing in reefer ran ges ,firstTo
I was
h andling
03ion
H 5, 8chthen
I De
moved
to
bay
,Posit
after
I bcat
ch tOp
he
reefe
unitt he
from
,I hois
d moved trolley forward t o enter betwee n
Department:
OPs
RTG
operator
partmen
t:
OPS
: RTG
erat
Und erline caus es
I was working on bert h 02 G t hen I g ot an order
t o m ove
H ( which
in two
ord
er on
inion
bay
thin
eor
2nd
in
bay 66it sfalling
o I wa d
itown
th e reefer
t ech t o give me th e con firm ation t hat
two rows
withto
5 02
tiers
E & G) conta
b ut conta
iner
collid
eewith
th e10
lasatnd
tier
rowan
Edmake
.
Exp erience:
2 ye
ars
half
Moham ed Seif
he unp lug ged th e reefer s o I wait ab out 5 t o 1 0 Witnes
min t hen
he me:
reefer
tech
tact
with
m e in
by
ph
one
anExp
dthask
me if
I have
an o rder
in bay 10 I said yes in B tier 1 but t here is 2 reefer
s : tNa
Hadha
ycon
M ohame
dmove
Ali
ID:
E xperience:
erience:
2? years,4
mon th
-Did you
ndle
a ny
thRTG
is ba
y779
b efore
e
accid
ent
N/A
Experience:
3s ign
month
Wael Ab d Elfat ah
a bove it need t o re - H and el it to t ake men tio n reefer a nd pu t it onDtepartme
he Yes
EX TI R,he
call
mon
e aend
he in
s aid
wait
mySBhupervis
and
er un p lug ged th e cab le and give me th e con firma tion fo r this
OPS
Position
Yard
or naft
dis
ch
arge
unit
me
bay
2 nicia
I was g oin g to 02 H18 an d the me gaph one was nt work so I us ed th e serine
tont:
t ake
th e atte
ntion
forsa:th
e reefer
t ech
and mad e the confi rmation for row FOX and h e inform ed me to
M ust afa Fath y
reefer in bay 10 on ly after t hat I d irecte d to bay 66 wh ich I have
order
tyou
oe/Repo
dis
ch arging
on
e reefer
on Afo2r on
TR? but tID:
he A was 4 t ier s o I mus t re han dle two cont aine r again so I wait
Technan
ical
Adund
vis
N
-Did
make
pN/A
reanhan
theEX
b ay
s tart and afte r I fin ish ed this row , I s top ped for 8 m inu tes , TR59
came
er th
e rt:
RTG
dame:
itdling
was check
th e time
his
h ot sea t cha nge s o I con firme d on the m entioned cont ain er in t he row E
Root Caus e
I was
t ocoming
con
working
tact
with
at
me
02
orGgive
and
an
I ay
y
had
ss
ign
, Iawait
order
abou
to
tdischarge
10
min
with
a
nreefer
oct
con
firmat
container
ionIsth
I toug
hou
from
ght
hwas
e2G
was
un4plugg
Afortier
ed at
the
2,
the
reefer
TR
bay
came
66my
also
and
wait
rteunder
dhe
to adjust
lift
my
it sed
lowly
RTG
,in
IPU
moved
tshe
to
eon
tget
ime
I road
was
Ihim
was
from
my
office
to
qu
idan
e
nd pas
sed
from
04in
k tdire
ed
to
quso
ay
ide
I s aw
PU
0obay10
back
reverse
F IEX
slow
down
sp,I
till
traig
ht
th ethe
recen
sta
ck
5 tie
rs
hes
ethe
rang
es,
it02
nly
I 04
ho
pinsafe
dista
nce
teed
osta
pass
ver
4 tiers
nhis
otwa
5
tiers
.sam
Imme diat e cau ses
before che ck orYes,
lo adI did
it anbdutafter
thtly
at we
I asdid
kednt
t he
TR
driver
to check
ree
fer cable
anht
d the
s ocket
for tiers
s avinagnd
time
,ist
heuchecked
it and
inform
edome
tha
t there
s damag
e , I re vers e
from
cab
in se
for
any coI TT
nnected
cab
le way,
didnt
tice
anyth
ingment
, btruck
while
lifted
itgave
t he reefe
rby
tech
call
from
t it
heagain,
mega
a nd
me tha
titthe
ree fer
socket
was to
s olooking
reefer
I tho ugh
container
t he my
wellto
s top
put
oriteking
mon
ove
the
fo rward
truck
conand
tain in
after
my
II put
bitutno
on
the
keep
TT,
Dep
re
turn
the
art
ack
: I Itdriver
rie
d to
warn
hme
im
Pos
hand
ition:
using
signs
hme
ornto
anlift
d car
lig
ht bupIthone
responded
he did
nt told
res pond
and
ed
liftim
mediately
again
and
and
observed
t ried
-What
ahe
bout
yo
ur
RTG
cabin
RTG
- RT G lift re efer wit h con nected
Plug
Th e reefer s ocket was b roken
back
tovis
staion
nd from
by pos
ition
an d and
called
YSperfo
V . rman ce ?
Peop le
ca use
d ue
to
th
e ab
plu
gbes
was
con
nected
inerformance
a void
h im
by take thein
far-righ
t but and
tbroken
herestart
was
a
cont
er
ide
mein
from
htit.side and
t. he acciden
t wa s hap
pene
d. my yard SV.
Vision
was
clear
a nd
noain
norm
alit
ies
RTGrig
p
him came and
hold
something
his hand
to
hammering
under
the
container.
I stopped
working
and
call
Und
erline
caustio
esn
-La ck
of atten
Commen t: - In cas e of h and lin g a twin cont-D
aine
rsuTh
e TRany
d rivers
was
ad jus
tin notice
g the fro
conta
on
thes fro
nt ofwrong?
the
TT,ent
while
the baworking
ck co ntainer
mu st b e a dju sted b y t he RTG o perator
o yo
have
work
re late
dyou
o that
r nt
person
pro
blem
ur att
ion while
?
-When
youaliner
did
something
1-prob
Didlems
the reefer
plug
ou
t syst
emaffect
work?yo
-Didnt follow SOP
id you wa rnashim
th eodr rivers
give hcouldnt
im sign
th
s ee
at you
it (b lin
will
d pass
poin t).
from this road ?
Root Caus e
When he out-D
from
histhe
TRinst
and
started
- No,
toyou
give
itNo
wasn
me
t . a hand
sign
to lift the reefer again.
-What
is
ruction
which
reserved
before
- The
Yes
RTG
, I u sed
operator
my car
h ad
horn
a pos
and
itive
car
dru
ligh
gthand
tes
. t. lin g any ree fe r ?
- People cau se:
Ash raf Souidy
En gin eering: Ahmed
Wh yrmat
d idnion
t yo
u inform
abouutnthis
failudre?
Wait the re efer te ch to g ive me th e2-confi
t hat
th e reefer
plu gge
and d idn t lift any reefe r On ly
Immediate
1 -Did nt follow s op :did nt ch
eck wit h thecauses
re efer tech th e stat us of th e reefer .
S alah
H SE: Ah med kara wia
-N
o a nswer
-Does your Cabin glasswith
clean
&kno
provide
clear
vision?
And
about
the
illumination
in this place?
h is
wledgsetopp
anded
check
reefe
rwhat
on
e
sneuve
yste m
ing?
th is bay.
-Why
you
didnt
till heallfin
ish ing
histhma
rin
2-p oor d ecisio n making : when t he tech la te he lift t he reefer with out ret urn t o his s upe rvis or.
3 - D id you h ave in struction
youaid
tclear
oyou
inform
ENG tAnd
eam
withillumination
a ny failu
re
or was
ab norm
alit ies in the eq uip ment ?
It old
have
follow
vision.
ins truction
the
this
bay(
? good.
I s low down myYes,
sp eed
till h-D
is PU
trunk
wasthis
st raight
on t heinroa
d and
I66)
cont
inu e move normal
RTG operator put the reefer container on the EX TR guide.
- Yes , bu
was sttres
sed
an
so Isdidnt
t hefor
case
to EN
G Itea
m. the de cision to lift it .
No, I didnt I waited
thteI reefer
ech
but
hd
e wa
late sright
oreIport
afraid
de lay
and
t ook
-Are
the EX
TR
position
was
while
you
put
it?
-Do es the scree
n syst em work ?
Yes.
D isconn ected Underline
th e power fro
m t his socket till fix.
Did you receive a pre-sh
ift safet y t alk:
YE S N O
causes
Heshaim Behairy
-Wh at was your spee d whenYe
thse accid ent t ake place?
1-Miscalculate the distance between the reefer container and the EX TR guide.
-Did you have a confirmation
on yoursp
syst
em rega rding to th is re efer ?
M .El Haddeidy
It was normal
eed.
D id you receive t rainin g in ho w t o No
d o the ta sk involved: YE S N O
In your opin ion way th e accid ent ta ke place ?
TR 54 hit Trailer TT 84
Sinai
E xperience: 6 Years
I was working u nde r Dock (discharg ing & load ing ) it was planne d to dis ch arg e 4 s ing le un its ( 20 Fee t) while d ischa rging th e fo urt h one I h eard ab normal sou nd from wires, the n the
dock con troller a sk m e to sto p as he not ice wires g et out from pulley ,we call E NG te am for in spection.
-Wh at was th e und er dock b ay s tructure ?
It was se a s id e h atch and I dis ch arge b ay 0 2 & 03 s afely th en I st art t o dis ch arge b ay 0 1 and it was clear .
-wh
ile working
you
or collide
witmed
h con
tainers
or Ves sel
ody
Involved
Pe rso,Did
n: Na
me:hitAhme
d Moha
Abo
El Wafa
ID : b20
02?
No. I was workin g un der d ock moving in sid e cell guide no po ssibility to h it th e h eadb lock a nd th e W harf cont roller was working with me an d no co llision take p lace
-Did you
from
clear o perator
cabin glass ?
Decomplain
partmen t:
OpsCrane de fe ct or un Position
: RT G operator
NO it was perfect.
Acc.
t oon:
yo ur
ro tation
,When
his Exp
a ccide
ntEla
tack
place
?hs
Invo lved
Pers
Name:
Moh
amed tAhme
derience:
Ab d
al 3
ID
: 3 65 7
mont
Afte
r 30 min
con
pairTR
or43
working
oursey)
D epartmen
t: from
OPS st arting my sePo
sitdion:
driver h
( Kotb
Exp
erience:
2 yeato
rs Zero pos ition bu t I found it not respo nding be cau se th e t win
I was hand lin g a twin cont aine rs fro m 0 3 A Lower, the n I tried to clos e the dist ance b etwee n the
twin
con tainers
cont aine rs were h eavy, s o I sta rte d to hoist down with th e t win conta iners an d before I reached to t he traile r by 0.5 mete r I st opp ed hoisting down t o give a chance for th e TR d rive r to
I was
co ntainer
09inthrigh
en It directed
t heI qu
ay.
adjus t hims elf un der t he RTG , bu t the TR did nt move an d- that
s dmischargin
ean th atgthe
TR wasin
st06
oppFed
pos ition,ttohen
con
tin ued to h oist d own to la nd th e con tain ers o n the TT, and
W
hen
I
was
driving
in
berth
06
b
etween
hig
her
an
d
lower,
I
d
ozed
litt
le
du
rin
g
drivin
g
uois
nfortun
hitbeh
TR ind
95 T
which
oppe
on to
st op
sigtellin
n. g me tha t
wh en th e land ed lam p wa s lig ht up , I s tarted to u nlock the s pread er from t he co ntainers and s tartedbut
to h
t up ,ately
t henI Iwoke
fou ndup
onafte
e ofr tIhe
Rs wastve
d todme
st op
t he conta iner wa s land ed on t he back e dge of th e t railer a nd cause a le aking o f th e int erna l cargo, I sto pped and called the YS V, th en while I hand ling ano ther twin cont aine rs, YSV
1 . Ho
ma ny
you of
were
working
ft ersin
your
las t rest
? the conta iners cargo.
informed me th at I la nded
it w
again
onhours
th e edge
an othe
r TR a
cau
g a leakin
g of
- One han
houdling
r.
1- What wa s your p rocedures while
a twin con tain ers o n a T R?
2 .tain
De:
iders
you
well
before
yo
ur work on
da y?
- W hile IIn
han
volved
dlingPerson
a twin: con
Nam
Hisha
o ns leep
themTR
M oham
I mus
ed
t coSamir
ncentrate
t he TR sid eID
a :nd11
ba22
ck edg es.
- N o,
d idn
t at
s leep
and
It his
wa scase
fatig
ue. Sup ervisor
Dep art ment
:2OPS
-I D
id th
hap well
pen ed
in Positio
n: .Yard
3-eDon
id the
you sin
form
your
supbut
ervisor
tExpe
hat
was
fa
tig
ue?
- I do concen trat
ide
ed ge
only
I d idn
t myou
ake
rie nce:
at tent
3 ion
years
t o t he back edge .
No , clos
I didnt.
3- While ha ndling a twin con tainers, s hou ld- you
e the dista nce b etween t hem to z ero pos ition?
4 -of
D
you
wo
working
h( one
oursby
toda
y?),rth
-I It
was
p referred
s tan dinto
g in
clos
beerth
it to
0 4ze
fox
ro an
pos
d ition,
the rebwas
ut ifanorequ
t happ
ire dened
wo rkI sho
at the
uldetnd
ake
thid
berth
em
as05
single
arkndallth
con
eb
tainer
eginning
of
one
be
an0
d4tha
F,Itttake
hou ght
a long
t o ret ime,
adju so
st my
I hacar
ndling
postition
hem in
ont he
th eroad
TR as
b etween
an open
t he
ed
- Ye
s. toare.
two sid e, s o I started t o back re vers e in st raight p osit ion aft er I rea ch ed to th e road
I s tart
ba ck reverse ag ain wit h mane uvering like ( S) su dden ly I no tice that I hit s ometh ing I
t win
as
ted
hey
4 - D id you
s toptped
ake tim
hat
mediately
in the train
.
ing ?
- No, bu t I care abou t finalize t he work in s hort time .
5-Did
- Was
yoyou
u ch
r ecked
min d bus
th eyroad
withwhe
in ternal
n youorrevers
ext ernback
al prob
by lems
PU? ?
- No rmal t hin gs as
Yes
I p,Irepa
d id red for ma rriage.
-D id you h6eard
D idan
you
y hsorn
uffer
alarm
fromor
annyotice
illn ess
anyanligh
d took
t coming
an y me
frodicin
m a noth
es? er PU?
- I mad e a s urgery an d took anNo
an, tib
I didnt
iotic bu t I st oppe d for 3 weeks ag o.
-you r ca r wind ows was op en or clos e wh en the a ccide nt hap pen ed ?
D id you re ceive a pItre-s
was
hift
clo
sased
fe ty talk:
YES NO
-Are there any prob lems in your mirrors an d glass ?
N o,
D Mirror
id you wa
rece
s in
ivego
training
od co ndition
in h ow
, an
toddo
the
thglass
e t askginvo
ive me
lved:
a clear
Y ES visio
NOn .
-Did you us e the car mirror wh en you st art m aneu vering?
N o , I did use it I depe
Arend
yoon
u aware
my first
of check
the rule
&sI /was
p rocedures
give m y related
at ten tion
t o in
t his
this
womomen
rk: YE St toNO
mon itorin g the work .
-What wa s your s peed wh en the accide nt hap pen ed?
If requ ired
It ,was
weren ormal
you wea
s pee
rind
g the
it less
correct
than PPE
20 :km.
Y ES NO
Unlikley 2* waiting 5 = 10
2 - All RTG op erat or mu st give m ore att ention while han dling th e t win
co ntainers in th e yard .
3-mu st in sure that t he twin m ood lam p is tu rned on before lock th e
sp reade r twis t lock.
F-03-02
Item
Date
Time Of Incident
Related to
Type
Number
Contarctor
CO.
Incident Details
Nature of damage (if applicable)
Case Explanation
Root Cause
(As per preliminary
Corrective Action
Risk Value
Action
Owner-ship
Deadline
Status
(open/closed)
New
Penalty
Code (if
applicable)
SYNERGY NO
F-03-02

Date
Time Of
Incident
Related to
Type
Number
Incident Details
Nature of
damage
(if
applicable)
Case Explanation
Root Cause
(As per preliminary
Corrective Action
Preliminary
Investigation By
Risk Value
Action
Owner-ship
Deadline
Status
(open/closed)
New
Penalty
Code (if
applicable)
SYNERGY NO
Date
Item
1
Time Of Incident
January 3, 2013
20:00
January 4, 2013
11:15
January 5, 2013
6:30
January 12, 2013
11:00
January 14, 2013
6:50
January 15, 2013
2:30
10
January 19, 2013
22:00
11
January 21, 2013
17:30
12
January 15, 2013
14:30
13
January 26, 2013
17:10
14
January 31, 2013
6:30
15
February 1, 2013
2:00
16
February 4, 2013
23:50
17
5-Feb-13
17:30
18
2/7/2013
23:15
19
February 8, 2013
13:30
20
2/9/2013
13:00
21
February 10, 2013
21:05
22
2/14/2013
17:20
23
16/2013
23:30
24
March 3, 2013
7:05
25
March 3, 2013
3:05
26
March 10, 2013
17:00
27
March 12, 2013
10:00
28
March 12, 2013
10:30
29
March 14, 2013
12:00
30
March 16, 2013
19:30
31
March 18, 2013
3:30 AM
32
March 19, 2013
1:30:00 AM
33
March 19, 2013
23:30
34
March 26, 2013
20:00
35
April 6, 2013
20:10
36
April 6, 2013
1:30
37
April 11, 2013
2:30
38
April 11, 2013
18:40
39
40
April 13, 2013
1:30
41
April 15, 2013
6:00
42
April 16, 2013
4:30
43
April 10, 2013
10:30
44
April 22, 2013
6:30
45
April 27, 2013
3:45
46
May 2, 2013
15:30
47
May 10, 2013
3:00
48
May 12, 2013
17:30
49
May 9, 2013
18:30
50
May 30, 2013
10:00
51
6/10/2013
4:00 AM
52
June 14, 2013
7:00
53
June 13, 2013
8:20
54
June 13, 2013
23:30
55
June 18, 2013
5:00
56
June 21, 2013
11:00
57
June 22, 2013
4:30
58
June 22, 2013
12:00
59
June 22, 2013
17:40
60
July,5,2013
23:00
61
July,7,2014
7:10
62
July,7,2015
10:30
63
July 12, 2013
1:00
64
July 11, 2013
8:50
65
July 11, 2013
11:00
66
July 14, 2013
13:10
67
July 14, 2013
10:20
68
July 17, 2013
16:00
69
July 26, 2013
17:00
70
July 28, 2013
13:58
71
July 19, 2013
11:00
72
July 31, 2013
22:30
73
August 10, 2013
8:15
74
August 4, 2013
1:30
75
August 12, 2013
11:30
76
August 13, 2013
15:00
77
August 13, 2013
8:00
77
August 21, 2013
11:30
78
August 23, 2013
79
August 23, 2013
3:00
10:55:00 AM
80
August 1, 2013
9:30
81
July 14, 2013
10:20
82
August 27, 2013
17:00
83
August 29, 2013
2:00
84
August 29, 2013
18:00
117
9/5/2013
4:50
86
September 3, 2013
13:30
87
September 11, 2013
4:00
88
September 12, 2013
3:30
89
September 12, 2013
13:00
90
September 15, 2013
1:00
91
September 15, 2013
14:10
92
September 17, 2013
17:30
93
September 18, 2013
6:30
94
September 20, 2013
95
September 20, 2013
96
September 22, 2013
9:00
97
September 23, 2013
15:30
98
September 23, 2013
19:15
98
September 28, 2013
7:00
100
September 28, 2013
9:00
101
September 29, 2013
7:00
102
September 23, 2013
7:00
103
October 2, 2013
1:00
104
October 7, 2013
18:00
105
October 12, 2013
17:30
106
October 13, 2013
16:00
107
October 16, 2013
4:22
108
October 16, 2013
14:00
109
October 16, 2013
15:00
110
October 17, 2013
2:00
111
October 21, 2013
21:30
112
October 21, 2013
11:30
113
October 23, 2013
15:45
114
October 23, 2013
22:00
115
October 24, 2013
6:00
116
October 25, 2013
6:45
117
October 29, 2013
16:00
118
October 28, 2013
9:00
119
October 30, 2013
4:30
120
October 30, 2013
18:20
121
November 10, 2013
2:00
122
October 11, 2013
2:00
123
November 11, 2013
1:00
124
22/11/2013
15:30
125
28/11/2014
9:00
126
28/11/2014
0:30
127
30/11/2013
13:30
128
December 2, 2013
2:00
129
December 6, 2013
14:30
130
December 12, 2013
4:40
131
December 12, 2013
132
December 17, 2013
23:30
133
December 16, 2013
19:00
134
December 22, 2013
7:45
135
December 19, 2013
13:20
136
137
138
139
28/12/2013
2:24
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
622
623
624
625
626
627
628
629
630
631
632
633
634
635
636
637
638
639
640
641
642
643
644
645
646
647
648
649
650
651
652
653
654
655
656
657
658
659
660
661
662
663
664
665
666
667
668
669
670
671
672
673
674
675
676
677
678
679
680
681
Type
Number
QC
CQ 08
RTG
39
TRA
53
TRA
47
QC
10
QC
QC 11
RTG
CR 36
TRA
TR 93
NM
RTG
47
RTG
20
Terminal Bus
OPS BS 08
RTG
CR 40
OPS white
TRA
OPS white
RTG
TRA
TR 125
RTG
RTG 32
RTG
20
RTG
23
QC
Spreader
SQ 08/ QC 13
Spreader
SQ 11/ QC 09
QC
QC 06
Terminal Bus
BS 05
RTG
RTG 25
RTG
RTG 17
Spreader
TRA
SQ 14
TR120 & TR85/TT137
Terminal Pickup
TRA
PU 10
TR 39& ENG PU 08
Spreader
SQ 22
TRA
TR 09
Spreader
SQ 15
TRA
TR 07
QC
14
TRA
129
QC
QC 09/SQ 25
QC
QC12
TRL
96
TRL
59
Terminal Pickup
10
QC
16
Spreader
SQ 24
RTG
RTG 05 & RTG 38
QC
QC 06
QC
QC 16, TR 91, TR 107
TRA
TR 32 & TT 77/ TR 113
QC
15
TRA
TR 82 & 2417
TRA
128
QC
TRA
68
RTG
19
QC
QC
15
QC
QC10 (SQ 11)
RTG
RTG 19
RTG
RTG 23
TRA
15&48
RTG
24
QC
08 (SQ 10)
QC
QC 14 SQ04
RTG
CR 26
TRA
Truck 47/ low bed 03
TRA
TR 79 & TT 98 / TR 135
RTG
40
TRA
62
QC
17
TRL
51
QC
QC 11
Spreader
QC 17
Spreader
20
TRA
TR 82
Terminal Pickup
Ops Pu 90
Spreader
SQ 08
Injury
QC
QC 13
RTG
CR 26 / CR 22
TRA
TR 61 & RTG 31
Spreader
SQ 08/QC 05
Terminal Pickup
Ops PU 40
TR
43
Terminal Pickup
Safety PU 01
Terminal Pickup
ENG PU 08
TRL
TR 98 / TT 157
& TR 58 / TT 57
QC
Terminal Bus
TRA
TR 111 TT 84
QC
QC 11
QC
QC14
Spreader
20
TRL
TT 135
Spreader
SQ 08
Terminal Pickup
20
Spreader
SQ 17
QC
14
RTG
15
QC
13
QC
14
RTG
43
TRA
78
TRA
TR 26
RTG
RTG 11
QC
RTG
57
QC
QC 09
RTG
20
RTG
41
QC
13
QC
RTG
41
RTG
36 & TR 02
RTG
42
QC
QC
14
QC
TRA
TR75 / TT34
Spreader
17
Spreader
SQ 19
TRA
TR 47 &RS 05
QC
QC 13
QC
QC 04
RTG
RTG 30 & TR 98 & TR 110
Terminal Pickup
PU 20 & PU 21
RTG
50
RTG
50
RTG
32
RTG
47
TRA
TR 54
RTG
26
RTG
18
Nature of damage (if applicable)
Two hoist wire rope
Dents at the land side right wheel guard of the RTG
TR 53 front glass damage
Ops PU 40 right mirror broken
Wire rope total loss
container damage from the bottom which

led to cargo leakage
TT121 total loss ,CR 36 right side guard and 3 containers
TR 93 stairway damage
breathing difficulties
Reefer Container Socket damage
make damage in spreader and

container No. YMLU 3150179
Dmage in OPS BS 08 engine cover
Damage for the reefer socket
front glass damage of TR71
Reefer socket
TR Cabin rear glass broken
2 containers (CMAU 524898-8 & TRLU 557556-1)
damage to the socket @02G 46F2
damage to the socket @02G 73 G 1

damage on the reefer container power cable
in the 4 Flippers of the QC & an air pip on the vessel.
Spreader SQ08 had a severe accident affected its Telescope beams
SQ11 had a severe accident affected its

Telescope tension rod
Hoist wire & pulley guard
OPS BS 05 Driver door and front bumper & containers No

MSKU 0907316
Cut in the container bottom
Damage in container No. SZLU9627592.

- Total lost for TT 141.
- Damage in pipe oil and E-room guard for RTG 17.
4 twist locks
slight dent in TT137 and broken glass of TR120

and slight dent in the chassis.
right front glass broken
Damage in ENG PU 08 front left lantern

& dent in the PU 08 back.
Flipper motor damage
ENG PU front bumper & some of engine components
spreader damage
while TR07 maneuvering in 04J27A1 Scratch container

MSKU2926465 caused cut about 10CM.
Damage in the gangway
cut with a long of 80 cm in container

MSKU7031950.
2 hoist wires +2 flipper gear box +container defected.
Hoist wire
Damage in TT96 right double rear tires & its rim.
Damage in the RTG ladders Cage & TR 59 left
front bumper and hood
K-stream gangway damage.
iliper gearbox damage.
damage on RTG 05 reng (under gantry motor) from electric

room and disel side
, also RTG 38 oil level indicator glass (under gantry motor)
Broken from electric room and disel side
HIS/ Near Miss

right side glass cabin fall down
TR 91 door and mirror holder & container door
TR 32 front glass damage & TT 77 back bumper
Container 20 TEMU 3723837

+ SQ01 twist lock Twin piston damage.
TR 82 Front Glass get cracked .

Ext.TR right side Door dented & front glass cracked and right
side lighting mark broken.
Cont. MRKU 4285420 dented & Cont. MRKU 7619351 scattered
cuttings.
TR 128 Front glass broken.

TR handrail broken & many dents in the head front
Dent in the TT35 from the right side & Damage in 2 landing
gears
Head block dented

One Flipper dented
Flipper of motor guard dented
Hand rail dented
Hatch caver dented
Cut at two containers
Small cut in the corner post of the container.

RTG Anti Collision-to-truck Damaged, Anti collision-toContainer Damaged
RTG guard sensor support damaged
RTG oil level indicator (above right gantry gear box).
Spreader twist lock
Landside & Seaside hoist wire ropes defected.
Dent in the left side of the container & container door also damaged
Damage in gantry motor fins.
Damage in the gear box guard.
Cut in some electrical connections.
Damage in the Right-Seaside Twin Cylinder Hydraulic.

Damage in Right-Seaside Twin box
RTG Diesel side ladder dented & TR muffler
Many cracks in the Front glass of TR 15.
Damage in the spreaders chain gearbox gear & chain lock.
1. Damage in Landside left flipper assembly.

2. Damage of Landside/Seaside hoist wire ropes.
Spreader twin lock damaged
Crane to truck censor
X-Ray gate Damage
head of TR 79 and TT 98 of TR 135
Damage in the Reefer Socket no.28 in 02G54-G4
TR 62 front glass broken
Dent in the 5th wheel lifting
damage in two rims and their rubber tires
four twist lock dent need to change
handrail of head block of spreader 07 which work on Quay

crane 17
Four flippers damaged
TR 82 (broken front glass, damage in front barrier, broken TR

screen)
PU front glass
left quay side flipper motor damage
Fracture in his toes & rive wound . (3-4 stitches).
N/M
may lead to serious injury
Crane to truck censor in CR 26.
damage in the Top of a/m reefer container
Gear box of spreader 08 on QC 05
damage in the PU front

left light and cut in pick up front bumper.
damage in TR 43 bumper and front glass
Broken left hand
damage in both of pick up and bus.
damage in the PU front left light, Engine hood and cut in front bumper.
Damage in the right side of TT 157 and scratch in the

end of TT 57 from left side .
Damage in hoist crane wire
2 trailer rims defected
Fire out side the crane operator's cabin
Cylinder of the spreader twin
TT 135 right leg support broken
flipper motor damage
Crack in the PU front glass
dent in TBU tension rod
Damage in sea side hoist wire rope.
Damage in 5 containers as a result of falling
Right Hoist wire and safe guard for the wire on the head block
Damage in the two twist lock pins.

Big crack in the right twin gearbox.
1. Cut in the spreader telescopic chain

2. Damage in 40 feet side twist locks
Dent in ENG PU 04
Damage in reefer stand body and a cable tray.
Damage in the reefer container plug socket

&reefer stand plug
Damage in the left/yard side hoist wire rope

Dent in the guard of the left/yard side pulley
Damage in the container MRKU 9144682
N/A
Damage in container valve, cargo leaking
Cut in the container floor cross members
Damage in left/seaside flipper arm spring steel.

Damage in the holders of right/seaside flipper.
Hoist wire
damage in 6 container fall down between 03B&03C + 1 total

loss
Damage in the container which was on the mention truck and damage in the RTG AS
Damage in container no MSKU5886772.
Damage in left/seaside flippers arm and one of large scope

fallen down in the sea.
(5 container damage(SCCT Claims) + four twist lock damage
Cut in the crane wire right sea side
Reefer Container damage
damage in flipper's motor
A damage in the cargo outer wooden cage.
Cut in two containers
Hoist Wire damage
Damage of two containers bottoms.
OPS PU 20 damage in the right spot light at the trunk & OPS
PU 21 dent at the trunk.
lead to damage at some containers also reefer stand
Damage in reefer socket at ( 02H 66 A 4 )
N/A
caused a hole in the floor of reefer container TRIU8840812
Damage to the related socket, and cut to the reefer cabel
TR 54 front glass broken & dent in TT 84 rear bumper
Big dent in the right side (last tier) catwalks handrail.
1- Major damage to the truck cabin.

2- Damages in the two containers
Case Explanation
reader stuck with the vessel, After releasing spreader from the vessel ,inspected hoist wire ropes and foun
both wires need to be replaced.
hile RTG 39 was reversing back from 06 C to 06D and TR19 was waiting to pass to quay, the RTG hit the T
while operator TT53 Entering 02G The truck slipped which lead to collides with TT90 caused damage to both TT&TR
while TR47 attached with TT30 reversing back hit OPS-PU-40 which caused damage in the pick up.
While CQ 10 was discharging twin containers from under deck, the sea side right wire rope was damaged
During QC 11 loading container No.MRKU6842313 On M/V CMA CGM MAUPASSANT Bay 17 the container hi
the cell guide head which cause the container damage from the bottom
While RTG 36 loading from Bay 33 Row F ,It Hit another container from Bay 35 Row B.
While TR 93 moving on one of new unfixed gutter covers it hit the truck stairway
uring the inspection process of a IMO container in the inspection area, 3 stevedores from TRADEMAR Co
inhaled excessive quantities of vapor (Leather Glue) and were transferred to SCCT clinic suffering from
breathing difficulties. Two were treated for first aid at the SCCT clinic with oxygen/fresh air and released.
he 3rd worker, (Mohamed Abd ELfatah Ibrahim ID 6422), because he had chronic sinusitis, was transferre
y SCCT ambulance to Port Fouad General Hospital for more advance treatment, direct oxygen therap
He was later released and declared healthy.
RTG 47 HANDLED GESU9457559 from 02H 14 G4 without previous confirmation from reefer
RTG 20 lifting the twin as 40 without calling twin bottom
While bus 08 was moving from the Qside

to muster room parking he colllides with
TT 16 attached to TR05
RTG lifted up connected reefer without any notice from reefer technician.
During the operation between QC 11 QC 12 when TR 14 comeback hit TR 71 make damage in the front of the truck and the glass broken .
RTG 47 HANDLED GESU9457559 from 02H 14 G4 without previous confirmation from reefer
he TR driver reverse to adjust the truck under the container with careless way leading to move the truck t
the container
While RTG 32 loading from 01H bay 10 hit container which located in row C3 which lead to damage in 2
Containers.
RTG20 Handled connected reefer which caused damage to the socket @02G 46F2 with no previous notification to reefer Tech.
RTG lifted up connected reefer unit No. TRIU6668453
hile crane no(03) loading one container on bay 26 row 10 under deck the four flippers didnt rise up ,it hit air pipe caused
damage.
Spreader SQ08 had a severe accident affected its Telescope beams
andby team received call with twin up fault , after change Spreader, received at workshop ,noticed that SQ11 had a seve
damage in its Telescope tension rod
During loading under deck the wire stuck in a small ladder (vessel structure)
While Bus NO.05 moving in the road of 01J the bus driver slept in the way and hit the containers No MSKU 0907316. whic
located there.
While RTG 25 is loading container NO.PONU0627104 on T 123 the container stucked on the trailer
While RTG 17 loading reefer container No. MWCU6580302 From Bay 03 H 58 Row F 01 , It Hit Another
Container No. SZLU9627592 From Row A Which Lead To Damage (Big Dent ) In TT141 and fallen container
RTG 17 out of order for eng check.H39
hile QC04 SQ 14 was handling on CMA CGM CORNEILLE @bay62 ,the operator lift twin containers while th
spreader was in 40 feet mode
TR120 collided with TR85/TT137 causing slight dent in TT137 and

broken glass of TR120 and slight dent in the chassis.
Eng-PU10 right front glass broken due to

falling wrench during tightening CR41 operator cabin bolts
While TR39 attached TT142 doing maneuvering behind QC14 hit Eng-PU-08 which was waiting in waiting
area.
During loading a container, the flipper hit the hatch cover in blind side
While TR09 was moving between 02 lower & Higher to get quay side,he notice his colleague coming from
quay side ,he stopped to talk with him. and while reversing back he hit ENG PU 01
While QC11 disc on M/V ALABAMA the twin box hit corner cost of one of the remain on vessel while vessel moving.
while TR07 maneuvering in 04J27A1 Scratch container MSKU2926465 caused cut about 10CM.
During crane 14 making gantry and pass the gangway To complete cargo operation the vessel suddenly moved caused
damage in the gangway.
While TR 129 reversing back, it hit the container MSKU7031950 located in 03L55A1
During loading under deck of bay 24 the container set on the left cell guide due to the cell guide has gaps "created of two
separated peaces"
ring normal operation on QC12 we received a hoist BDN call ,after check we found hoist over slack and during handling t
slack the wire stuck under head block door causing damage for the landside right wire
while TR 46 was making maneuvering between the waiting area and the beginning of the Mike area ,the right rear tire
ploded, then the TR was moved to the Mike waiting area on the metal rim directly which also made a damage to the me
rim.
While RTG 07 make gantry in 05 C hit TR 59 mirror by ladder from cabin side
During one of Eng. Team was driving PU10 he felt drowsy and collided with concrete barrier.
After finishing operation, MV K Stream Gang way was hit by CQ16 while moving gantry
while QC12 was discharged from below

deck,spreader 24 stuck with cell guid
crown caused damage to filiper gearbox damage.
while RTG 05 gantry Hit RTG 38
During operations we found the right side glass cabin fall down From Q.C06 in truck lane 02.
During discharging twin left on truck 107 hit an empty container on truck 91 leading to fall down on the first
while TR32 getting under the crane he hit TR 113 in the in TT77 which caused a damage in front of the truck and the
mentioned tail.
While crane 13 load twin container on bay (61/63)U, the loaded container on bay (63) was stuck in the vessel tank
82 hit an external truck (2417 ) while it was maneuvering to get out from 02 C 02 at the wrong direction lead to shift
external truck strongly toward 02 D 02 containers block and hitting the container at the A raw.
New subcontractor trainee while training hit TT 35 by TR 128 (training TR).
ile QC05 discharging from sea side under deck bay 54 MV CMA CGM MUSSET in blind point spreader was stuck in center
the hatch cover.
ile RTG 18 was crossing in 03 C from lower to higher container blocks it suddenly hit reefer container loaded on TR
ich was trying to pass quickly toward the Quay side before the RTG crossing over.
While RTG 19 discharge twin in truck 145 he Lift Twin Container With Spreader On 40 Mode.
hile QC 06 was lifting Seaside Hatch Cover, QC operator found that HC was stuck from the right side and t
left side was free resulted in a twisting of Landside & Seaside hoist wire ropes.
hile QC 15 was discharging 2*20 feet containers from bay 22 there was 20 feet container was attached with another of th
discharged container (from bay 21) from below by a closed twist lock from the right side corner casting and suddenly the
below container fall down from a height and rest in between the vessel and seaside QC cell beam.
While QC Operator was loading Twin lift (in 45 spreader mode) in a blind point on bay 26 deck at seaside the middle twin
orner castings stuck in below containers and the operator tried to snatch the spreader by making a slight hoisting resulte
in a damage in cranes spreader (SQ 11).
during RTG 19 loading from 03G46C4 is fall down CTR NO.MWCU6670155 in 03G46B4 it effected heavy
damage as attached photo and need to make across stuffing.
during RTG 23 moving gantry from 04E higer to lower is deviated and hit truck 68 effected damage in RTG
diesel side ladder and TR 68 muffler damage
TR 15 with TT 38 hit TR 48 while maneuvering between 02 B L & 03 B H resulting in many cracks in the
TR front glass and some scratches in TT38.
While RTG 24 was discharging Twin move from TT 73 at 03 A 58, the RTG operator lift both
containers in 40 feet spreader mode resulting in a damage in the spreaders Chain gearbox gear & Chain
Lock.
While crane 08 was loading twin move in bay 02 (M/V Mekong Spirit) the cranes spreader suddenl
stuck inside cell guide.
While operator quay crane 14 discharging on deck bay16 vessel/crillon he informed wharf controller that
crane b.d and after eng team coming and inspection found damage in spreader.
While RTG 26 was making gantry to park beside

RTG 22, it hits RTG 22
During turning to enter the x ray the low bed hit the X-ray door which fall down.
During TR135\TT98 turning to enter birth 04 TR79 came behind it and hit him from the back
uring operation, RTG 40 operator lifted up a connected reefer unit No MWCU 6722053 located in Y 02G 54 G 4 without an
notification from reefer technician, which lead to a damage in the reefer socket.
While TR 143 was driving with low speed and give traffic light
TR 62 hit him causing damage as photos attach
while CQ17 was discharging on TR137/TT124, the container hit the trailer causing damage in the truck.
While TR33 moving in yard in 03H the left wheel was broken by it self and separate from TT51, as the
attached showing.
While QC11 disc under deck. Lift twin left as 40 mode spreader unit which cause stuck the units in cell guid
and make damage to one unit
while QC17 was discharged from below deck center HC ,Row 03 the spreader collides with SP HC
C 10 was loading twin container from the truck to the vessel and when the operator make lock, the flippe
must be up but unfortunately the flippers still down and the operator don't note so the operator loaded the
container inside the vessel under with all flippers down which lead to SQ20 all flippers damaged.
ile TR87 in the quay side slow his speed to wait TR which stopped in front of him, there was TR 82 which was behind TR
and unfortunately 82 hit TR 87
ile MV/ Sea Land Meteor was berthing in the north and vessel supervisor was going to check the bow of the vessel, vess
crew throwing the vessel's rope on PIC-UP 90
While CQ 16 was catching a container from TR, the flipper hit the container from the top which lead to flipper motor
damage.F120
ne of Eng Technicians had been injured in his left instep while he was working to change the spreader of Q
2, his left leg trapped between the spreader & the spreader support of low bed trailer causing a fracture
his toes & rive wound .
While lasher installing lashing sticker, the QC operator hit his back with the container .causing him minor
trauma at his back
- While RTG 26 was making gantry to park beside RTG 22, it hits RTG 22.J90
During handling reefer container MWCU5679137 truck 61 was moved before lifting the spreader of RTG 31
while QC05 was charged below deck ,Row 01 the spreader collides with SP HC
while YSV was maneuvering by pick up 40, he hit steel barrier which placed by Elkotby Subcontractor team to secure the
repair for HM02 which lead to a damage in the PU front left light and cut in pick up front bumper.
uring TR 43 make a Maneuvering to enter 03K . hit TT 156 attached to TR 107 caused damage in TR 43 bumper and fron
glass.
ring lasher was dismantling a short lash bar from the 3rd tier cat walk and while he get it down it hit his left hand in the top hand rail of the c
walk.
During Safety pickup 01 exit from parking hit the parked OPS BUS 01 and made damage in both of pick up and bus.
er ENG-PU-08 rear tire air pressure adjustment, the driver hit the tire workshop support beam.
fter TR 98 / TT 157 driver had charged a container from QC 12 , he made a maneuvering to exit from crowded area whic
cause hit of TR 58 / TT 57 ( tail to tail ) ( TT 157 to TT 57 )
while CQ 08 disharge from the subject vessel the crane operator note some sneaked in the wire , the
supervsior asked him to stop operation immediately to check wire status with eng team whom advice that
there's damage in hoist wire and the crane get out of order.
while TR 111 attached to TT 84 make maneuvering to get out from QC 12 the rear rim collide with the edge of hatch cove
located at back reach of QC 12
Have been informed that there was small fire outside operator cabin of QC 11.
While QC14 was discharging on mentioned vessel , Two empty containers were fallen into water due to the
spreader hit first row.
Remain on board unseated twin left which Lead to be hit by the loading twin.
, Leading to the subject damage.
while TR 134 with TT135 moving to crane 17 and cross crane rail trailer leg dented because of havey wieght of twin
continers
ring QC 06 discharge CTR in six tier with jammed twist lock, spreader hit the another CTR causing damage in flipper mo
While Yard Supervisor in duty was checking for yard operations, the Pick-Up front hood suddenly opened in an unexpected
way and pressed the PU windscreen wipers resulted in a crack in the PU front glass.
Eng Team received a spreader BDN on QC17 ,after inspection they found damage in SQ17 tension rod .
CQ14 snag fault. After inspection for the hoist wire ropes, we found the sea side hoist wire rope need to be replaced.
while RTG 15 disharge container in 05A21 E2 , it hit another container in 05A23 B4 which lead to container fall down and
caused damage in three container more
While CQ 13 discharge from the subject vessel he note that the hoist wire get outside the pulley.
hile QC 14 was discharging twin moves from below deck of M/V YM INREMENT (bay 14-row 05) the QC operator complain
at he wasnt able to make lock on the containers and after engineering team inspected the spreader they found a damag
in the two twist lock pins and also a big crack in the right twin gearbox.
hile RTG 43 operator was lifting twin move in 05 A 54 from TR 115, he lifted it on 40 feet spreader mode causing spreade
(SR 25) chain cut and damage in 40 feet side twist locks.
While Eng PU04 maneuvering behind CQ03 TR78 reversed back and hit it causing dent in PU.
ring TR26 locating under RTG 21 for RTG glass washing equipment to clean RTG21 cabin glass , the washing equipment
the reefer stand and the related cables.
G 11 lifted up connected reefer unit PONU4815985 from 02G 54 G 1 without any notice to our side that caused to dama
on mentioned socket.
while CQ 05 was loading on MV MSK KENTUCKY, the crane operator note some sneaked in the wire , vesse
supervisor asked him to stop operation immediately to check wire status with eng team whom advice that
there's damage in hoist wire and the crane get out of order.
uring training with RTG 57 the trainee hit the unit at E4 and the unit was fall down causing damage as den
in the right side, dent rear bottom rail, dent rear top rail
During operator close trolley door the

doorknob dislocated due to safety nail inoperative .
While loading the subject container on the truck.

The container seated on the trailer sharp edge causing small hole in the pipe .
hile loading the subject container on the truck, the container seated on the trailer sharp edge causing 70c
cut in the container floor cross members
While QC 13 operator was discharging 20 feet units from below deck (bay 37) in quay side (row 03), SQ 22
suddenly stuck in between seaside cell guide pad and center hatch cover, after that the operator tried to
release spreader but unfortunately resulting in a damage for both seaside flippers.
hen crane NO.05 working on M/V CMA CGM LAMARTINE wharf controller crane NO. 06 observed snatched
wire
During Rtg 41 discharge in 03 C Llower on bay 34 (twin left /first move) hit bay 38 which lead to many
containers fall down between 03B&03C
While RTG 36 moving Gantry Between 04C higher and lower hit truck 02 caused damage in the container
which was on the mention truck and damage in the RTG
While RTG42 was discharging in bay 70 twin containers, he making the spreader 40" mode to handling in
bay38 but another twin was coming and he lifting it with 40" mode.
during CQ06 loading on M/V BMC MASTER is load one CTR when he come back to load another CTR with
more hoist down the limit switch is stopped the QC06 due to the SQ04 is hit the cell beam from sea side
effected damage in two flipper.
uring QC 14 handling on M/V MSK UTAH bay 26 under deck twin containers while spreader was with 40 fee
ntainer mode which lead to container fall down under deck causing damage to 5 containers and damage
SQ23.
hile CQ 05 DISC from the subject vessel the crane operator&Deck controller note some sneaked in the wire
e supervsior asked him to stop operation immediately to check wire status with eng team whom advice th
there's Damage in hoist wire and the crane get out of order.
While TR75 making reversing in 07A to moving from the block, he hit container No TTNU8038401 which
caused damage in the container
During MV/ ARCHIMIDIS was sailing with full speed from the quay side in berth02 to be on time with the
convoy , which made the (MV/CMA CGM LYRA) moved forward and backward lead to damage in QC12
spreader while it was working in the hatch cover land side ( under deck ).
during load on dock a twin move in blind point cause damage in flipper's motor.
hile RS05 were going to handling an OOG container with OHF TR47 moved froward and hit the cargo caus
a damage in the cargo outer wooden cage.
hile QC 13 loading twin containers on M/V HUMBER BRIDGE location 61/63 11 10, the quay crane operato
seated it on head cell guide
During QC 04 discharge single unit from location 33 09 02 the wire get out pulley and snatched
uring RTG 30 loading a twin containers in TR 98, it stuck with the TT tails back edge and after this the sam
RTG while loading another twin containers on TR 110, the same was happened on the TT back edge
While PU20 returned behind and PU21 is coming forward between 04 F and 05 F lead to damage in both o
them
On 03H 62 while RTG 50 discharging one container from truck to row F , the RTG operator hit a container in
row E lead to damage at some containers also reefer stand.
G (50 ) handled plugged reefer no (MWCU6922745) with no previous confirmation from reefer tech. Which caused dama
to the reefer socket at ( 02H 66 A 4 )
While M/V CHRISTY berthing in Quay side, one of mooring workers fell down in the sea during going down
vessel gangway
During handling reefer container TRIU8840812 to be gated out, RTG 32 operator put it on the guide of ex
uck which caused a hole in the floor of a/m container, the hole is penetrated into the reefer unit as shown
the attached pics.
RTG 47 handled reefer MWMU6364860 with no previous confirmation from reefer Tech , which causes a
damage to the related socket, and cut to the reefer cabel
R54 when going out of QC11,it hit TT84 from the back side(attached to TR141) causing damage in the fro
mirror of TR54 and metal broken in the TT84
fter handling reefer container for discharge from an ext. truck; RTG operator directed to load the reefer un
into the E row inside 05 G 18, but while hoisting down the operator hit the right side (last tier) catwalks
handrail leaving a big dent in the handrail with no damage in the reefer socket.
uring RTG 18 discharging lift twin containers as 40 ft. mood which led to container fall down on the TR cab
Incident Details
Root Cause
Immediate causes
Obstruction ( Many dents in the cell-guide ).
Underline causes
Wrong handling.
Root Cause
Organization Root cause:
1- Management & Supervision
( Decision Process ) - Deck controllers numbers not adequate with the working loads.
Immediate causes
1. Wrong position of the TR.
2. Engine Failure of the TR.
Underline causes
1. Failure to act from TR driver. (Stopping the TR behind the RTG & Using the TR hand brakes).
Root Cause
1. Not Following Procedures from TR Driver.
TR 53 Collide with TT 90
Underline causes
Driving in bad weather (very cold and rainy )
Root Cause
1- People cause
Fatigue(overwork/lack of rest/breaks)
2- Environment cause
Exposure to extreme/unexpected weather
Immediate causes
Reversing back with the TR with a blind point.
Underline causes
The TR driver was harrying up.
Root Cause
1. People cause :
- Lack of attention
- Not following procedures.
Immediate causes
QC operator failure to act with handling the twin containers roughly while the twin containers were
vibrated.
Underline causes
Working in a blind point without observer (deck controller).
Root Cause
1- People cause :
- Poor decision making from the QC operator (working in a blind point without deck controller)
2- Organization cause:
- Lake of supervision due to lake of deck controller numbers.
Corrective actions taken Live
- Secured the spilt cargo area with cones.
- Handled the damaged container and send it to the x-stuffing area to re-stuff it in a good
condition one.
- Clean the cargo spilt.
Immediate causes
Container hit by another one.
Underline causes
Wrong handling.
Root Cause
Environment & Effects:
5- Housekeeping
Staking / Storing. ( Bad stacking ).
Immediate causes
TR moving on unfixed heavy gutter cover, which moved and it the TR stairway.
Underline causes
The gutter was un fixed with its bolts.
Root Cause
- Inadequate construction fixation.
Immediate causes
Involved person inhale excessive quantities of vapor (Leather Glue)
Underline causes
1-Heavy duty workload.
2-Lack of supervision.
3-Process change .
Root Cause
1-Lack of awareness regarding IMO containers during handling and inspections in the customs
People cause:
1-1-lack of attention. (using new reefer unplugging system)
2-poor decision making. (checking with reefer technician after loading the container)
Immediate causes
RTG operator handled a twin containers as 40 ft. container.
Underline causes
1- RTG operator didnt check the location shown in the system.
2- Bad visibility due to bad weather (heavy rains).
Root Cause
- Lack of attention.
Immediate causes
BS 08 collide with TR 05
Underline causes
N/A
Root Cause
1-Lack of attention/due care
2- Not following/incorrect following of standards/procedures
Immediate causes
( Lack of communication Miss understanding the message )
Underline causes
Wrong handling.
Root Cause
People cause:
1- Activities & tasks.
( Operator not following the procedures ).
1-Poor decision making.

2-lack of attention. ( only checking the mirrors one time not frequent checking).
Not following/incorrect following of standards/procedures.

- Not fully concentrated.
Immediate causes
TR 125 cabin collide with container
Underline causes
Tacking shortcut and breach SOP
Root Cause
1- TR Driver Careless
2- Not following/incorrect following of standards/procedures
human error.
over confidence
Immediate causes
RTG 20 Lift connected reefer unit
Underline causes
Reefer LOG system cover OPS Vessels units only &didnt cover gate units
Root Cause
Not following/incorrect following of standards/procedures
As the operator hoist the connected unit before confirmation from reefer tech.
Immediate causes
RTG handle connected reefer container without checking its status with reefer coordinator.
Underline causes
Rushing in work.
Root Cause
- Lake of knowledge of the procedures of the reefer load system.
- Not following the procedures (didnt call the reefer tech. to check he status of the reefer container).
Immediate causes
Hoist down a spreader under deck with flipper down.
Underline causes
Rushing in work.
Root Cause
- Lake of attention, (didnt check the position of the flippers).
- Failure recognize changing in circumstances (the flippers didnt rise up).
Accumulative damage
Underline causes
Activities and tasks:
That due to the actual emergency situations, absence of deck controller who is responsible to make the survey
on the structure which may affect on the normal operations, caused that crane operator didnt notified about
the weak points & blind points (The ladder).
Root Cause
Work environment effect:
Vessel structure.
Immediate causes
OPS BS 05 Collide with container in 01 J
Underline causes
Lack of attention/due care
Misuse of seat belt
Root Cause People cause
Not following/incorrect following of standards/procedures
Immediate causes
-container stuck on the trailer
Underline causes
-Presence of old damage in the trailer edge (dent) which cause the stuck between the unit & edge
Root Cause
-Trailer structure with blind points to operator
Immediate causes
Container No. SZLU9627592 hit TT 141 and RTG 141.
Underline causes
The involved person hit the fallen container during full speed trolley back.
Root Cause
People cause :
1. Lack of experience.
Immediate causes
Twin twenty Ft containers lifted by 40 Ft mode .
Underline causes
People cause:
1- Communication ( Communication of rules )- As the wharf controller didnt gave the clear
instructions of bay plan after opening the center hatch cover.
Management & Supervision
( Decision Process ) - Deck controllers numbers not adequate with the working loads.
Root Cause
People cause:
3- Attitude & behavior:
Not following the rules.
A- The operator using the Bypass without permission from his supervisor.
B- The operator not using the screen.
Poor decision taken, as the operator decided the kind of containers without check, he just
Not following correct procedures/standards.
didnt keep a safe distance
depends on his previous(Driver
experience.
between his Truck and front one).

-lack of attention.
Technology Cause:
-Equipment to fit for purpose (As the place which the technician was tightening the bolt was very
narrow to reach by human hand.
Bad decision making (miss calculating the distance of maneuvering)
Organization cause: task requirement (Number of deck controllers are not adequate with number of operated QC).
People cause:Poor decision making ( hoisting up with full speed on blind point).
Immediate causes
TR 09 Reverse back and collide with ENG PU 01
Underline causes
TR Driver
1-Failure to recognize changing in circumstances(presence of PU in blind point to him )
Root Cause
TR Driver didnt follow SOP (Reverse back without guide )
Immediate causes
The spreader hit the uneven twin containers in the next row
Underline causes
The vessel moved suddenly while QC 11 hoist down under deck.
Root Cause
People Cause:
1- Failure to recognize changing in circumstances (the deck couldnt recognize that the vessel could move).
2- Ineffective identification of hazard ( the uneven twin containers was so close to the previous row which the
QC working in it , that raise the risk of collision).
Poor Decision making ( when he decided to make maneuvering in crowded area and not waiting
for clearness)
Immediate causes
- QC 14 clashed with MV EGY PRINCESS gangway.
Underline causes
- The gang way position changed due to the sudden movement of the vessel.
Root Cause
- Unexpected changing in circumstances of MV EGY PRINCESS due to the sailing of the behind vessel.
Immediate
causes
Immediate causes
- TR 129 hit the container
Twin container
stuck
under deck
Underline
causes
- The TR driver didnt see the container while reversing back (blind point).
Root Cause
Underline
causes
- Poor decision making from the TR driver, he reversed back although he didnt see the container from the left
Poor design direction,
for Vessel cell guide
Root Cause
1-Deck controller didnt make pre operation inspection ( Ahmed ELsawaf)
2-Over confidence from both Deck and wharf .
3-Both of Deck and wharf breach SOP as they
i) start loading before Deck in his position
ii) Changing their position without confirmation from their direct supervisor.
Immediate causes
Wire collided with the head block door.
Underline causes
Poor decision making due to over confidence.
Root Cause
Didnt follow the work procedures.
Immediate causes
- The tires were squeezed while taking maneuvering in a small distance while it loaded with a heavy twin
containers (the tire exploded).
- Moving directly on the rim without the tire (causing the damage of the rim).
Underline causes
- TR driver miscalculate the distance which make the maneuvering.
Root Cause
- Poor decision making from the TR driver
1- Miscalculating the distance which take the maneuvering
2- Moving with the TR on its rim directly (didnt wait for coming of TSV)
Immediate causes
- While The RTG made gantry it hit TR 59s left mirror
Underline causes
- The TR was so close to the RTG lane (unsafe position), and its driver was outside the TR.
Root Cause
1- Not following procedures (from the TR driver by leaving his TR in unsafe position).
2- Miscommunication between RTG operator, TR drivers and the SVs.
3- Failure to recognize hazard ( the RTG operator didnt double check with the supervisor that his message that
he will gantry received or not, specially he saw the area under his RTG was crowded).
Immediate causes
Pick-up driver hit the concrete barrier.
Underline causes
Felt drowsy while driving.
Root Cause
-Fatigue/lack of rest
Immediate causes
QC 16 hit K-stream gangway.
Underline causes
QC 16 Moved gantry without monitoring.
Root Cause
-Lack of communication(from Wharf &QC operator whom didnt receive clear message from each
other ).
- failure to act from the wharf who didnt stand near to gangway/emergency button while moving
gantry check for clearance.
- Poor Decision from QC operator who started to move gantry without informing from Wharf via
radio.
-Not following instructions from wharf who didnt listen to vessel SV who asked him whether its
clear for gantry or not.
Investigation Nex Day shift
1- People cause:
Not following procedures (RTG 05 operator didnt follow his training instructions by check his way while gantry
and didnt depend only on the anti collision sensors specially in his cabin side).
Immediate causes
The right side glass of the operator cabin fall down From Q.C06
Underline causes
Vibration that resulted from the normal QC operation which increase the probability of the glass
falling down.
Root Cause
The glass frame maybe not properly fit (as the pane fall down after more than a month since it
was installed).
Immediate causes
While the QC 16 was trolley back with a twin container, the twin container hit 40 ft. container on a TR 107 which
was waiting in the next lane.
Underline causes
Wrong position of TR 107 under QC 16.
Root Cause
People cause:
1- Miss calculation of the safe distance between the two TRs due to Lack of attention from the TR driver & the
wharf controller of TR 107 waiting position.
2- Not following procedures from the TR driver about making a safe distance between his TR and the front TR
about 3 meters away (after entering between the two QCs he knew that the distance between the two QCs was
close to each other, so he tried to be more close to the TR in front of him toward QC 17 to avoid the spreader
pathway of QC 16, but the end of his trailer was in the spreader pathway).
Immediate causes
while TR32 getting under the crane it hit TR 113 in the in TT77.
Underline causes
The driver felt drowsiness while driving.
Root Cause
People cause:
1- Fatigue
2- Not following procedures (didnt inform his TR SV about his status).
3- Poor decision making ( when he felt drowsiness in the first time he decided to continue without stop and
informing his TSV).
Not presence of D&W controller during handling as we checked with roster they mentioned there was less that 7
Deck controllers and 13 Wharf on shift.
1.Lack Of attention:
As the Terminal driver has enough space enable him to notice the ext. truck while moving but he didnt take
that into consideration (that there will be a truck coming from his left side).
2.Absence of proper control on the External truck driver:
As the external truck was loaded in a special condition (the opposite yard direction) and there was no
supervision while the driver was trying to move out of the container block.
1.Lack Of Experience/Training:
As the involved TR driver is a fresh trainee (his 2nd training day) and hasnt sufficient experience
to deal with such circumstances.
2.Inapropriate pre-task check:
As the TR driver forgot to check that if there is any thing looking abnormal in the cabin and so he
didnt noticed the abnormal position of the extinguisher.
3.Fire Extinguisher was improperly fixed:
The wrong placement of the extinguisher helps in its sliding toward the brake pedal.
Immediate causes
Right land side flipper hit the central hatch cover & containers and handrails
Underline causes
Working in blind point without guidance
Root Cause
Organization:
- Insufficient work demands ( absence of Deck controller).
People cause:
- Lack of experience of the QC operator.
- Inadequate checking process from QC operator on the spreader after the first hit
- Poor decision making from QC operator due to over confidence when working in blind point without guidance
while he could work in unveiled rows till the presence of the deck controller

As the TR driver decided to take the risk of passing before the RTG in order to avoid collision.
Not following of safety traffic standards:
Since the TR driver didnt give the priority to the RTG to cross firstly and decided to pass before it depending on
that the RTG will stop allowing him to pass firstly.
Immediate causes :
Lift Twin Container With Spreader On 40 Mode causing twist lock bent.
Underline causes :
Lack of attention.
Root Cause :
Fatigue.( As the operator didnt have enough sleeping hours before work )
Lack of attention:
As deck controller wasnt concerned about checking the side locks of the hatch covers whether is
it opened or not.
Inappropriate positions of person:
That the deck controller wasnt in place while QC was lifting the HC.
Bad communication:
As there was no communication between Deck controller and QC operator to check if the HCs are
ready or not.
Working environment / Obstruction:
That the right side lock for the seaside hatch cover was closed and prohibit HC to be lifted
securely.
Organization factor:
Not presence of D&W controller during handling as we checked with roster they mentioned there was less that 7
Deck controllers and 13 Wharf on shift.
Working environment:
As there was an obstruction (Twist Lock) in the corner casting of the fallen container which played a role in the
attachment of the container with the lifted container.
Immediate causes
Middle twist locks of the twin left get closed while it was settled on the below twin containers.
Underline causes
QC operator was loading in a blind point and wasnt able to recognize whether the middle twist locks were
closed or not.
Root Cause
QC operator decided to deal with the problem with his own way depending on his experience and didnt wait for
the maintenance help.
Immediate causes
RTG 23 Deviated and hit TR 68
Underline causes
Over confidence from RTG Operator (as he precept that he could re adjust that significant
deviation alone)
Root Cause
People cause
1-Poor decision making/judgment
2- Lack of attention
3- Failure to obey safety systems as he was requested to stop gantry once he realize he make that
deviation
Root Cause
People Cause :
1.Lack of attention:
TR 15 driver didnt notice that he might hit TR 48 while his maneuver and thought that there is
enough space for him to take the movement.
2. Incorrect Following of Procedures:
TR driver wasnt stopped on the Stop mark at the end of the bay, and also he wasnt in the right
position away from RTG lane (TR right mirror was on the RTG lane).
3. Poor decision making:
TR driver decided to take the wrong action (maneuvering within a very tight space) although he
was able to get out of the truck and call for RTG operator or even to stop RTG movement through
pressing Emg-Stop button.
People Cause :
Lack of attention:
As shown from the log file we found that RTG operator pressed the Twin up button by mistake
when he was trying to press Twin-Telescopic store new position button for the 2nd time (both
buttons are so close on the left console), that lead to deactivating twin mode without any
attention from the operator which caused the incident.
People Cause :
As QC operator took wrong decision when he hoisted down the container in the under deck with
full speed & took the decision without check (especially it was his first move inside the row, and
he should inspect the status of the cell guide or even ask if there is anything abnormal within it).
Organization cause:
Inadequate work planning:
As there was only one deck controller for 2 working cranes and that considers not enough to
maintain safe operation procedures.
Immediate cause:
Spreader twin box damaged
Root Cause:
Accumulative rough handling
spreader dismantled and moved to Workshop.
Immediate causes
While TR 42 get maneuvering , it hit the X ray gate by the stopper bars which attach on the low bed .
Underline causes
Stopper bars was not straight and the driver did not check it before use the low bed .
Root Cause
People cause:
- Lack of attention of TR driver .
- Working under influence of drugs.
Immediate causes
TR 79 hit TT 98 of TR 135
Underline causes
No safe distance kept between TR 79 and TR 135
Root Cause
People cause:
- Not following the procedures (TR 79 driver) of fasten nor check the seat belt.
- Poor decision making of TR 79 driver who decide to maneuver without check the way instead of slow down to
keep a safe distance and to check the right side before maneuver.
- Improper use of the safety device of TR 135 driver.
Immediate causes
RTG 40 Operator lifted a connected reefer on 02G54-G4
Underline causes
Reefer container was still connected.
RTG operator wasnt fully concentrated during lifting process.
Root Cause
People Cause :
A. Lack of attention:
1. Fatigue: RTG operator slept only 3 hours the day before the incident.
2. Working under stress: there were many Trucks for loading so the operator was hurry.
B. Not following Procedures:
RTG Operator didnt check on the reefer log system whether the reefers are ready or not and also
didnt wait to take a confirmation from the reefer technician.
Immediate causes
TR 62 hit TR 143 from behind.
Underline causes
TR 62 driver wasnt attention to his road.
Root Cause
People Cause:
- Lack of attention (The involved TR 62 driver wasnt attention to his road).
Immediate causes
Container hit the trailer by rough handling.
Underline causes
Ineffective adjustment ( Not adjusted censors ).
Root Cause
People cause:
1- In adequate pre-task check.
2- Not following the procedures ( As the 1st crane operator didnt inform his colleague about the
faults).
Organization:
- Insufficient identification of hazard ( Working in the blind point without guide (Deck controller )
People Cause:
- Not following procedures (The involved QC operator didnt check the flippers if they up or not)
Immediate causes
TR 82 hit TR 87 from behind.
Underline causes
TR 82 driver was driving with high speed and not take safe distance between him and the other truck.
Root Cause
People Cause :
- Not following procedures (The involved TR 82 driver was driving with high speed and didnt take safe
distance).
1- Working with rush in a blind point for the sailing man

2- Not following the procedures (VSV didnt drive in the safe position).
People Cause:
- Rough handling from the QC operator.
Technology cause:
- Accumulated fatigue on the flipper motor which lead to flipper motor broken easily.
Immediate Cause:
The leg of a ENG Technician trapped between the spreader & the spreader support of low bed
trailer.
Underlying cause:
Organization Cause.
1. Inadequate SOP for this job.(using generic SOP)
2. Work pressure
3. Poor decision making
4. Poor communication between work team.
Root cause:
People Cause
Operating / Controlling the panel by unauthorized person .
Immediate causes
Lasher hit by container
Underline causes
1- Vessel stability and structure (manual twist locks). The nature of the vessel lead to men being
on the deck placing stacking cones. Further, the instability of the vessel caused an out of
sequence work scenario.
2-Lack of escalation in safety awareness during non-standard working procedure. Even though we
have SOP to cover this situation, we need to ensure a heightened sense of safety during this type
of operation.
Root Cause:
Operator Fault- carelessness with safety. The operator deviated from SOP by not receiving visual
confirmation via eye contact and hand signals from the lashers on board.
Immediate cause:
- RTG 26 collided with RTG 22
Underlying Cause:
- Poor decision making. (When the operator depends on the sensor to stop him).
Root Cause:
People cause:
1- Not following the work instructions. (As he didnt stop on the stop sign between H & L when
crossing the main drive way & didnt use the standard distance to down the speed).
1- Not following the procedures.

2- Lack of experience.
People:
- Poor decision making
- Not follow SOP (as the operator didnt call the deck controller as a guide)
Immediate causes
OPS-PU-40 hit a steel barrier while PU driver was maneuvering around a working site in 02 M Lower.
Underline causes
The steel barrier was slightly outside the other barriers pattern.
Root Cause
People:
Lack of attention : as the PU driver didnt notice the steel barrier while he was maneuvering.
Immediate causes
TR 43 hit TT 156 from behind.
Underline causes
While maneuvering the trailer is not appear in the mirror
Root Cause
People Cause:
- Lack of attention (The involved TR 43 driver wasnt attention to his road).
People
- Lack of attention of the lasher
People
Not following the traffic procedures that while driving, was busy with another thing except his
way.
People:
Lack of attention: as the PU driver didnt see the workshop shelter support while maneuvering.
Immediate causes
TR 111 attached to TT 84 collide with the edge of hatch cover.
Underline causes
No warning cones in front of hatch cover edge as agreed before .
Root Cause
1- Lack of experience .
Trailer evacuated to Workshop for inspection .
Immediate causes
- Fire in QC 11 ( Outside the operator cabin ).
Underline causes
- Contaminated rags due to poor housekeeping.
- Absence of ashtray.
Root Cause
People Cause:
- Lack of due care (From the cleaning company 3rd party, as they hide the old rag which contaminated with oil & grease under the
A/C base) .
People:
-incorrect following of standards and procedures: didnt take his safe distance which he received it in his
training.
-Poor decision making: hoist down before get out of the vessel.
Organization:
- Lack of supervision due to shortage in the deck controller number
Environment:
- Obstruction
People Cause:
- Not following procedures (* Involved TR driver didnt check the leg support level before driving, *
Involved TR driver didnt inform TR supervisor that TT 135 fifth-wheel plate down after loading
Immediate Cause:
- Flipper motor damage due to hit by another container.
Underlying Causes:
- Absence of D&W controller.
Root Cause:
Lifting with defected twist lock.
1. People cause: Inadequate pre-task checking:
Corrective
actions
taken
Live.
Since the involved YSV didnt perform
even a fast
check on
the PU
prior to driving, hence he wasnt able to
- Spreader replaced
immediately
by
recognize the opened hood. Eng. Team.
Immediate causes
2. PU hood safety lock inappropriate adjustment: as the safety lock wasnt in its appropriate position in order to
-SQ 17 stuck inside cell guide
hold the hood ring to prohibit its opening.
Underline causes
- Poor vessel cell guide construction.
Root Cause
-Handling spreader stuck before arrival of ENG Team .
- Inadequate communication .as the wharf didnt mention spreader stuck in his call to ENG team
People cause:
1. Poor decision making (working in blind point without guidance).
2. Failure to act when the container stuck.
People:
-Lack of experience/training: this was the 4th day in his rotation after finishing the RTG training.
-Lake of attention: RTG position incorrect.
-Poor decision making: used full speed.
-RTG operator sent to make a drug test.
-The container damage was moved in another place.
- Due to unreported damage to the hoist wire

Immediate causes
Damages in the SQ 13 twist lock pins & right twin gearbox while discharging under deck.
Underline causes
Immediate causes
Working environment:
RTG 43 operator lifted twin move on 40 feet spreader mode.
Improper stacking for the twin containers under deck caused the twist lock pins to hit the side edges of the
causes
containers (corner castings) andUnderline
also resulted
in cracking the right twin gearbox.
People
Cause:
Root Cause
A. Lack of attention: RTG operator was hurry inPeople
handling
the twin move and didnt realize whether the twin
cause:
mode was really activated or not depending only on the blinking of the console twin button.
Incorrect following of procedures:
B. Technical cause: after inspecting the twin activation button lamb on the console it was found irresponsive to
appears
to be activated
allresulted
the timeinwithout
trying
to activate
QC operator was pushing
hoisting and
down
in full speed
under deck
a strong
collision
with theit.containers corner
castings & containers body frame from the middle.
Root Cause
People Cause:
Not following Procedures:
Immediate causes
TR 78 reversing back and hit ENG PU 04.
Underline causes
N/A
Root Cause
TR Reversing back without clear vision (PU was at blind point while TR adjusting his position )
People cause:
Lack of attention as the TR driver though that the TR was loaded by reefer container not the glass
washing equipment.
People cause:
Lack of experience.
Not following the procedures from the operator side who didnt check the unplug system.
Miscommunication between the reefer tech. and the RTG operator.
Immediate causes
Left/Land side hoist wire rope damage, dent in the guard of left/land side pulley.
Underline causes
Unreported damage.
Root Cause
People cause:
Rough handling procedures during normal operations.
Immediate causes
20 container no. MRKU 9144682 fell down after being hit by another container while training.
Underline causes
People cause:
RTG operator miss-calculated the safe height while trolley backward.
Root Cause
Lack of experience:
RTG operator still in his training period (spend only 5 days in training).
Immediate causes
- The lock knob slipped away from its path and fall down.
Underline causes
- The falling prevention stopper was Brocken.
Root Cause
1- Accumulative stress due to the normal work demands.
Immediate causes: Damage in container pipe and cargo leaking.

Underline causes: -The TR was incorrect position
-miscalculated the right distance on TT from RTG operator cabin.
-Truck TT sharp edge was a blind point to RTG operator when he get more closer,
(BOSCER TT is short).
Root Cause
From RTG operator:
1-lake off attention because he heard a horn and didnt stop.
2- Incorrect following of standards about handling container tank: he didnt wait till TR driver adjust his TR
position, and didnt stop the TR driver when he saw him spoke on the cell phone.
Immediate causes
From TR driver:
1- Lack of attention: because he was speaking
in the cell causes
phone while loading container and didnt return back.
Immediate
2- Lack
experience:
when on
he took
the 1st sharp
container
in acausing
wrong position
he moved
take the 2nd
one
without
Theofcontainer
seated
the trailer
edge
70cm
cut
in thetocontainer
floor
cross
Damage
in
left/seaside
flipper
arm
spring
steel.
communicate with RTG operator by using megaphone or call his supervisor. And when he call supervisor after
members
Damage
the
of aright/seaside
observed
the in
leak
heholders
didnt give
clear messageflipper.
to him.
Underline
causes
3- Incorrect following of standards: speaking in the cell phone while work under RTG.
Wrong
position
from TR .
Underline
causes
Root Cause
People:
People
cause:
- Poor decision making from RTG operator who saw that the TR position was wrong and continue
hoisting
down.
1. Lack of attention: QC operator didnt notice
that
spreader was stuck below center hatch cover.
2. Poor decision making: from the operator side, that he took the decision to hoist up with no
coordination with the deck controller.
Root Cause
People cause:
Immediate causes
- N/A
Underline causes
- N/A
Root Cause
- Unreported damage .
Immediate causes
RTG 41 Hit containers
Underline causes
RTG Was Deviated
Root Cause
People cause
1-Not following procedure &SOP
2-Poor individual safety awareness .
Immediate causes
Immediate
causes
Immediate
causes
- RTG36 hit
TR02
RTG 42 Lifted twin
containers
Underline
causes with 40 ft mode
Underline
- TR02 obstruct the way during
RTG36 causes
gantry moving from block to another
Damage in left/seaside
flippers
arm
and
one
of large
scope fallen down in the sea.
1-Lake of attention Root
fromCause
the attach
operator(New)
People
cause:
Root
Cause
Underline causes miscalculated
the
safe
distance
which lead to activate limit switch .
TR driver
Not
following
procedures
Immediate
causes
People:
- Work under influence of drugs .
5 container
damage
andtaken
four twist
damage.
Corrective
actions
Live
. fix the damage parts
- Informed ENG team to
Underline
causes
Comments and Recommendations by the
Investigation
committee on how this could be avoided in
Root
Cause
1-Absence of Dock controller (there is 7 deck+14
wharf) for 14 QC in this day, and there is 4 QC
future
work on mention vessel and only one deck .
2-the 40 ft mode was work not twin mode ( when he press twin mode the 1st time and didnt
People
responded, he press it again the twin mode
take cause:
two order one open and one close after the QC
operator saw it open and start to move he didnt see when it close again .
1. Poor decision making: didnt take enough safe distance .
Corrective
actions
taken Live
Root
Cause
People cause
SQ 04 replaced
by
another
one,
and
transferred
to check
the workshop
further repairing.
1- Lack of attention/due
care.(didnt
the twinfor
lamp)
Unreported
damage
I161
2- Bypassed
control
3- Not following/incorrect following of standards/procedures(as he didnt ask assistance from Dock
controller .
4- Poor decision making didnt inform his supervisor& activate the bypass before confirm clear
situation and depend on himself.
Immediate causes
- TR75 hit the container
Underline causes
- TR driver reverse back without guide .
- Heavy traffic .
Root Cause
People :
- Not following procedure .
- Lake of attention .
Immediate causes
- Damage in the spreader
Underline causes
- Sailing with full speed for the M/V ARCHIMIDIS .
Root Cause
Organization :
- Negligence 3rd party
- The mooring ropes automatic system of the shifted ship.
Immediate causes
Spreader collide with container
Underline causes
Handling in blind point
Root Cause
People cause
Lack of attention
Immediate causes
- The cargo wooden box of an OOG container which was loaded to TR 47 hit the OHF which was attached to RS
05
Underline causes
- The distance between the OHF and the cargos outer box wasnt the safe distance, the TR driver entered
under the RS earlier.
Root Cause
- People cause:
1- The TR 47 driver didnt follow his instructions by not entering under the RS till the operator give him a
Immediate
causes
permission.
Twin container collide with cell guide

Underline causes
Handling heavy containers
Root Cause
People cause
- Not following/incorrect following of standards/procedures
As the operator didnt stop hoist down before reach the cell guide by safe distance .
Immediate causes
Hoist wire get out form pulley and snatched
Underline causes
N/A
Root Cause
guard of hoist pulley broke due cumulative rough handling during normal operation
Immediate causes
- RTG 30 landed the twin containers on the back edge of the TT /TR 98 & TR 110
Underline causes
- Lake of attention & not following the SOP from the RTG operator
Immediate
causes
Root Cause
OPS PU 20 trunk hit another
OPS PU
21 trunk while driving reverse.
- People
cause:
1- Working under influence of drugs.
Underline causes
While maneuvering the driver didnt look at to the car mirror.
He didnt heard the horn due to the car windows was closed.
Root Cause
People Cause:
- Lack of attention The involved driver wasnt attention to his road).
Immediate causes
RTG 50 Operator hit container in 03 H 62 E 5 and make it fall down and collide with reefer units in row F
Underline causes
N/A
Root Cause
People cause
-Lack of attention
Immediate
causes
-Didnt follow SOP
- RTG lift reefer with connected Plug The reefer socket was broken
Underline causes
Root Cause
- People cause:
1-Didnt follow sop :didnt check with the reefer tech the status of the reefer .
Immediate
causes
2-poor decision making : when the tech
late he lift
the reefer without return to his supervisor.
During mooring worker and SV was going down M/V CHRISTY gangway, the gangway slipped from
the quayactions
and hittaken
the vessel.
Corrective
Live
Disconnected the power from this socket till fix.
Underline causes
The gangway was not safe for use.
Root Cause
People cause:
- Not following our safety procedures (1- Mooring SV violated our security rules and took mooring
worker with him to go up the vessel. 2- Mooring SV used unsafe gangway.)
- Mooring worker is rescued and took his first aid.
Immediate causes
RTG operator put the reefer container on the EX TR guide.
Underline causes
1-Miscalculate the distance between the reefer container and the EX TR guide.
2-EX TR guide was small and sharp.
Root Cause
People cause
Immediate
causes
1- Incorrect loading on EX TR.
TR 54 hit Trailer TT 84
Underline causes
Immediate causes
Lack of experience of TR 54 Driver (10 months )
Root Cause
RTG 26 operator hit the right-side reefer stands
handrail while discharging 40 feet container in 05
G 18.
Lack of attention/due care of TR 54 Driver (looking at VMT while Driving)
Underline causes
RTG Wasnt correctly adjusted on the working reefer containers bay.
Root Cause
People cause:
Lack of attention: since RTG operator didnt correctly recognize his position on the bay after
making spreader side-shift from right to left side.
People cause:
Lack of attention & negligence from the RTG operator side as he did'nt turn on the twin mood
before starting to handle the twin containers.
Issue #: 02
No.
In your point of view, what was the reason of this incident ?
rts to avoid incidents & we are working in very narrow areas from long distance, so we need the deck con
If the deck was with you in this case, did you think that this case may be avoided?
Yes.
Why you didnt attend the TBT ?
Because I came early.
YES
NO
Did you receive training in how to do the task involved: YES

If required, were you wearing the correct PPE:
YES
NO
NO
NO
- Deck controller with every QC operator.
Witness Person: Name: Mina Girgis
Department: Ops
ID:
Position:
1953
D & W controller
Involved Person: Name: Waleed Ahmed Aly ID: 3670

Department: OPS
Position: TR Driver (Kotby)
Experience:
6 Months
going out from the block toward the quay, I found RTG 39 going out from 07 C so I stopped at 07 D to wa
to move the TR quickly but it did not move because the air was evacuated so I used the horn to draw the
Why you stopped behind the RTG?
To wait and see where it will be directed.
DO you know that the SOP is to change your direction not to wait the RTG direction?
Yes I know.
Did you use the hand brake ?
Yes I did.
Where was you stopping?
I was stopping at the right to have a chance to escape.
Involved Person: Name: Mohamed Nasr Nasr ID: 1362

Department: OPS
Experience:
1 Year & 6 Months
Mohamed
Mohamed
Elfeeky
ID:
3415
as going to 07 D, after making wheels turning on the plates, I moved with the RTG then I heard the sound
Did
you turned
seat before
Department:
OPS out the
source(Kotby)
Position:moving?
TR Driver
Yes I did but the TR was at right behind the RTG leg so I could not see it.
Experience: 18 months
to 02 G in opposite direction in order to handle reefer unit ,after I enter the G block I adjust my TR exactly in TR lane under RTG then I feel doze till collid
-Does tour TR (53) have any abnormality in braking system or defected front glass?
No .braking was in good condition but I didnt use it .
-How many hours did you slept before coming night shift?
7 hr
-Did you take any drug makes you sleep while driving ?
No
-Did you face same situation before ?
No
-From your opinion what is the cause for this accident ?
Involved Person: Name: Ahmed Mohamed Abd El Hameed El Zahar

ID: 3671
Department: Ops (El Kotbey)
Position: TR driver
er, I was driving between 3 K and 3 L and when I start to turn to right with the TR head between 3L higher and lower (the trailer was still in the way bet
and wait the RS in the way between 3 K and 3L because the RS wasnt reach 3P yet and the area was crowded with people, so I started to reverse back w
1- Did you notice that the Ops PU 40 was existing before you reversed back?
Yes, I saw it and passed beside it before turning right, but when I reversed back I forgot its existence because of my conversation with the x-stuffing labo
2- Did you look at the TR mirror while reversing back?
e area which Ops PU 40 was waiting as a blind point cant get by the lift mirror, because the heat and the trailer not in the same line (the head only turne
3- Did you know that reversing back in the yard is forbidden ?
- Yes, but I need to.
4- When did you can reverse back in the yard if you need to do it?
- There must be an observer to guide me to reverse back if I need in safe matter.
YES
NO

YES
NO
NO
NO
- Be more concentrate and call an observer to guide me reversing back if needed.
Involved Person: Name: Mohamed Hassan Rizk ID: 0112

Department: OPS
Position: CQ Operator
Experience:
7 years
AN SHA when the vessel supervisor asked me to discharge one twin from another bay, I moved by the cra
ut there was a problem on the locks of the spreader so, I called the deck controller to visually check the p
wn again to solve this problem, I did so but the problem was still exist then he asked me to hoist up gain
but the right side did not. After that we stopped and called the ENG team.
Was you hoisting down in full speed at the second time?
Yes, I was inside the cell guide and this is a normal movement.
Was the wires slacked?
Yes it was.
Did the crane movements stopped ?
No, it was working normally.
Was you able to see the position you was working in?
No the vision was not clear because it was shaded and the time was early morning.
Was there any deformation at the cell guide?
No, the spreader moved smoothly inside it.
Witness: Name: Mohamed Abd Elhamed
ID: 1344
Department: OPS
Position: D&W Controller
with CQ 11 while I heard a call from CQ 10 operator to check the position of the spreader under the deck o
der was not able to lock on the containers, I asked him to hoist up then down again on the containers to s
I asked him to hoist up again and try to close the spreader to 20 mood then open it 40 but when he sta
didnt so I told him to stop and called the ENG team.
Did the cranes movements stopped after the slack?
No it did not stopped as he hoisted up again.
Did you see any defects in the wire rope?
Yes, after the left side raised and the right did not I saw a defect at the wire on the sea side right.
Was there any defect at the cell guide?
No, the cell guide was in good condition.
wo containers under deck, but it was a blind point to me because the previous row (6th row sea side) was
containers stuck with the cell guide head.
1- Was it the first move in this bay (5th row sea side)?
- Yes.
2- What was supposed to do when you found that you will work in a blind point?
- Work carefully and call a deck controller to be with me.
3- Did you call the deck controller before working in that blind point?
- No, I called him after I noticed that the twin containers were stuck.
4- Why you didnt call him to guide you in this blind point?
busy with other QCs in the same vessel because I heard them, and if I call him he will come late and this
5- What was the circumstances that cause this damage?
preader, it vibrated due to the elasticity of the wires (normal condition) and while hoisting down with that
cell guide.
ow had a part was taking a space of my current charging row and I didnt know that because it was a blin
troller was with me adjusting the position together when I charging the 2nd twin containers after the incid
YES
NO

NO
NO
It was full speed?

Yes.
Why you moved in full speed, as you are in 1st container in this bay?
ows from A to F & found that all are in the same which I handle from row F, then the speed of the trolley w
Did you check the distance between the containers in your bay & other bays ( 31 & 35 ) ?
No.
Why you didnt check this distance?
Because I put all my concentration in the height of the rows in the same bay of my working operation.
hen you make trolley forward to take this container, did the spreader hit or touch any containers from bay
No, because I entered from bay to bay & the spreader was higher than the containers.
Did you faced any technical faults in the RTG which may lead to this incident?
No.
Are you slept well?
Yes, approx 7 hours.
Did you suffer from any home conditions which may affect on your concentration ?
No.
During the incident, you was calling in phone / Speaking with anyone in the SG phone?
ainer, I was talking with tower controller in some issues regarding to the operations, but while I was trolle
In your point of view, what is the reason of this incident?
Bad stacking.
Why this behave repeated this days in your opinion?
pervisors give a negative comments to the operator who made the wrong stacking & I think the training in
Involved Person: Name: Mohamed Mohamed Abd El Maksood

ID: 3219
Department: Ops (Trademare subcontractor)
Position: TR driver
Experience: 2 Years
as the first containers charged on the vessel and the wharf told me to move and wait behind the QC until
maneuvering and to enter the waiting area behind QC 11 and while I drove in the waiting area behind QC
to see what happened, then I found one of the gutter covers hit and stuck with the TR stairway.
cting the incident site we found one yellow barrier beside the rain gutter, did it barricaded this area as a w
- No, the barrier was as you see it when safety and engineering came, it was away from the rain gutter.
Did you hit the barrier and remove it from the gutter cover when you entered the waiting area behind QC 1
- No, I didnt even touch it.
YES NO
Mohamed
AbdinELfatah
6422
Did you receive
training
how to Ibrahim
do the taskID:
involved:
YES
NO
Department:
Outsource(Tradmar
Position:
worker
Are
you aware OPS
of the
rules / proceduresCo)
related
to thisstevedore
work: YES
NO
Experience:
5 years
If required, were you wearing the correct
PPE: YES
NO
charging subjected container content for customs inspection process we smell bad odor which makes us f
workersinwere
inside
?
Did you receive- How
supervision
the last
1hrcontainer
of your work:
YES NO
Two
+
me
- Did you know whats cargo content?
Adhesive material.
- Before you start working, did you attend TBT?
Yes ,I did.
- Did you open this Unit for ventilation before start discharging?
Yes we open it & left open for 1 hour before discharging its content.
- Did you inform your Supervisor about abnormal smell ?
Can you describe what happened ?

er containers I was working on 2 G 58 then I moved to D bay 14 & 18 I checked with yard supervisor to co
ring loading, suddenly I found the hanging cable from container and accordingly I called reefer to check th
Q: was the vision of your screen was clear ?
A: yes it was.
Q:Do You suffer from any sight problems ?
A: never.
Q: Why dont you use the new reefer system to check whether the container is plugged or not ?
A: I was not familiar was the new system, I forget how to work with the screen.
Q:So, How did you confirm the unplugged containers ?
A: I called yard Supervisor.
Q: why you didnt confirm with reefer technician ?
A: I already confirmed after loading the container and found the hanging cable.
- Yes, it is shown in the screen.

t happened to make you took the twin containers as 40 ft. container if it shown in you
d the visibility was not good and the two containers had the same color so I thought i
no. of the container with the number of the container you should discharge in the sy
ystem and it show the same number of one container of the twin containers but I did
the location of this container was in 08 B 63 but I was discharge it in 08 B 54.
4- When you checked the container no., did you check its location?
didnt check it, I only compared the numbers of the container with number in the sy
5- Was there any TRs waiting in front of the involved TR when you reached to bay 54?
ront of it, one of them was waiting at bay 54 which I called it to move to allow the rig
YES
NO

NO
NO
Amr Mahmoud Hamed ID: 1527

Department: OPS
Position: Bus Driver

Experience:
5 years.
n I reach main drive rood after J I check my right direction only ,I decide to continue moving but unfortunately when I look to my left side I s
-How much your BS speed ?
About 25 km /hr
-Did you stop at stop sign before main road ?
No ,I didnt
-Did you stopped by using brake or by collision effect ?
I used my brake when I see the TR coming from my left .
-how many hour did you slept before coming night shift ?
5 to 6 hrs and this my normal .
-Do you have any problems affect your attention while driving ?
No all things is OK internally & outside CO.
-How do you think we can avoid this Accident ?
I dont know.
No.
Are you aware about the system of reefer handling?
Yes.
Did you followed this system during your working hours?
No, because it wasnt working & but after you left the RTG, someone from IT accessed to the monitor & activated the system.
Are reported to your supervisor about the breakdown of the system?
No.
Why?
I preferred to work manually
to show me how this system working, but you cant reach this system; as you tried to open it but you didnt find it, my question is : Are you used to work
Without it.
This system installed from approx 6 months, during this period you used this system?
No.
Why you didnt use it?
Because sometimes containers appeared clear & ready for loading , but when we check it before we found the cables is unplugged.
Are you trained about how to use it?
Yes.
Are you slept well before working ?
Yes.
Did you have any home circumstances which may affect on your concentration?
No.
YES
NO

YES
NO
NO
NO
Did you receive supervision in the last 1hr of your work: YES
NO
4 I decided to change to lane 06 I asked the wharf to move reverse he said its clear then I checked the mi
Q:Do you know about traffic SOPs in our terminal ?
A:yes,
Q:Does it mention that its possible to move reverse at any place in out terminal ?
A:No. it doesnt.
Q:So, why you moved reverse?
A:Normally we do so if a Wharf is guiding me.
A: Why you Hit however you have a guide?
Q:because I start moving while he was not in back side of my track.
Q:where he been ?
was next to my window he told me it was clear back and ask me to go on and I checked the mirror then I m
Q:did you check the mirror carefully ?
A: I checked the mirror once before start moving only.
(Truck Supervisor asked)
Q: did you left a safe distance between you and the front track ?
A: yes I did.
Q: are there any Trucks are next to you in lane 05 &06 ?
A:No.
Q:So, why dont you turn the wheels directly to the next lane as long its clear from tracks?
A: I decided to do reverse as it was clear.
ck Supervisor added if you turned lift to lane 5 and 6 it would be more easier and safer than reversing you
ontainer at 02H 14 and while lifting the container I forget to check the screen which showing the containe
Q:Do You suffer from any sight problems ?

A: never.
Q: was the vision of your screen was clear ?
A: yes it was.
Q:Do you know about new reefer system ?
Ibrahim Mahmoud Ahmed ID: 3482
A: yes, I know.
Q:So, why you dont use it ?
Department: OPS Out Source(Kotby) Position: TR driver
A:I was not concentrated and focused with work.
Q:Do you have any family problem ?
Experience: 2 Years
A: No I dont.
o me & ask to take container from QC 08 which was standby so I stopped in my Lane ,when the QC hoist
Q:So, what makes you not concentrated?
et down and start reverse move then I use TR hand brake to stop the TR but the TR didnt stop and collide
obody informed me, and I forgot, and with work stress and what happened to my colleagues before startin
-when the Wharf controller ask you to reverse back , What was the position of the container ?
(operator talking about the 4 cases which had been transferred to hospital before starting the shift.
Above the Trailer by approximately 1 meter .
Q:So, you think that was the reason of your accident?
-Did the Wharf controller ask you to reverse quickly ?
A: Yes.
No.
-Tell us what the sequence of your actions when Wharf controller ask you to reverse
1- I set down partially (shoulders towards right direction TERBREG Cabin door )
2-relase Hand brake (it was applied when I stopped first time)
3-change the Gear from N to R
4-start moving backward .
5-apply hand brake again but this time the gear still on R mode .
ng or instructed by your TR supervisors ,is it possible to stop the TERBERG TR using Hand brake while gea
No.
atement ,you didnt set down completely and move the TR ,Do you think you can control 100 % the TR in
No.
-Why didnt you set down in the normal position and move the TR safely and stand up again ?
I was afraid from QC operator rough handling on my TT which will cause me low back pain .
-Do you have any history of rough handling with 45 unit ?
t tier then I landed the container and to free the container i give unlock command and it shows unlock to
1st tier in A and 1st tier in B and 3rd tier in C so I moved according to the view I reach to the top and foun
them fall in bad D&E bays.
Q: do the vision clear in your cabin and the window is clean ?

Yes,
Q: How many hours did you slept before coming to the work ?
I slept around 6 hours.
Q: what do you think lead to accident ?
A: It was my fault because I didnt check whether the spreader is empty or not.
Also he added:
ck and unlock command on spring means if you push forward it may return to the opposite direction and
entioned from the operator on RTG 32 we found that: (after applying lock and unlock commands several t
He also mention the indication light inside the cabin for lock and unlock having the same color showing.
( lock(Red) and unlock(red)).photo attached
After checking the cabin the light indication lamps for lock and unlock are red.
Q:But in both cases it shows you not to raise the container because its locked ?
A:yes I was just mentioning that, but I know the fault from my side.
Ramy Elsaid Shehata ID: 184

Department: OPS Position: RTG operator
Experience: 7 years
my yard SV to go to 02 G 46 for handling OPS vessels/OPS gate reefers, when I arrive I start 2 rehandle move 02 G 46 F4&F3 safely but when I handle F2
-Does your Yard SV confirm with you about F2 ready for handling?
NO, but its logically if I have to handle F2 and found F3 & F4 unplugged F2 should be unplugged
-Did you check LOG system screen ?

SV was under RTG arranging Ext TR &Terminal TRs form loading and told me I will arrange the TRs acc to loading sequence so I understood that the uni
-Do you know that Gate reefers didnt connect or appear on LOG system ?
NO.
-Did you take confirmation from reefer Tec. Related to this bay before handling ?why?
NO. because there was a lot of EXT.TR & Terminal TR waiting in my range for long time and I thought all the bay ready for loading
o the mentioned address I found only one container in that bay, and I saw from my RTG cabin that the container was disc
received a call from the reefer tech. that the reefer was connected and I made a damage to the socket in the stand and
1- Did you checked on the new reefer load system that the reefer container was disconnected?
- I checked it and this container wasnt in the reefer load system.
2- Did you call any one from the reefer team to check with him before handling this container?
- No, I didnt
call Person:
them because
saw from
my cabin
connected?
Involved
Name:IAhmed
Isham
Sayedthat the container wasnt
ID: 1553
3- In your
job training,
did you depend on your vision when youPosition:
charge reefer
containers?
Department:
Ops
QC operator
- No, I took the risk from my side
to accomplish
the&job.
Experience:
1 year
1 months
Didfor
youfixing
receive
pre-shiftand
safety
talk:
unction, so we called the engineering team
the aproblem
it was
aboutYES
9:00 NO
pm, they told me to continue the
r under the deck I discovered that the 4 flippers didnt rise up (still down) so I stopped and try to rise it again before hois
receive
training
in how tohappened
do the task
involved:
NO I lift up a container from a
and made some moves withDid
meyou
on the
QC and
no problems
again.
After 30YES
minutes
y side under dick, I adjust the container between the cell guide and start to hoist down with full speed, I found that the 4
Are you aware of the rules / procedures related to this work: YES NO
engineering team for checking up the first problem with the flippers, did you stop operation with the QC till they came or
If required,
wearing
the normal
correct after
PPE: the
YES
I continued the work till they came
becausewere
the you
flippers
retuned
call, NO
avoiding slow down the operation
2- How did you know that the 4 flippers are up during operation?
Did you receive
supervision
the last of
1hrthe
of equipment.
your work: YES NO
- I depend
on the in
efficiency
How
do you
this
incident
could
beifavoided
in future?
3- From your
position
in think
the QC
cabin
can you
see
the flippers
are down or not?
- Never take the risk and call the reefer
- Yescoordinator
I can see it.to check the status of the container.
4- Why didnt you check the flippers position before hoisting up in land side?
- I depended on the efficiency of the equipment, and I was accomplishing the work saving a time.
5- Did the wharf tell you that the flippers were down before hoisting up?
- No, he didnt tell me (its not possible because it is the operator manner).
6- When you made a hot seat change with your colleague, did he mention any problems he faced with the QC?
- No he didnt mentioned any problems with the QC.
YES NO
YES
NO
NO
NO
Did he/she give a pre-shift safety talk: YES NO

When was the last time you spoke to or witnessed the involved persons work
Involved Person: Name: Ahmed Sadat Ahmed Qassem

ID: 108
Department: Ops
Position: QC operator
Experience: 8 years
ours and I didnt complain from any defects during my working time except one break down happened that the twin moo
work properly for the rest of my working time on the QC09.
1- While your working time did the spreader get stuck or hit any thing?
- No, nothing happened more than the usual operation.
2- When you received the QC 09, did the last operator complain from any thing?
- No, he didnt mentioned any thing.
3- Did you call the maintenance team when the twin mood was defect?
- I told the wharf and after I pushed the reset bottom the twin mood worked properly.
YES NO
YES
NO
NO
NO
Direct Supervisor: Name: Mohamed Hegazy
ID: 776
Department: ops
Position: Vessel supervisor
The normal, also the distance between the twin & the collision was very small.
If the deck controller was attended this case, did you think that he can avoid this incident?
nk so, because it was normal operations, but sometimes he can see the structure of the vessel which I cant see it from t
YES
NO

YES
NO
NO
NO
Really I dont know.
Direct Supervisor:
Name: Mohamed Hegazy
ID:
Department: Ops
When was the last time you spoke to or witnessed the involved persons work?
During the normal operations time.
Who is the responsible of monitoring the vessels structure which may affect the operations?
Name: Waleed Mohamed Soliman ID: 0865

Department: OPS Position: BS Driver
Experience: 2years RTG Operator then return BS Driver from 6 weeks .

as driving OPS BS 05 from north barking to muster room suddenly I feel snooze and I surprised by container in front of m
- How many hours did you slept yesterday?
From 9:30 pm to 4:30 am
- Did you feel fatigue ?
NO ,but the weather was dusty and very hot which make me snooze .
- When did you felt snooze ?
While I was in
front of
Khalid
ID:amenity
1018 building A
- Did you take any medication affect your consciousness during working hours ?
NO.
Department: OPS- Position:
RTG Operator
- Did there was passenger with you ?
NO. the bus was empty from
passenger 2.5
. years
Experience:
- Diddown
you fasten
your
seatthe
belt
?
R enter under RTG I catch the rear unit and hoist
1 meter
above
trailer
till the TR driver adjust his position .whe
Yes,
unit then I went to next unit (front one )
But
when
we
(investigation
team
)inspect
the cargo
scene coming
we found
thethe
beltrear
wasunit
fasten
onitsempty
seat
While loading front unit I surprised
by some
from
from
bottom.
-why
didnt
thespeed
seat belt
in proper
- What
wasyou
your
hoistuse
down
while
loadingway
rear?unit?
Allspeed
of my,generally
colleaguewe
usestop
the hoist
seat belt
in that
wayto(only
upper
belt only
) .
Slow
before
landing
ensure
correct
position
- What is the RTG operator guide for this type of trailer ( DUTCH LANKA )while loading process ?
This type of trailer have two blind point for the operator
1-the rear edge small
2- the main chassis is very narrow and middle locks not appear to operator while loading
So we depend on the TR driver who stopped after ensure the trailer is correctly stopped .
- From your opinion how can we avoid this accident ?
To make the DUTCH LANKA trailer dimensions visible to operator as the modification on TT 118 .
- No, I didnt make any movement.

7- How long you was working?
- I was working From 2 hours.
8- Did you sleep well yesterday?
- Yes.
YES
NO

YES
NO
NO
NO
- We can install cell guide in all bays in A and G to prevent any fallen containers.
Direct Supervisor: Name:
Tamer Abu Slema
ID:
1501
Department: OPS
Position: Yard supervisor
Abd Allah Ahmed Naem
hour
ID: 3400
ss under QC 13 then I moved to berth

I waited
for
clearness
from
moving
trucks on berth, then I adjust my
I didnt
know,
because
I didnt
open
it.
Why
youslow
didntdown
open and
it? then stopped suddenly and suddenly I h
the front truck to discharge, then the truck
driver
In discharging
operations
we usedmay
to work
without
it.
Do you
have any family
problems
effect
the work
?
Are you trained for -No,
that you
mentioned
in
the
above?
I dont.
No, we trained about using the screen in all conditions.
What was your speed ?
Why you didnt ask the wharf controller instead of using the bypass?
I was just
moved
down
of theascrane
and
I even
think
I have
the 2nd
gear,this
I was
less than 20.
I think
that this
container
an open
top
& the dont
spreader
deal
with itshifted
as this type,
so I used
command.
s moving with two containers Did
each
one
was
about
18-19
tons
whichoperations?
may cause the truck not to stop imm
you
make
this
behave
in your
general
Did
check
the
very
well before
? is the same in the 1st in
the container in the 1st raw
in you
seaside
wasfor
40 Ft
& clearance
as the normal
operation
the 1stmoving
raw seaside
Before start discharging
bay,
you was
ask the
wharf about
your discharging plan?
-Yes, I hit from
him this
after
mydid
truck
in straight
position.
No. ? how was he drive?
What about the front driver
-He slowed down slightly and immediately stopped, and I did so as well.
you receive a pre-shift safety talk:
YES NO
What wasDid
the
distance between your truck and
the front one?
-It wasinabout
container.
Did you receive training
how to40
do the
task involved: YES NO
I think 40 container is enough to stop if you are driving less than 20 Kmph, what do you think ?
be able to stop the truck
andaware
I meant
torules
move
the TR head
away
from
the accident
Are you
of the
/ procedures
related
to this
work:
YES NO by steering right but
distance if its 40 container distance or 20 container length). The driver said.
If required,
werelights
you wearing
correct
YES were
NO working?
Did you observe
the stop
for thethe
front
TT? PPE:
Does they
-No, actually I didnt notice.
Also he added this is not the place which the Truck can stop on the way so I didnt expect him to stop.
1- To follow the safe handling procedures.
involved
person
ll the Bypass command.
2- To ask the direct supervisor
before
using
CanII:you
describe
what happened
Involved Person
Name:
Adel Mohamed
Elwakeel ? ID: 01566
Department:
Ops I slow down
Position:
or charging I found captain TR
stopped then
and D&W
give Controller
some horns to harry him but he didnt m
Experience:
5 Years.
irror I found the truck at my back, then Cap Tr ask me to go for discharge
(by using hand signs which is a
Did you apply break suddenly ?
Can you explain what happened in brief?

No,
I
didnt
it
was
a slight press just to slow down. (the truck didnt stop)
the work instruction. There was only 6 moves on deck remaining and then the crane start to open the center hatch cover
I was
just reducing
my about
speedthe
to bay
come
under
the QC.
at my supervisor asked me about
something
concerned
plan
and I forgot
to tell the operator that the 1st r
Can
you
observe
if
the
back
TR
driver
was
close
to
you
? his answer was he lifted bo
1st raw land side container is 40 feet or 2*20 feet, I answered him that it was 2*20 feet then
No I couldnt spreader
observemode.
,then I asked him
e normal working instructions to inform the
QCit operator
about
the working
sequence
or any strange situations in the bay
Was
about 40
container
length
?
Yes.
No, around 20
container length.
Can You describe what happened ?

side operator cabin and this job required 2 persons one for tightening and the other for grasping the bolt i
manage hand movement, so I lost control for the tool and it fallen down.
Did you
use theHandak
gloves for
this process?
Mohamed
Saada.
ID: 3588
Yes, I used it.
Department: Ops
(Trademar)
Position: TR supervisor
Did the wrench was
oily ?
Experience:
14 Months
it was
not.12 to confirm the container, and when I was d
nfirmed by the QC 14 Wharf, but he told me toNo,
move
to QC
do you
think
we
can avoid
reoccurrence
forPU
that
ng in front of this TR, How
and there
was
also
another
TR was
behind the
by incident?
a distance of a length of a TR
We can
use a with
special
for such
process.
ately my TR rear right rubber wheel
clashed
thetool
PU back,
causing
the ENG PU forced to move toward
1- Could you see the PU in your mirror when you maneuvered?

rted to couldnt see it when I began to straight my TR in the main drive way, and hence the accident happ
2- Did the ENG PU 08 was in the waiting area before you came to QC 12?
s, it was in the waiting area, and was there even after I get the container confirmed and start to move my
3- Did you see that the distance between the other TR and ENG PU 08 could let you pass between them?
- Yes, I saw it was enough, it was approximately a distance of TRs length.
YES NO
YES
NO
NO
NO
- No pick ups wait in this area (the waiting area behind the back reach).
Direct Supervisor: Name: Hany Nour
ID: 3588
Can You describe what happened?

er at 4th raw sea side which is a blind point and after free the container I hit while I was raising the spread
Was it your 1st move on crane?
-no it was the 4th move but 1st at the blind point.
Did you use full speed while hoist up ?
Yes.
Was there a deck controller with you at the time of incident?
-No, we were working 4 cranes on vessel so he may be busy with other QC operator.
So, why you dont call him ?
-because its normal procedure for me and Im familiar with it.
If its a normal procedure what you think the role of deck controller ?
For opening/closing hatch covers and loading/discharging in case of stuck containers.
If you not using full speed while hoist up does it make any difference ?
es, any also there was an open top container and it has a wide base which made it more difficult for vision
statement had been taken for the deck controller, he mention that he was not with the Crane time of incid
Also structure of the vessel is free from any deformation that may cause the damage.
Department: OPS Out source Tradmar Position: TR Driver
Experience: 2 years
rt to drive between 02 lower & Higher to get quay side when I reach F block I notice my colleague coming
while reversing back I hit ENG PU 01
ur training period or working in operation ,did you trained to reverse back in side Yard or under QC withou
No ,I didnt
-Why you reverse ?
To ask my colleague which QC he working with, I was stopped near RTG turning plates .
-Did you check the way behind you before moving backward ?why
No , because I have reefer unit on my trailer which block my vision .
-How many meter you moved backward ?
About 1.5 or 2 meter
-Did PU Driver notify you by horn ?
ar due to my TR engine noise but my colleague try to stop me by shouting and horn but I realized after co
-Did the PU driver switch the light on ?
es ,after accident I descend the TR I found light on but he was in the middle of my trailer and visible to me
Witness: Name: Wael Abd ELshafi Mohamed ID: 0060
Department: ENG
Position: First Elec.Tech.
Experience : 9 years .
ming from 02 G carrying reefer unit so I wait him to make his maneuvering then start move when we reach
me .
-Did you notify him by horn ?
but I get confused when the TR stopped ,as I didnt predict if he will continue or he will revered his direc
-when you realized that he reversing back ,Why didnt you try to avoid him?
I start moving back but he was already hit me .
-What was the distance between you and TR 09?
About 1.5 or 2 meter.
-How many meter did you moved backward ?
About 3 containers raw (G,F&E)
-Have you internal PU driving license ?
YES
NO
Start to handle the uneven twin containers first.
Direct Supervisor: Name: Saad Kamel Ashry
ID: 883
Department: ops
Involved Person: Name: Adel Dyaa El Deen Bayoumy.

ID: 1196
Department: Ops
Experience: 6 years
twin containers from the 4th row quay side under deck but we couldnt due to the twin was uneven. So we started to ha
wins containers in the 3rd row. We handled from the 3rd row quay side 3 twins containers and no problems happened and
the 4th twin from the same row, it hit the uneven containers on the 4th row quay side (the next row).
1- Did the your vision was clear during every move?

because I was stand on the cat walk of bay 34 due to no hand rail was exist in the cat walk of bay 30 (Nature of the ves
2- What was the speed of the hoisting down the spreader at the time of accident?
as the normal speed, and the same speed of handling the previous 3 twins containers on the same bay (3rd row quay sid
3- Did you feel that the vessel moved (make list or trim) while you hoist down the spreader?
Experience: 7 months.
7 then my address changed on the display to 05 J then I directed to there and while maneuvering my truc
Did you slept well ?
Yes.
Did you suffer from any fatigue or stress?
No.
Do you have any family problems ?
No.
Involved Person: Name: Hazem Yehia Taha
1869
-Was the area crowded with external truck that enforced you to make ID:
sharp
maneuvering ?
Department: Ops
Position: D&W controller
Yes it was, but it was not that
much crowded.
Experience:
18 months
-So
why
did
you
do
sharp
maneuvering
?
made the last move I checked the gang way position because the QC 14 would be moved
to another bay and I found the
Because
there
was
a
truck
in
front
of
me
and
other
one
back
to
me
which
made
me to
maneuver
her vessel behind MV EGY PRINCESS was sailing causing MV EGY Princess moved suddenly and
hence
the gangthat
way way
mov
damage
to thefor
gang
way.
-whyayou
not wait
clearness
?
Actually it was a bad estimation from myself and I didnt expect that may cause an accident.
1- When did you checked the gangway?

- Aprox. 5 minutes before the QC 14 moving, during the last container move of the QC.
2- Did you notice that the other vessel which in behind MV EGY Princess was moving?
- No, I didnt notice.
3- What is your position while the QC is gantry?
sea side when the operation will start, and from land side (back reach) in the middle of the operation because there were
4- From your point of view, what was the cause of the damage?
- The vessel was moved suddenly and unexpected which made the gangway change its position.
YES
NO

YES
NO
NO
NO
NO
I dont know
u know that there was a deck controller assigned to work with you as you are the only QC working on this
Yes,
eck inspection for the under deck cell guide status is it clear from abnormalities or not ? & why didnt you
Normally ,we (QC operators) start working after Wharf controller confirmation not Deck controller
Involved Person:
Name:
Toney
Hasan
Farghalyassistance ?
ID: 3269
-When
you
askAhmed
for Deck
controller
Department: Ops (Trademar).
Position: TR driver
rong with any move under
deck or on deck. And sometimes we work without
Deck controller at all and we
Experience: 2 years
-Did you notified about this type of cell guide before working ?
No.opposite of me, then the RTG operator told me to get back
RTG and I found that another TR was entering but in the way
-Who
you
loadingmy
instruction
to start
4 container.
moves?
back
andgive
while
I adjusting
TR, my trailer
hit the
1- Did
you
know that
reversing
back Iisascend
not allowed
inside
the both
yard?of them under QC .
I dont remember who
was
working
as the
wharf
but when
the QC
I see
- Yes I know but it permitted only to adjust my TR bout aprox. 2-3 meters.
2- While
you reversed
back ,WasRafaat
your TR straight
or not?
2-Name:
Abd Elrahman
ID: 0979
- It was straight.
3- In your point of view, why did you hit the container?
Department:
D&W
Controller
tle and so I decided to adjust it and while
I was doingOPS
that Position:
the left end
of my
trailer disappeared from my left mirror and
4- While you reversed back, were you looking to the front or to the end of your trailer?
7 years
- To the end until it disappeared to Experience:
the head deviation.
5- Were you
busyassigned
with any thing
whileas
you
reversed
back. and I work as wharf contro
ELsawaf waiting in wharf cabinet.
he was
to work
Deck
controller
reader stuck many times today morning, but he- No,
asked me to changing our positions (I work as a deck &h
working bay and before I arrive, I surprised by the spreader stuck .

YES NO
-Did you take confirmation
from the Vessel SV about changing
position ?
Did you receive training in howNo,
to do the task involved: YES NO
-Who give instruction to start loading process to QC operator?
I did, related to this work: YES NO
at mean you give instruction to QC operator while your deck controller stand beside you under the QC ,Wh
If required,
were operation
you wearingcome
the correct
PPE:
YES
NO SV .
Instruction
for start
directly
from
Vessel
d you inform Vessel SV about current situation (D & W stand under the crane )before confirm start operatio
Did you receive supervision in the
No,last 1hr of your work: YES NO
-Do
you
think
presence
of Deck controller with the operator on board will prevent this accident ?
- Get out from the block to let the other TR to pass and then start to adjust my TR inside the block but not with reversing
Sure.
-if the same scenario repeated what will you do ?
Did he can see the spreader from his point?

For sure no.
Why you asked him, as permission?
No, just to give me the bypass order to let the operator move up.
Are you used to take the same decisions as a regular?
Some times.
Why?
From my experience in similar situations.
The radio channel was clear?
Yes, we take the crane channel to get the clear communication.
In your point of view, what was the root cause of this incident?
Take the decision without thinking.
YES
NO

YES
NO
NO
NO
NO
- Yes, I knew they were heavy.

2- While your maneuvering, did the rear tires squeeze?
No, I was see the left rear tires in my mirrors and they werent squeezing (the damage was in the double left rear tires).
en the waiting area & the beginning of the Mike would allow your TR for getting the maneuvering without squeeze the tir
- Yes, with my point of view it would get my TR maneuvering without squeeze the tires.
4- Did you know that it was wrong to move directly on the rim of the tire?
- Yes, I know but the TR was blocking the way.
YES
NO

YES
NO
NO
NO
- If any thing Wrong happen to my TR I will stop and not move from the place until TSV come.
Department: ops
Hany Nour
ID: 1423
Position: TR supervisor

YES
NO
NO
NO
- I must leave the safe distance away from the RTG lane.
Involved Person: Name: Haytham Ismaeel Thabet
ID: 755
Department: Ops .
Position: RTG operator
Experience: 7 Years
opped at bay 42, so I shouted from my cabin window because the microphone wasnt exist to the TR driver under my RT
ring under the RTG but I stopped him and informed him that I need another TR with him into this bay 58 and then TR 59
to them to let TR 59 entered first, but I surprised that a third TR driver (his TR was at 05 C Lower) came and stopped the
to each other, so I hoist down the spreader and I called my Yard supervisor to solve the problem. The YSV sent the TSV w
abin to inform the TR SV that I will move to bay 42 and I didnt know if he get my message or not then I made gantry an
1- Why did you hoist the spreader down?

nd the three TR drivers came out of there TRs onto ground and starting to talk to each others, and they didnt want to en
2- Is it allowing to hoist down the spreader to be close the ground?
- No, its forbidden unless in presence of the maintenance team.
n RTG 45 then I went to the Workshop to drop the workers then I returned back to the workplace to pick th
barrier.
Did you fastened your seatbelt the time of incident ?
-yes.
What was your speed ?
It was around 25 Km/hr.
How many hours did you slept at the morning ?
around 5 to 6 hours as today is Friday and I have to go for prayer at 12:00 noon and I slept from 1:00 to 6
Do you suffer from any disease that makes you take a medication that may effect your concentration?
-no, I dont
Were you had a company while driving ?
-No, myself only.
Why you dont ask your supervisor to take rest as long as you were tired?
-we had a overwork as we were working on PM at RTG45, so I didnt take a rest.
Experience: 5 years
ind the yellow line and I had been informed from vessel supervisor that we will move gantry from K-stream
C operator to move gantry to ALBAMA then I found the K-stream gangway hit by QC 16 then I informed the
When did you informed the QC operator to stop ?
-I informed him when I found that the gangway hit by QC16.
When did the QC operator stopped gantry ?
-he stopped with the last STOP call.
Was the damage as we checked on live scene ?
ked the QC operator for moving back After the accident the gangway stuck with berth bollard causing se
What was your position the time of accident ?
-I was on lane 3, the vessel SV asked me did you checked the vessel gangway I told him yes its clear.
How did you checked the gangway was save ?

-I checked because we had to adjust a container on position 2 berth-side and I was close to the gangway.
When moving gantry what is your proper position on QC ?
-Not always near to the sea.
Involved Person I : Name: Amr Waleed ID: 182
Department: Ops Position: QC operator
Experience:
visor that we have to move to ALABAMA MV then I moved gantry to the vessel then I heard STOP..STOP
Did you noticed that you are near to gangway or the is a possibility to hit the gangway ?
-No, I just asked him to secure the area and make sure its clear from obstacles.
Did you watch from your cabin Wharf position ?
-Yes, he wasnt near to gangway.
In normal procedure how is the communication between QC& Wharf ?
-we have to get clear message with confirmation.
Why you asked him to check for gangway ? did you noticed gangway from your cabin ?
trolley berth-side as I was starting to move gantry and the vessel height lower the Quay cell beam, which
YES
NO
NO
- The sensor must work properly.
- Dont make gantry with full speed when there was a RTG exist in my way.
Department: ops
Hany El Bostany
ID: 1567
Position: Yard supervisor
Witness Person: Name: Mohamed Ali Abd El Fattah Isa

ID: 1003
Department: Ops .
Position: RTG 38 operator
Experience: 2 Years & 6 months
was working at 04 B 29 , and while I handled a container inside the bay I felt a hit with my RTG, then I found RTG 05 hit m
1- Did RTG 05 was gantry with full speed?
- I dont know, because I was concentrating with handling the container inside the bay.
YES
NO
NO
Technical Advise/Report: Name: Hesham Nagy

Department: ENG
ID: 0473
Position: ENG Shift Manager.
Comment:
- Was the pane that fall down is the original one of the Operator cabin?
No.
- What is the reason behind changing the old pane with a newer one?
. Complain mail by 17/03/2013 we begin to co-ordinate with the subcontractor to provide a newer pane to
- Did the pane installation process performed by the SCCT Eng. staff?
No, because Eng. staff are not fit for such process so we ask for a 3rd party to perform the task.
- Did the newer pane was within the supposed specifications or not?
There are no exact specifications available concerning the glass.
- Did you receive any complain regarding the newer pane from operation?
We didnt receive any complain from Operation about the new pane till the date it fell down.
- Was it the first time we deal with that subcontractor?
No, it isnt, and also he had a good history (about 8 years) for providing us with all SCCT Equipment.
- Does the Status of QC operator cabin glass involved in PM checklist?
No, it isnt involved.
- Do you think that the vibration of the operator cabin play a role in this case?
Just if the pane was incorrectly installed in this case it may fall down.
you prepare a standard procedure to test the effect of vibration on any mounted object in the operator ca
ulted from the crane movement wasnt the main reason behind this incident especially that the crane vibr

When was the last time you spoke to or witnessed the involved persons work 1 hrs ago
2-Name: Mahmoud Mohamed Metwaly ID:1726
Department: OPS
Experience: 1.5 Year

oved to vessel to catch another Twin ,while making my pass(hoist down +trolley) I surprised by TR waiting in lane 02 bu
1- Did you noticed TR in lane 02 (TR 107) before you discharge the Twin ?
Yes I noticed his presence but I thought it was out of my spreader pathway .
2- When did you notice the TR 107 position?
While I was at lane 02 but I was so close to the container on the TR 107.
3- Did you use your cabin mirror which provide a backward vision ?
No I didnt .
4- what was spreader path movement speed ?
It was full speed
5- Did TR 107 was moving or not?
It was stopped.
6- Was the hoist limit switch working or not ?
It was working properly .
7- Did the wharf notify you about TR waiting in lane 02 near your handling TR ?
No. he didnt
YES NO
YES
NO
NO
NO
- No, it is the 3rd one.

2- Did you sleep well yesterday?
- Yes, I slept about 6.5 Hrs.
3- Did you feel fatigue previously in this shift?
- I had a slight flue and a took a medicine (Paramol).
4- Did you feel the drowsiness in this shift before?
- Yes, I felt the drowsiness one before the time of accident and I washed my face and continued my work
5- Did you tell your SV about that?
- No, I thought it was little fatigue and will be gone by washing my face.
6- What is your training instructions when you feel fatigue?
- I call my TSV who send me to clinic which decided to continue or not.
YES
NO

YES
NO
NO
NO
Experience:
Name: : Mahmoud
El-Mor N/AID: 1047
Involved Person:
mpanied by a PU belonging to gate service to drive me to myDepartment:

location andOps.
left me,
after I got
2 containers I tried to get out then I found 2 Ext. TR. (One of the
Position:
QCthe
Operator
he time I was about 1 meter from the bays margin when I was maneuvering to the left side I get surprised by a TR moving toward me moving at the opposite sid
the bay. Experience: 1.5 years.
Summary of statements :
2 20 Containers sea side and the view from QC cabin showing that the bay and cell guide of the bay is looking smooth and clear, normally to make easy while
What was your speed
you tried to maneuver?
wrongwhen
happened.
at low speed (about 20 km/h) because I was loaded by an empty containers
and
I
was
What was your hoist afraid
speedthat
? the containers may fall down at any moment if I increase my sp
It was normal speed but I slow down before I reach to under deck for a distance 2 containers height.
Was it your
first was
time your
entering
What
load the
? terminal?
No,
I
entered
the
terminal
many
times
before
through
the77
lastor278
months.
Around 60 tons, then it showed overload after I stacked
tons.
Was there is a Deck controller with you on vessel ?
Do you
awareQC
about
thewere
trafficworking
directions
thecontroller
terminal?with 4 QC then he moved to QC 14 for hatch cove
h me but during loading first single units but he moved
to other
as we
withinside
1 Deck
and I was depending on the other ext. trucks as a guide, and I noticed the direction arrows outside the containers blocks because I was familiar to it but inside t
Do you understand what is written in the bat number regarding the driving instructions inside the terminal?
No, as I cant read or even write, so I wasnt able to understand what is written and when I got that bat number I use it as a sign to ask for my location.
Do you have a driving license?
Yes, I have a 2nd class license.
Do you have an entry permit?
Yes, I have. But after the accident happened I searched for it but I didnt find it.
Are you the main driver of that truck?
No I am a spare driver as the main driver has special conditions inhibit him from working so I am working instead of him.
Did you noticed the truck before collision happened?
Yes, I noticed it but I didnt imagine that it will hit me because the TR driver should take his right-hand direction and I was taking my left-hand direction.
I face the same conditions for another time what you are going to do?
I will take my caution asking for the directions inside the yard and will follow the instructions because my life was in danger.
Witness Person:
Name:
Ahmed Megahed Hassan
ID: 3225
Position: TR driver (Trademar)

Experience:
3 years
Can you explain in details what did you see?

I was entering from the A container block going from QC 14 toward 3 G 42 and there was a truck in front of
r the truck?
R screen.
e same truck before taking my
ng?
Involved Person: Name: Mustafa Mahmoud Mahmoud Ali Atia ID: 1699
Department: OPS Position: QC operator
Experience:
1 month
k at the 5th row sea side, I discharged 5 containers from this row and while I hoist down to get the last one, the spreader
d while that the spreader stuck and go up in sudden way and hit the up deck containers, then I started to adjust it and I
V about that then I decided to go to 4th row sea side to discharge the containers in unveiled row, I get a container from 4
r was on the container on the TR and it was ok but the wharf informed me that there was a problem in the right land sid
e in the blind row, and while I hoisted down, the spreader couldnt enter the row then and while I was adjusting it the spr
w and hit the lift side of the row (hand rail), then I tried to made it stable and after that I told the deck controller to start e
cause the flipper guard was hit causing a sharp edge and there was a cut in the two containers in the 6th row under dec
1- Did you call the deck controller before you started to dealing with blind row?
e I knew that he dealing with QC 06 in the same vessel, and there was one deck controller dealing with two QCs in the s
2- What is your training instructions when you want to handle containers in blind row?
- Call the deck controller to help me and if he was busy with another QC I can handle with my self.
3- In the first hit, what issues did you check in your spreader?
flipper and found that it was a small dent in the right one and when I was in quay side I checked the spreader movemen
4- Why did you decide to continue the work when you find that there was a problem (changing in flipper shape)?
- I thought that it was a small dent and I wouldnt use the flipper because I was in discharging process.
5- When you check the spreader status after the first hit did you see that there was a broken nail from the flipper?
- I didnt check it well.
Involved
speed at the stop mark then I noticed the truck was moving toward me so I expected that it will stop, but suddenly I f
d & of the container) in front of me.
the end tip of the trailer.
er?
Involved Person I : Name: Ahmed El-Ezaby
ID: 1017
Department: OPS Position: RTG Operator.

Experience: 2 year.
I moved
to bay
67 for
discharging and while hoisting up I surprised the twin containers att
e then
should
stop as the
priority
wascontainer
mine.
As the two twins were in different colors why you didnt notice ?
- I was not concentrated.
What was your time rotation for work ?
- I was working from 3-6 AM.
Did you felt tired while working ?
- Yes,
How many hours did you slept before work ?
- I slept from 2:00 AM to 10:00 AM and didnt sleep since 10:00 AM.
Why you didnt sleep after 10:00 AM ?
- I was busy with some family issues.
No, I didnt notice if he was on deck or not.

Did you hear any message from the deck telling you to stop?
No, I didnt hear any message from the deck while opening the HC.
Did you know who was working with you on deck?

ess if I had a problem, in this time I asked the wharf for the decks name and I call for him on the radio ask
nemr beside the bay before opening HC. After the problem happened the other deck appeared and started
Involved Person:
Name:
Position: Deck & Wharf

Experience:
3 Years
rking for QCs 7&8 while my colleague was working for QCs 5&6 and there was a problem in bay 34 that th
e for it, so I went to my colleague to give him a disclaimer form paper and after that I searched for the dut
are ready, after that the operator open the yard side HC and start to discharge 2 containers from under d
other 2 HC, so I told him that the operator would discharge 2 containers more then would open the other
I found the QC stuck from the right side while opening the Sea side HC so I told the operator to stop imm
Did you check for the hatch covers locks before opening them?
cause I wasnt the deck that responsible for the crane, since it was the responsibility of my colleague but
But Duty officer told me that all HCs are ready to open.
Did the QC operator ask you whether the HCs are ready or not?
No, but the wharf controller who asked me.
Where was you when the seaside HC was opened?
I was standing below the catwalk because there wasnt a safe place to stand on the deck.
Did you notice any one standing with the crane at the time the incident happen?
ound the spreader shifted toward the vessels bridge and when I was shifted the spreader away from the bridge I noticed a container fallen
e?
g the below container.
bridge and I thought that the vessel was moving. But I think that the fallen container was approximately still inside the cell guide and wh
the quay.
ent to happen
Did you make hoist up at high speed?

No, it was just a snatch not a full hoist up.
Did you check with deck controller before your hoisting up?
Yes, of course .
Did you notice whether the middle twist locks was closed or not?
No, as I cant recognize that from my vertical position and it was a blind point to me.
When you was hoisting up have you got any alarm for overload?
No, the crane did not record any sign for overload.
YES
NO
NO
YES
NO
NO
NO

I will stop trying to do anything and will ask for the maintenance help at once.
Witness Person:
Name: Amro Moheb
ID: 1739
Experience:
3 years and half
de and I was standing at the right side, in the first I noticed that left side was not setting properly (away from the corner
little bit but nothing has happened after that I shifted to the right side.
ears
ainers then I have to move gantry to handle in bay 04 E 18 ,so I start moving but unfortunately when I re
little inside the 04 E block to adjust the RTG on its lane .
ve way that I hit his TR.

d you notice any deviation ?
joystick .
stopped at the middle of bay 38.
?
wer ?
efore cross and switch the spreader mode to 20 feet mode.
deviation )how will you response ?

or to contact ENG dept.
RTG at 06 F for repairing purpose ,the same problem appear again and one from ENG. team inform me th
ID: 3380
R Driver
04 E L in front of bay 34 then I noticed RTG 23 was coming from 04 E h to 04 D L ,when RTG reach turning
repeated horn but he didnt notice me and hit my TR .
Your right mirror was adjusted at the right position or not?

ut the mirrors stand was moving with the TR movement so I couldnt able to adjust it every time at my wo
workshop in order to fix the mirror issue.
why you didnt try to get out of the TR and talk to the RTG operator or just press the Emergency
Stop button?
ance is quiet enough to me to make my movement but unfortunately the tail slightly shifted toward right s
Did you attend today safety talk?
Yes. It was about respecting safety roles inside the terminal and follow safety regulations.

Department: OPS
Abd El-Alim Abd El-Fatah

ID:
3295
Position: TR Driver (Trademar)
Experience: About 2 years & 6 months
as after the Stop sign about meter and there was RTG moving from the left side of the TR driver and als
the TR driver surprised by the coming RTG he tried to make a reverse movement but unfortunately there w
noticed the reversal movement of TR 15 he used the horn many times in order to stop TR 15 driver.

Department: OPS
Mohamed Ahmed El-Shaabany ID:

1721
it, then returned back and waited for the coming truck, once it arrived I took the twin that was loaded on
about or meter I noticed that the twin mode wasnt activated so I hoisted twin move downward on th
At any time did this incident happen?
Incident happened at my 2nd hour.
Did you check for the twin lamp on the spreader?
Yes, it was illuminated, so i pressed the lock button.
Did you store the twin mode after your 1st move?
Yes, I stacked the 1st twin move then I stored the twin mode and returned back to another twin move.
Did you notice the incident by yourself or the truck driver who informed you?
each twin move for about a meter before get a full hoist up so I noticed the incident from the beginnin
How much time you waited till the next truck arrive?
I waited for about 3 or 4 minutes after the previous truck left.
Did you attend today safety talk?
No, because I came early today.
No, there was no deck on the bay as it was the time of handover and the deck was at the gangway.
Do you have any feedback about that vessel?
Yes, i have a feedback concerning that vessel but i wasnt know that it was the vessel that i worked on.
Do you informed by deck controller about any old damages in the bay?
No, as it was my first move and the previous operator just loaded only one 20 feet container inside.
Did you attend today safety talk? What was it about?

bout the competition and we have to work hard to make a better productivity but there was no mention fo
Is it normal operation procedure to make a full hoist down while descending in a cell-guide?
the normal is descending in a low speed till passing the 1st quarter of cell guide then hoisting in a full spe
After stuck happened, did you try to make any movement with the spreader?
No, i just stopped and informed the deck controller.
Involved Person: Name: Tamer Mohammed abd elatif
ID: 147
If there was a deck with you on the bay, do you think that the accident would happen?
would for sure follow up with me
at each move
about any
old damages inside cell gu
Department:
OPSand would inform me
Position:
QC operator
How do you think this

incident could
be avoided in future?
Experience
: 9 years
I moved to discharge another 2 20 container on deck 2nd raw sea side at bay 16, I landed my spreader
pen
on theto
vessels
board
was
to spreader
the absence
of deck
so Ibut
think
that providing
a deck
contr
e
is tilting
sea side
I tried
to due
adjust
position
by controller,
list command
I failed
then I tried
to hoist
up
up from my cabinet, once i started to hoist up I noticed the middle twin twist locks was out and seemed t
Witness Person:
Name:
Islam Gabr
ID:
673
Have you felt
something abnormal
that may lead to that damage?
Department:
Position:
& Wharf
then I hoist up
and it was OPS
working then I moved to 2nd twin
I tried Deck
to hoist-up
butcontroller
I doesnt respond and I
2 years
from 1st Experience:
time.
Is it the normal procedure to ask the wharf for by-pass if you find something wrong with you ?
Where was
when
thethis
incident
happened?
No its not the correct procedure
but you
I have
done
to save
time as there was not any risks.
my handover with What
my colleague,
I knew
about
the incident
I made
handover
was your and
hoisting
speed
before
landing after
on last
2 20the
containers
? when the QC op
It was normal.
Involved Person: Name: Khaled Ibrahim Abd EL Aziz
ID: 3566
Department: OPS (Sub. Trade mar Co.) Position: TR Driver

Experience:
2 Years
ray area , the attached low bed of my TR hit the X ray entry gate by one of stopper bars which was not straight and I w
1. Did you checked the low bed before you entered the X ray area ?
- No , but I know that a lot of stopper bars were not straight .
YES
NO
NO
- give more attention of the others faults.
- Keep a safe distance between me and the front TR.
Direct Supervisor: Name: Mohamed Braia ID: 1364
Department: OPS Position: TR SV
Involved Person: Name: Baleegh Hamdy
ID: 3516
Department: OPS ( Trade mare Co.) Position: TR Driver

Experience:
5 Months
ay side) to enter berth 04 then I slow my motion to pass TRs in the opposite way and while I was start to enter Bert 04 I
Department: OPS
Experience:

About 1 year & 6 months
54 on the same block and took a container for discharge from a truck and put it in the Bravo row, but I fou
Gulf & Fox rows so I started with the G4 Container but while I was lifting it I found it still plugged in.
Did you check the reefer log system screen before lifting the mentioned container?
No, i didnt because of lack of attention.
Did you try making any connection with the reefer technician on the bay?
No. I didnt try to ask for anyone.
Did you feel fatigue due to working stress?

ere was a lot of trucks waiting for loading on bay 54 and also i didnt sleep well yesterday as i slept only fo
heck for the reefers that ready for loading on the Log system or even check with the reefer technician bef
Mohamed Elsayed Ahmed
ID:
1921
Department: Engineering
Position: Reefer Technician
Kindly explain what do you know about the incident?

was a loading instruction on bay 54 and once I reached the bay I found the RTG operator lifting the conta
Is there any way to inform the RTG operator if the containers are unplugged or not?
TG operator if the containers are ready for lifting or not, these ways are either through Log system or throu
How many containers on the bay have to be unplugged?
There were 7 containers for loading on this bay and the mentioned container was the first of them.

s were taken are enough to avoid re-happening of such incident and I think that it was happened because
Ahmed Antar Mohamed

ID: 3745
Department: OPS
Position: TR 143 driver (Cambell)
Experience: One month
me from the berth and entered the road between 06 lower and 07 higher to enter 06 D lower and there was TR 62 behind
ght to enter 06 D lower but suddenly I noticed OPS.bus.04 was coming with high speed from left side so I waited the bus
7- What was the distance between you and TR 62?
- I dont know.
8- Did you stop suddenly?
- No, I just slowed my speed.
Wael Ali Ahmed
ID: 159
Department: OPS
Position: OPS bus driver
Experience: 4 years
r and 07 higher and there was TR 143 in front of me then the TR gave left traffic light to enter 06 D lower but I gave him
- The TR gave me sign with his hand that I can pass. While I was passing, suddenly the rear bus hit TR 143 from behind.
9- What was the distance between the rear TR and TR 143?
- I dont know.
10- Did you know the rear bus speed?
- Slow speed.
While making hoist down.

Did you checked the functions of the crane before starting operation?
Just the flippers.
Why you didnt check the whole functions?
o make the whole check when the crane starting the 1st move, but in this case I received the crane alread
Did you informed by the previous colleague about any faults in the limit switch?
No.
Are you trained to depend on the safety devices not to take care while handling the containers?
dures, I stopped hoist down when the spreader reaching the cell beam the it supposed that the switch aut
case the limit wasnt working at all.
YES
NO

YES
NO
NO
NO
NO

1- To take care while working & didnt depend on the devices.
2- To make all safety devices as a standard at all cranes, this to adjust all limits like the others.
Involved Person II:
Name: Mustafa Mohamed ID: 763
Department: Ops
Experience:
2 years.
-IN which hour the accident take place ?

In the 2nd hour as you know we work two hour and take a break one hour .
-Do you have any problems affect your attention while working ?
No , every thing is ok
-Does your Cabin glass clean &provide clear vision?
Yes , I have a clear vision .
-Are you working with sequence or un sequence manner ?
I was working sequence manner
-Where was the Dock controller at the time of accident ?
Working on another QC10.
- Why you dont asked him for a help ?
Because I thought that all bay 40 ft containers .
-Did the Wharf controller inform you that you are going to discharge twin ?
He didnt mention that , he told me that I will discharge all bay.
-Did you discharge any other twin in this bay?
No this is the only twin I founded in this bay
-Whom supposed to inform you about changing lifting mood (40 or Twin)?
The Wharf controller or the system screen in cabin .
-Did you follow your System screen during your handling ? Is it working? Did you inform your SV ?
No , because it didnt work, in this case I didnt informed my SV.
-Did you notice the steel support in the center of under deck ?
- yes, And this area is blind point for me .
Involved Person: Name: Mohamed Awad Abdullah

Department: OPS
ID: 263
Position: Crane Operator

Experience:
7 years ( Since 2006 )
e in the central hatch, and the land side hatch cover (previous row) was have 6 tiers above it , I discharge
hoist down and IInvolved
felt that Person:
there was
a problem
and so IElsayed
tried toHelmy
hoist up but it didnt
, I switched off the sp
Name:
Mohamed
ID: 911
saw anything and after
that I calledOPS
deck controller , whilePosition:
that the spreader
moved forward for 1 meter a
Department:
QC operator
up . I discovered that there was a damage on the handrail of
head block 2then
I made one move and stopp
Experience:
years
- I was charging twin container on the vessel, I took the container from the TR.
1 when
WhatIismake
the reason
of this up
hit?automatically.
- In the normal,
lock, flippers
closed
to be in
a little
less than
ft mode
which
made and
the spreader
escaped
from
celland
guide
and gohap
un
he
container
the vessel
bay,40
flippers
was
still down
slippers stuck
in the
cellthe
guide
damage
2 Was there a deck controller
with
you
while
you
were working in that blind area ?
1- How
long
you
were
working?
- No was
one was
me .
- This
thirdwith
container.
3 Did
for adown
deckin
controller
to help
youworking?
?
2- Did you
faceyou
anyask
break
the flippers
during
- No were
, I didnt
.
- No, flippers
working
well.
4 Did
you work
with
full speed
? down in the bay?
3- Did you notice that
flippers
werent
upthe
before
hoisting
- No , while
working
under
deck
point .in my eyes so vision was
nt because I was concentrated
in the
QC screen
and
alsospecially
the sun on
wasblind
reflecting
YES
NO
NO
- I must inform my supervisor about any defected things.
Hassan Abdelaal
ID:
1443
Department: OPS
Position:
TR supervisor
Department: OPS
one hour
El-Sayed AbdAlla Mohamed

ID: 3688
Position: TR driver (Sinia)
Experience: one year
- I received my TR under QC 07 then I directed to my address in berth 08.

06, I noticed TR which stopped and was waiting another TR to enter the yard so I slow down my speed but unfortunately
9- How long time you was working before the accident?
- Approximately 30 minutes.
10- Did you stopped suddenly?
- No, I didnt stop suddenly.
11- What was your speed?
Department: OPS
Position: Vessel SV
Experience:
2.5 years
and Meteor Which was berthing as an indicator for its captain and then he asked me to check the bow position, I while I
e from a blind point which crashed my PU front glass. Then I informed them on the marine channel about the incident by
1- Did you see the sailing man while he dropped the line rope?
- No, he wasnt there even after I get out from my PU.
2- Where did exactly you drive PU 90 while directing to the vessel Bow?
- In the middle of the quay wall Between lane 2 and 3.
3- Was there a safe position for you while berthing the vessels?
- Yes, in bow direction and back ward a little toward the yard.
YES NO
NO
YES
NO
NO
Direct Supervisor: Name: Nader Helmy
ID: 565
Are you aware

of the
the rules
/ procedures
related to this
YES
Who is
responsible
of controlling
thiswork:
panel?
NO
- Engineering.
YES NO
Why he controlled the panel instead of the designated person?
- As I mentioned
this due toinhis
also
we
wereYES
only NO
two persons.
Did youbefore,
receive supervision
therequest,
last 1hr of
your
work:
How
did
youthis
noticed
the
victim
got injured
?
How
do you
think
incident
could
be avoided
in future?
the vessel SV hoisting up I heard him saying why he is hoisting up then he shout lower lower the sp
Direct Supervisor: Name: Why
Ayman
ID:
1149
did Taha
OPS SV hoist up ?
OPS
Position:
OPShe
supervisor
he make this hoist up,Department:
but after the
accident I informed that a wire
slack, so
decided to hoist up to avoi
Where was your colleague position ?
s stepped on 2nd or 3rd step of spreader ladder (left side), not sure because I was busy with my side.(righ
What
youryou
opinion
avoid
reoccurrence
of similar
When was
the lastistime
spoke to
to or
witnessed
the involved
personscases
work ? one hour
- All OPS supervisors should be trained how to safely operate control panels.
Who Mohamed
was the leader
of this
job?
Mahmoud
Youssef
ID: 17171
Department: OPS
Position: D&W
Me.
one years
How can you communicate with the others, wasExperience:
it by UHF radio,
verbal or hand signals?
- Was verbal, because the distance was very narrow.
- When the QC operator was hoisting down to catch the container, the flipper slipped and hit the container from the top.
Did anything affected the communication?
1- Did the operator use high speed hoist?
No, but we have
many
duties
before
& we also
received
many
brake
down after this task
- No, hoist speed was slowthis
but task
the spreader
made
skew, when
he calls
down for
on the
container.
Does that duties affect your concentration on this job ?
- No.
receive
a pre-shift
safety
talk: replacement
YES NO
WasDid
theyou
Truck
moved
during
spreader
?
- No.
Did you receive
training
in
how
to do went
the task
involved:
YES NO
What do you think
wrong
?
- I think his foot stepped on the wrong position, If I were in his place the same situation will happen to me.
Are you aware of the rules / procedures related to this work: YES NO
- Wrong action from Ops SV.
Witness:
Name:
eslam
ID: YES
6-7 Years.
If required,
were Mohamed
you wearingSeif
the El
correct
PPE:
NO
Did you receive

supervision
in the
last 1hr D&W
of your
work: YES NO
Department:
Ops.
Position:
controller.
How
doone
you on
think
this
incident
could hoisting
be avoided
in future?
m Eng. Team one in the right
and
the
left,
and while
down
a slack happened to the wire Mr
houting to lower the spreader then we found him in this situation can not step on his foot then, we ask the
Department: OPS
Ayman Taha
Position:
ID:
1149
OPS supervisor
Where was your position at the time of incident ?
Witness:
1-Name: Fawzy Helmy Abdo ID: 6224

(Lasher who work in operator right side )
Department: OPS (outsource Inmar ) Position: Lasher
Experience: 7 Years
as loading un-sequence ,and we ask The dock controller to arrange for work with sequence which will be
container without installing stickers ,I show to him to stop in order to install stickers, and he respond to m
-What was the position of the container when you start installing and after you finish?
eginning he was about 1 unit away from us and we start installing when I finish I found the container abo
-What was the operator speed for hoist &trolley?
Slowly.
-What was your colleague (injured) position ?
s small Feeder vessel the catwalk was narrow he was standing on leg on catwalk and the other on the con
ue injured ?(he stand up and hit his back with the container or he was working with bended back and the
The container hit him while he was working
-What is the normal process for this type of work (un-sequence )?
Dock controller have to coordinate with QC operator .
uct form your Lashing Supervisors not to work un-Sequence or near spreader with less than 3 unit separat
e Dock controller to work sequence but he inform Vessel Supervisor who confim that we have to continue w
-Before the incident ,Did you install any stickers in that bay with same operator ?
Yes ,we install 2 units.
-Did you know the staking position of the container which cause the incident ?
g to stack the container without stickers due to un-sequence working ,normally in sequence working we in
-What is the safe distance between your position and the spreader position ?
2 units and the spreader be in the third .
In the previous moves did you communicate with the operator with signs ?
Yes ,he was inside the cell guide before and I show to him by signs and he respond directly
-From your opinion how can we avoid this kind of incidents ?
Both of lashers and crane operators give more attention .
- No.
When you became close to RTG 22, did the speed became slow or not?
- Became slow.
When you crossed the bays between H & L did you notice any defects in the gantry stop?
- I didnt notice any failures in the function.
What was your speed before crossing from H to L?
- Full speed.
Did you stopped on the Stop Sign between H & L?
- No.
Why you didnt stop on the stop sign?
prox empty in this area & I checked the road which was totally free from any vehicles, so I decided to cont
How can you check the road while your speed was the full speed?
- I slow down the speed before the main drive way.
Are you trained for this behavior?
- No.
Whats your instructions when you crossing between H & L?
- To stop on STOP sign to check the road then start moving & the spreader to be in 20 Ft mode.
When you decided to stop / remove your hand from gantry joy stick?
- Before CR 22 approx about half distance of 40 FT container.
What is the standard distance required to remove your hand from the joy stick in the similar case?
- Approx one 40 ft container.
Why you use the emergency stop?
heard a horn from the TR behind me to alert me to stop then I stopped and saw that the spreader of the RTG cut the top
1- What is your working hour in the rotation in the time of the accident?
- The second hour in my rotation.
2- What is your instruction while the RTG putting a container on your trailer?
t insure by turning my body on the TR seat toward the trailer to see that the spreader was hoist up in a safe height (app
3- Was that happened in this case?
hought that the time I spent to check my next address in my TR screen, the spreader will be hoisted up in the safe heigh
YES NO
YES
NO
NO
NO
Direct Supervisor: Name: Mohamed Baraia
Department: OPS
ID: 1364
Position: TR SV

Wetness: Name: Mohamed Atef ElSayed El Hadidy
ID: 1041
Department: OPS Position: RTG operator
Experience: 2 years
d the container I made unlock and started to hoist up a little bit and then hoist down on the TR because I want to call th
ader two right lock were attached with the two right cost corners so I was afraid that if the TR was still moving the spread
was waiting behind, so I started quickly to hoist up to avoid that so the lift flipper cut the container.
Involved Person: Name: Elsayed Yassen

Department: OPS
ID: 674
Experience:
4 years
charged one container from under deck 1st tier and I was moving to charge another one in the same row and same tier
d the crane stopped , so I called the Eng. Department whose came and switch on the crane , and so I hoist up with the c
1- Did you face a problem when you get the first container on this row ?
- No , it was smooth one .
2- Have you any instructions about your work in blind point area ?
that must deck controller be with me but I did not call him because I know that he has work with another crane on the s
3- Where the spreader are clear visible for you ?
- Till the tear no. 3 under deck .
4- What about your hoist down speed while you charge this container ?
- It was normal because I was working in blind point area .
YES NO
YES
NO
NO
NO
- The truth , I should call the deck controller while I working in blind point and I will stop moving till be with me
Direct Supervisor: Name: Emad Salah Salem ID: 292
Department: OPS Position: VSV
Involved Person:
Name: Mohamed Abo Bakr Khalifa
ID: 296
Position: Yard Supervisor

Experience:
8 years
or working in the maintenance of HM02 in 02M Lower and they surrounded the working area by barriers but I noticed a b
le RTG operator to notice the barriers and not to make any breach close to the working site. So I informed them about th
iers (taking a rounded shape around the working site) I suddenly hit a steel barrier (not in the same pattern like the othe
Why you didnt notice the steel barrier?
Because it was shorter than the others so it wasnt in a clear view to me.
while you was talking to the Subcontractor workers, was you still driving?
No, I stopped my car before starting to talk to them.
What was your exact direction while you was maneuvering?
I was maneuvering toward the southern side.
From your point of view what was the reason behind that incident?
That incident happened because I was out of my attention.
Why you was out of attention?

I thought that I passed all the barriers and didnt imagine that there will be other barrier in front of me like the steel bar
Subcontractor workers should place their barriers in a right manner, and I have to pay more attention while maneuvering

Department: OPS
Ayman Mohamed Mahmud

ID: 3395
Position: TR 43 driver (Campbell)
Experience: 2 years,4 month
and there is a TR 107 in front of me and while maneuvering to enter 03k I was attention to plastic barriers suddenly the
1- What was your speed?
- Slow speed.
2- What was the distance between you and TR 107?
- About 3 m.
3- Why did you hit the TR?
- I take my maneuvering nearby plastic barrier and I give my attention to check my trailer to avoid hit the barrier .
4- Are there any problems in your mirrors and glass ?
- No, Mirror was in good condition, and the glass give me a clear vision .
5- Did you wear the seat belt?
- yes.
6- Did you sleep well?
- Yes, about 6 hours.
7- What was the instruction did you received it in the training ?
Slow down my speed while maneuvering, avoid people error, keep a save distance between me and any TR .
8- In which hour in your rotation the accident take place ?
I just receive the truck before the accident by 5 min after one hour rest.
9- What is the precaution that you can take it to avoid it repeated again?
Make a save distance between me an any truck , more attention.
1- What was your working hour in the time of the accident?

- That was the first hour after taken 45 min. as a rest .
2- Did you feel fatigue ?
- No , I didnt and last night I slept about 7.5 hours .
3- Did you trained about the safe practice of dismantling the lash bars?
- Yes, and it was one handunder the bar and the other hand catch it, and I used this instructions while working.
4- So what was happening causing this incident?
- I dont know.
5- Did you work alone in the same cat walk ?
- No , there was another lasher with me but he worked away from me by two containers distance .
6- Was the short bar heavy for your hand ?
- No , this lash bar was short bar and can carry by one person .
7- Did you use extreme effort for dismantle the lash bar ?
- No , I didnt .
8- Did you face any problem while dismantling the bar ?
- Yes , it take a long time to dismantle the lash bar , it was stuck .
9- Did you have a historical injury in your hand ?
- No , I didnt .
10- Were you harry ?
- No , I am werent
11- Do you wear PPE ?
- Yes , but the gloves used is unuseful.
12- Did you have the TBT of the accident day ?
- Yes , and the topics was to be
More care while dismantling lash bar .
No one work alone .
YES NO
NO
Department: HSE
Involved Person:
Position: Fire chief
Name: MohamedExperience:
Abo Zaid
6ID:
years
1809
ing for moving our Department:

files from the old
station to the new one.
And when
I startedengineer
to move, the files and
Engfire
WS
Position:
electrician
ropped down of the beside seat. I started to collect it while I drove then I surprised that I hit a parking Ops
Experience:
2 years, 3 month
In your
why this
accidenttohappened?
e work shop, I entered by PU 1-front
faceopinion,
,after finished
I directed
park my PU at the work shop parking,
- Because
I was Idriving
and the
I was
busy with
another
thing and
except
my wayhit
. it.
while
maneuvering
didnt see
workshop
shelter
support
I suddenly
2- were you fasten your seat belt?
- Yes,
was. support?
Did you see
theI shelter
No, I didnt
YES NO
Why you didnt see the shelter support?
you receive
in how lighting
to do the
involved:
YES give
NOme a clear visibility.
Because there isDid
a spotlight
overtraining
the workshop
intask
my face
and didn't
Did you turn on your PU light while move?
yes related to this work: YES NO
If required,
were
wearing
thereverse
correct position?
PPE: YES NO
Why
youyou
didnt
use the
It was more easy to enter by pick up front face.
How do
think
thisdirection
incidentwhile
couldyou
be avoided
in future?
What
wasyou
your
exact
were maneuvering?
I was maneuvering from tire workshop area to workshop PU parking.
Is this considered as a shortcut? In other words, is it allowed to move in this area by PU?
s area and SOP didnt mention any thing about that because some time when we need to get our equipm
we use this access to enter.
Sagiee Salem Salem ID: 3799

Department: OPS Outsource (Sinai CO.) Position: TR Driver
Experience:
1.5 month
ake my maneuvering behind QC 12 but I miscalculate the distance between My TR and the hatch cover and my Trailer re
-What was your speed while maneuvering ?
Very slow .
-Did you see the hatch cover before decide to take your maneuvering ?
Yes , I did
-Do you think that the area between your TR and hatch cover sufficient for safe maneuvering ?
It was enough but I found TR coming in my way so I decide to make sharp maneuvering
-Do you have any problems affect your attention while driving ?
No.
-in Which hour of your rotation the accident take place ?
2nd hr in my last 3 working hours for this day.
Experience:
Well experienced.
t we have some problems in the spreader, so Eng team start changing the spreader once i shifted to the another vessel, I got out of the cabin
surprised by my colleague asked me on the UHF to take care & the message became not clear due to the radio challenge, immediately I sto
a smoke outside the cabin, get out of the cabin to decide the source of that smoke & get into the cabin again to get the fire extinguisher bu
he elevator, get it & start fighting the fire but unfortunately the fire extinguisher became empty quickly; so I get down the crane & informed m
What is the time between the end of your smoking & the report of your colleague?
- Approx 20 minutes.
Are you sure that the cigarette is totally quenched?
- Yes
When you tried to fight the fire, did you noticed what is the material which get in fire?
- Yes, some old pieces of rag, papers & some pieces of the cabin mat.
Are you trained about fire fighting ?
- Yes, but I didnt find the fire extinguisher into the cabin & the used one get empty quickly.
YES
NO

YES
NO
NO
NO
- To clean the area surround the cabin from any garbage.
- To provide adequate ashtray outside the cabin.
NO
Experience:
2 years, 3 month
a llist position because there was another two cranes charging and discharging on it ,due to charging from the sea side
xth container from the 2nd row 3rd tier at the sea side and started to move trolley while I was move I hit the 1st row 2n
side.
What was your speed while moving trolley ?

Slow ,because I was discharge in lane 2
what is the safe distance which you received it in your training program?
About one container (2.3 m)
And what was your distance when the incident happened ?
About 0.5 m
Did you made hoist down while moving trolley?
Noproblem and while I was Loading the third move , I u
and side , I Loaded two moves in this row without any
Is the limit switch working properly?
s (10 meters approximately) , I stopped by force because
I hit something and after that I saw the oil sprea
yes
call deck controller , Engineering team to fix the problem .
Where was the dock controller when the incident happened?

- operator need his help .
With QC 13 because the crane
when the incident happened the work was sequences or Non-sequence?
It was
sequences
manner
- Did you faced any problem
while
you making
the first and second move ?
Is the vision was
clear
in
your
cabin?
No , there didnt
.
Yes
- Did your speed move in the
third one was like the 1st and 2nd move ?
Are you sleep well?
Yes , usually I get the container inside
Yes the cell guide and after that I get down .
- Do you have a
limited
while charging
(Loading)container
as SOP ?
in
Whichdown
hour ofspeed
your rotation
the accident
take place ?
No
, I rest
havent
. day.
In a 1st hr after
2nd
In this
- Did you noted any move ( Trim List ) on the vessel while your work ?
From
point
of Iview
what
was
reason
behind
that incident? the deck controller t
at there was list move for
the your
vessel
and
heard
him
onthe
the
channel
inform
the M/V isinform
not stable
trim)anything
and I didnt
taken
my he
safechecked
distance the
.
- Did theBecause
deck controller
you(list,
about
wrong
after
bay ?
No , he didnt .
- Did you ask for the Deck controller for any problem before?
No , I didnt .
- Are you was suffering from any problem before or while you working ?
No , I was in a good condition .
- Do you took your sleeping hours yesterday ?
ent to close the hatch coverDepartment:

in 20 ft modeOperations
at this time one from Eng. to stop
on the
hatch
cover to inspect the spreader
Position:
Yard
Supervisor
there
deck
controller
assisting
you
asked me to continue Was
normally
butamy
vessel
SV switch
the crane
off ?and make a handover.
Mahmud
Mohsen
Hassan
ID: 3793
- Yes, but he was busy with
another operator.
Experience:
5 years
Department: OPS -IN which hour the accidentPosition:
take placeTR
? driver (Kotbey)
Experience:
3 months
In pre-shift
the
two
hour
. land collapse
& lower yard ranges, but at theDid
F container
block the
PUlast
passed
over
a
you receive
a
safety
talk:
YES and
NO I found the PU hood suddenly o
so I took my left direction and pressed the brakes then remove my foot from the brakes and left the PU to move forward
- did
slept
before
shift?
took twin containers from the yard
inyou
berth
03well
lower
andcoming
I knewthis
that
TR Fifth-Wheel Plate was down slow
Did
you
receive
training
in
how
to
do
the
task
involved:
YES
NO
Yes
Ififth-wheel
did time did
At any
time
this container
incident happens
and how
you spend
in to
driving
this PU?
- The
twin
was heavy
so much
plate
started
down.
- When I reached to QC 11, wharf controller informed me that I must maneuver and back again.
Are at
you
aware
ofPM
the
rules
procedures
related
thisI work:
YES
-Do
you
have
any
problems
affect
attention
while
working
? myNO
Incident happened
about
7:15
and
after/ about
1 hour
&
quarterto
took
it from
colleague Tamer.
- While I was maneuvering,
TT leg
support
hit
theyour
ground
andsince
caused
right
leg support
broken.
No , every thing is ok
1- Did you
inform
your
supervisor
that
TT
fifth-wheel
was down?
What
was
your
while
this
incident
happens?
If required,
were
you speed
wearing
the
correct
PPE:
YES NO
- No,clean
I didnt.
-Does your Cabin glass
&provide clear vision?
2Why
you
didnt
inform
your
supervisor?KM/H).
Yesthe
, I in
had
a clear
vision
speed was
within
normal
range
(around
Did youMy
receive
supervision
the
last
1hr
of. your25-35
work: YES NO
uld inform him but after I will finish work under QC 17 and I didnt expect that TT leg support will hit the gr
wasin
the
Dock
controller
at the
of accident
? in the TR?
3- What did-where
you take
the
training
when
youtime
notice
problem
How
do
you
think
this
incident
could
be
avoided
in
future?
Yes, and heinformed
me there
was
a regulation
cut in theimmediately
call
guide and
asked
methe
to
slow down my speed.
you know
ourmy
safety
regarding
speed
inside
terminal?
-Do
I must
inform
supervisor
about
any
problem.
4- Did you check TT leg support level before you drove the TR?
If there was a Deck controller
with
me,should
he would
help25-30
me by
calling me on radio to stop.
Yes, my
speed
be within
KM/H.
No,
I
didnt.
Witness: 1-Name: Mostafa Mohamed Abou El Hamed ID: 1861
1st
From
your point
view what
was Mansour
the main reason behind that
Witness
: of
Name:
Ahmed
ID:incident?
1532
Department: OPS Position:
D&W
EX:2
years
at we
make full
survey
bays
condition
make
disclaimer
report
to the
line
,and
already
we made
hat
thehave
landtocollapse
wasnt
thefor
main
reason;
alsoand
if I was
driving
at a high
speed
and
the
front
hood was
closedthis
thisrepo
inc
Department: Operations side & 03 Quay side .
ng twin move inside row 02 sea side
Operator
to hoist up but he failed Our Vessel SV c
the
Did-spreader
you try tostuck
openand
the the
hood
even bytried
mistake?
Experience:
6
years.
came and enable hoist again ,
-What
was
thehood
hoistonly
down
cell guide
? spray water tank.
No, I didnt. As we open
the
front
tospeed
fill theinside
windscreen
wipers
It was slowasked
speed me
.
I was in different channel, then Amr Wharf controller
to move to QC06 because something wro
hear was
theWhy
message
(call)
from
the wharf
controller
to the
ved PU we discover that Did
the you
gas-tank
almost
so
is it that
possible
that
you pulled
the ENG
hood? button by mistake instea
do full,
you
think
happened?
No.bad
I was
on my
vessel
channel
- That ship has a very
twist
lock,
andradio
most
of its(16)
twist lock are jammed.
-Did that
any PU
oneas
from
theitENG
came to(in
the
dock
y be, but it wasnt me how fuel
I took
fromteam
the parking
front
of for
theinspection
Ops office)? and directed toward the ya
No.
Did you make a pre-task inspection on the PU before driving it?
2nd
Name:
Kotby
WeWitness
continue :working
withMohamed
40 Ft modetharwat
till we reach Row 03 Quay
SideCo.
,
then we haveNo,
to close
hatch
cover
at thisafter
timehand
one from
team ask
himnot
to within
stop onthe
theworking
hatch cover
as wethe
made
that
inspection
over Eng
(between
shifts)
shift. to inspect the
.
Position: dowel man
So if there was any problem in the PU how would you be able to discover it?
Department: OPS
nd side and it was 1 tier, the 1st row land side was higher than the 2nd row by 2 tiers, and the 3rd row land side was 1 t
ntainer. I reached the 2nd row and while I hoisted down the container, its right sea side twist lock stuck with the right lan
Experience:
day
ust it but the spreader didnt answer then I tried to give it an order
again then the4spreader
suddenly jump and gave the
r, then I received an order to discharge

another
container
the
same bay but in Eco 2nd tier after I lifte
1- Dida you
work in
the same in
row
before?
I stacked
2nd
& the
3rdofrow
land sideand
containers.
e another container in bay- Yes,
23 Bravo
4ththe
tier
byrow
right
side
container
saw it fallen. I stopped moving
2- Was it a blind point to you?
- Yes, because the 1st row land side was about 4 or three tiers.
3- Was there a deck controller with you while you handled that row?
Are the RTG
was in a right position when you started to discharge on this bay?
- No, he was with the other QC, and there was a dowel man but was standing at my left side.
Yes,
andthe
theVessel
proofmake
i was
discharge
one
container
before
in this bay.
4- Did
any
move while
you
handled the
container?
Did you
gantry
1st container?
- No,move
I didnt
noticedafter
any movement.
Nohour in the incident time?
5- what was your working
- It you
was my
in my 1st rotation.
Are
put2nd
thehour
1st container
correctly?
6- Did you push a by pass button after the first
Yestime the spreader didnt answer your order?
- No,I What
gave itwas
the second
order then
the
spreader
jumped
suddenly.
your speed
when
the
accident
happed?
Full speed
YES NO
Why you used the full speed and you still beginner?
I thought after the 1st
that
the bay
was
meinvolved:
and I was
stand
Didcontainer
you receive
training
in how
to clear
do theto
task
YES
NOin a right position and
following training instruction about hoist safe distance.
Are
you height
aware of
the rules
procedures
related
to this work:
YES2nd
NOcontainer?
What was
your
when
you /lifted
the 1st
container?
And the
Full hoist up in the 1st container, and about 11 m in the 2ndcontainer.
required,
were
wearing on
the bay
correct
YES position?
NO
DidIfyou
notice
anyyou
container
23 PPE:
incorrect
No, I didnt
Are you have a clear visibility in your RTG?
Yes, but the front
glasses need to clean.
- Nothing
Are you having any problem in your RTG?
Yes, the deviation in this RTG was high so I usually use the steering.
Did you inform your supervisor?
No
From your point of view what was the reason behind that accident?
was stand incorrect position on this bay, and when I lifted the 1st container with a full hoist up I didnt noti

Mohamed Awad Mohamed
ID:
1230
Department: OPS
Tarek Mohamed
Shabana2 years
ID:
593
Experience:
Department: OPS
Position: QC operator
years
to shift towardInvolved
bay 78 onPerson:
the same container
block in order
to Experience:
lift two
feet2 containers,
but there
a problem with th
Name: Mohamed
Ahmed
Abd40
El-ghany
ID: was
1190
ader functions and pressed the 40 feet mode button again after that the spreader was working well, after finish lifting bot
I started to adjust Department:
the containers stack
position on the system screen. After i noticed
what
happened
i found both 20*2 a
Ops
Position:
Crane
Operator
harging twin moves
from
below
deck
of
bay
14
on
M/V
YM
INCREMENT
from
the
quayside
and
while
i
was
trying to handl
the twin lamb stopped blinking and 40 mode lamb persisted.
eared on the spreader head block lamb, so i asked for the engineering assistance, after the engineering team arrived the
Experience:
2
Years
e no control on the spreader
andlifting
also there
wasmove
no hoist
the lamb
engineering
team
took
the control and made a bypas
Before
the twin
wasup,
thesotwin
on the console
blinking?
er to Ithe
quayside
in order
inspect
it. Then
the wharf
controller on
told
me
that they
towas
replace
the spreader
with ano
cant
remember,
but to
i am
sure that
i pressed
on something
the
console
buthad
what
it I cant
remember.
ck , but it was a blind point for me and I hadnt deck controller at this moment so I called wharf controller
When
were lifting
moves
in the first
time,
was the right
twin lamb
the
console
ainer and hoist
upyou
, I found
a bigtwin
smoke
resulting
from
spreader
sea on
side
wire,
so Iworking?
stopped immediat
Yes, I am sure it was working.
anypress
time the
thistwin
faultbutton
happens?
Do you remember ifAtyou
on the console or not?
It
was
at
my
second
hour
on
the
i remember that i pressed the 40 feet mode after shifting toward 40 feetcrane.
bay, but after i finished handling both 40 feet
twin lamb on the console blinking but I cant remember if I pressed on it or not.
Did you complain from any previous faults on the crane before this fault?
waslamb
the first
fault
that happened
my working
Did you checkNo,
theittwin
on the
spreader
or insideduring
your cabin
before hours.
lifting the twin move?
No i didnt, as i was hurry and depended only on the twin lamb on the console.
Did your colleague inform you about any problem with the spreader?
No, he didnt tell me about any problem
with
the spreader,
and also
i didnt notice
any thing looking abnormal with it.
Did you
notice
the twin status
by yourself
or what?
No, truck driver who informed me, that i hear his yelling from below as i was concentrating on the system screen.
How many moves you made before the last one you was trying to handle?
tly, i started to discharge on deck then opened
the hatch
covers
and discharged
about 2 tiers & half till the fault happen
What
did you
do after
that?
I started hoisting down step by step on the truck and i found spreader widely opened.
Tell me about the way you work inside the under deck?
ng my speed thensettled
thethe
spreader
seaside
on the concerning
cell-guide pad
and made
a hoisted
down, before approaching the
What are
standard
procedures
handling
containers
for discharging?
stem screen, and then i started to handle the container by lifting it for a little distance from the truck and adjust the cont
Did you made
any sudden
moveawith
the spreader
o even hit
it at any
part of the vessel?
stacking
then made
full hoist
up and directed
toward
the bay.
No, i was following the normal operational procedures and i didnt hit any part from the vessel.
Is there was a deck controller with you on the bay?
No, i didnt
notice
anyreally
one and
also i didnt
for anyorhelp
bay
conditionbefore
lookedmaking
good. any moveme
ther the spreader
twin mode
was
activated
on theask
spreader
not as
by the
visual
inspection
Yes I did and it was clear before I moved .
Involved Person:
Name:
Fathy
Ahmed ID: 3519
-Did you
have Mohamed
guide while
reversing?
No,
Position: TR driver
-what was your TR speed ?
It was very slow.
Experience: 2 years
-Do you have instruction to reverse back without guide ?
Reversing
with
guide process
Only under
shing equipment and go to RTG 21 for its
cabin glass
washing
at 05 QCs.
G reefer stands, and when I reached the me
he washing equipment
because
I forget with
to estimate
the distance
between
the equipment
-if theprominence
same scenario
repeated
you again
,what will
be your
response ?prominence and th
I will not reverse without guide .
1From
where didschedule
you enter at
to the
05 Gtime
Lower?
-What was your rotation
of accident ?
- I was driving my TR between 05 Lower and 05 Higher and 05 Lower.
Last two working hours in my first day shift.
Department: Ops (Trade mar)
2- So why did you enter the 05 G Lower with the opposite direction?
- I thought that I had a reefer container, and I forgot I was carrying the washing equipment.
3- Did you work with the RTG cabins glass washing equipment before?
- No, it was the first time.
4- Did
you worked
with OOG containers
any equipments
Involved
Person:
2-Name:orAntar
Ahmed Aliwith
ID:prominence?
0085
- Yes, many times but it was in Mike.
5- How
mentioned
block?Electric Tech.
Department:
ENGdid you enter the
Position:
Forman
- I adjust the head by the mirrors as I carry a reefer container , forgot that I was carrying the washing equipment.
6- Was your mind busy with any thing?
Experience:
9 Years
- No, it was clear.
standby lane and I found TR 78
coming
front
of mehour
so Iindecide
to deviate
7- What
wasin
your
working
the incident
time? into main rood to let him con
y maneuvering
to inter
the
standby
lane
again
I surprised
by the
TR reversing
& hit the
of my PU
- I was working
as a TR
head
driver as
there
is no,but
rotation
for the head
drivers,
they are working
by rear
requests.
-While you were moving beside the TR ,Did you notice it was reversing?
Did you receive a pre-shift
NO.safety talk: YES NO
-Do you have instruction for waiting inside standby lane ?
Did you receive training in how to do the task involved: YES NO
block) is away from the QC ,we have to park behind the QC which have BDN, but in this case I was movin
YES
NO
NO
- Be more concentrate.
hen I reached there, the reefer technician was down there, and while I wrote the number of the TR to confirm it, he shout
2G54 were ok. And there was TR 114 was waiting in that address, so when I finished at 02G30, I went to 02G54 and whil
tech. came with his back up with horn informed me to stop, then I stopped but after cutting the cable.
1- Did you checked in load system (unplug sys.)that the reefer container at 02G54G1 was unplugged?
y training period on the RTG, they told me check the system but to be more sure check with the reefer tech, so the check
2- Was the reefer unplug sys. Work properly in RTG 11?
- Yes, but I didnt use it, I confirmed with the reefer tech.
YES NO
NO
YES
NO
NO
- To check on the reefer unplug sys., and get a clear confirmation with the reefer tech.
Direct Supervisor: Name: Sad Kamel El Ashry
Department: Ops
ID: 883
Position: Y SV

Wetness: Name: Mahmoud Zahran Mohamed Isaa
ID: 1840
Department: Reefer Position: Reefer Tech.
Experience: 2 years
0 & 02G. I unplugged 02 G 30 B1,2 and I confirmed it in the unplug system and after that RTG 11 was reached, I tried to
ok to handle, then I went to 02 H 50 B 1 to unplug it, then we requested to new locations to discharge, so I went to the fi
No, he didnt tell me about anything concerning wires or head block.

YES
NO
NO
YES
NO
NO
NO

Direct Supervisor:
Department:
Name:
Operations
Abdalla Khaleil
ID: 290
Position: Vessel Supervisor
Did he/she give a pre-shift safety talk:

Witness Person:
Name:
YES
Mahmoud Hafez Nessem ID: 749
Experience:
8 years
During working on QC 05 did you hit the spreader head block into any object?
No, at all I didnt hit the head block.
Were you working on deck or under deck?
No, I was working under deck.
NO
Position: RTG Operator (ASST)

Experience:
Fresh Trainee (5 days)
e 4 containers in each row (in E, F and G) then i took the 4th tier container from F row and load it on the
taking 4th container in the G row in order to load it on the truck , but i miss-calculated so i didnt hoist en
rner casting of the E4 container with the lower corner casting of the container i held, and consequently i s
me to return the container back and to return to parking position.
How many days you have passed since the beginning of training?
It is my forth day in training.
Kindly tell me what you have been trained to do while handling containers?
ke a safe height of another container, but what really happened was that: I hoisted up and the trolley was
hoisted up for more than 1 and meter away from the E4 container, but unfortunately my assumption w
At any time this incident happens?
The incident happens after about hour since my last rest.
How many hours do you spend in training today?
I spent about 1 hour since the beginning of my training day.
Are you trained to check below while trolley back?

ourse, I was checking from below while hoisting up and making trolley backward but I miss-calculated the
Experience:
8 years
making hot seat change with my colleague on the trolley cat walk, I started to close the trolley cat walk do
e door of the trolley side and while I lock the trolley side doors lock, its knob slipped from its path and fa
1- Why did the lock knob slipped away from its path?
- Because the safety stopper of the Knob was broken.
2- Did you break it?
- No, because if I broke it I would feel a snatch but it didnt happen.
3- Did you notice any defect on the lock while using it when you start working with the QC?
- I dont know because my previous colleague who locked it, I didnt use it when I started the work.
Did you notice any problem while you using the lock when the hot seat changes with your next colleague
- There was no problem it was working smoothly.
YES NO
YES
NO
NO
NO
NO
No, everything is ok
-Does your Cabin glass clean &provide clear vision?
Yes, I had a clear vision.
- Is this situation happened with you before?
No
-In your opinion why the accidents happened?

k TT type is BOSCER, and the sharp edge is very small and i cant use it as a guide when I get closer.so it was blind poin
AlsoInvolved
I saw TR driver
wasName:
speaking
in cell phone
and didnt revers
back.
Person:
Mohamed
Abo-elenen
ID: 305
Did you receive
a pre-shift
safety
talk: Shabana
YES NO? ID: 593
Involved
Person:
Name:
Tarek
Mohamed
Department:
OPS
NO?
Position: QC4 Operator

Experience:
years
NO?
2 years
d after I loading the container and hoisted up , I feel thatExperience:
TR position was
wrong so I took his attention by
If required,
were
you
wearing
theI correct
NOthe container on the land to
sted up again with the container
and the
TR
moved
and
hoistedPPE:
downYES
to put
rs) toward quay side, then i directed to row 03 (quay side) and leaned spreader seaside part on the seasid
receive
supervision
in the ilast
1hr of
your work:
YES NO became completely be
easide. After that I triedDid
to you
hoist
up notice
for
a little
found
spreader
1Did
you
thatbit
thebut
TR was
in the
wrongseaside
positionpart
?
- Yes.
Then
I alert
him bycould
usingbethe
RTTGinsiren
How
do you
think
this incident
avoided
future?
When
did
this
incident
happen?
2- Why didnt you use the megaphone?
It happened at the almost end of- Because
my working
hours work.
(10 or 15 minutes before hand over).
it didnt
3- How do you contact with the TR drivers without the megaphone ?
Did you face- Iany
problem
with
spreader
TLS during
your working hours?
depend
on my
sense
and hoist
down slowly
No, absolutely, as I adjusted spreader
TLSyou
on the
Trim using
position
be the
4- What do
do after
thetosiren
? same with the vessel pose.
Tell
aboutthe
theTR
way
you was
working
was your
trolley
speed?
- Ime
thought
position
was
correctand
andwhat
so I began
to hoist
down
orking with the normal
and imove
leaned
cranes
spreader
on position
the center hatch
5- Why speed
you
didnt
and
setHany
your
spreader
TRcover
placenot
? on the cell-guid
Direct
Supervisor:
Name:
Mohamed
el Bostany on
ID:the
1567
- According to training instructions , I couldnt move gantry since I had loaded a container .
Why
you is
didnt
leanyou
the
spreader
on
instead
of hatch
cover?
6- What
the sign
are
use itOPS
for the
set cell-guide
the container
on the
TR trailer?
Department:
Position:
OPS S.V
e hatch cover (hatch
coverisprotruded
the cell-guide),
and thewith
difference
in height
- There
no signs ,above
just depend
on cooperation
the TR driver
. between yard and
Did he/she give a pre-shift safety talk: YES NO?
Did you notice that the spreader was below hatch cover?
When was the last time you spoke to or
witnessed
No,
i didnt.the involved persons work 4 hrs. ago?
3- How do you contact with the TR drivers without the megaphone ?

- I depend on my sense and hoist down slowly
Direct Supervisor: Name: Hosam Nasr ID: 1162
Department: Ops
Position: VSV

Witness:
Name: Nazim Dawood Nazim
ID: 1469
Name: Mohamed Gamal Abd ELfatah ID: 2010
Department:
Ops
Position: Wharf Controller
Experience:
5 Years
Department: OPS Position:
RTG Operator
The crane was working smoothly without any defect and I didnt notice any problem
Experience:
only 1 Month
g twin so ,I test(check ) the bay before start
handling
,then
I catch the
twin and
till 18
meter which exceed
Name:
Abd
El-Rahman
Rafat
Attiastart hoist upID:
979
reach row Department:
D I surprised by containers
in previous bay falling down due
to contact
withController
my spreader.
Ops
Position:
Wharf
-when this damage Experience:
take place ?
7 Years
At
6:45
am
,it
was
my
last
working
hour
in
my
night
shift
. so I called the QC operato
ischarging a container , I noticed that the crane wire left sea side defected
and
-Did you checked the bay before working ?how ?
check the problem .
Yes ,I did .by moving with empty spreader inside the bay for inspection with 40 feet spreader mode before handling .
1. Did there was
or in
damage
the the
QC05
before
-Didany
youhit
work
this bayon
before
accident
? your notice ?
- No ,No,
theit operation
working
normal .
was my firstwas
move
in this bay.
-Where was your pervious working position?
I was working
in 03 CMohamed
H then I moved
gantry
till 03 C L .
Name:
Mohamed
Metwaly
El-ghettany
ID: 179
-While
youre
moving
gantry
,Did
you
observe
any
deviation
in
RTG
gantry
Department:
Ops
Position: ?QC Operator
No. there wasnt any abnormalities
Experience:in the
9 RTG.
Years
-Before you test your bay ,Did you checked the position of the RTG on the gantry yellow lane ?
erator in the red shift and I do my pre use check
, I didnt notice any abnormalities or problems till I made
Yes, it was normal.
-What was your trolley speed ?
Technical Advise/Report:
Name: Ahmed Salah
ID:
Did you recognize the RTG Gantry siren before crossing over it?
ner put when I moved trolley IDepartment:

saw the two
container
fallen
down in QC
the Operator
under and the spreader closed in b
Ops
No I didnt,
but IAbdu
am not
sureMohamed
if itPosition:
was working
Involved Person:
Name:
Hosny
Mansuror not. ID: 1361
YES NO
While
passing
over
did
you
try
to
alert
RTG
operator
by
Truck horn?
Experience:
7QC
years
Department: OPS
Position: using
Operator
ore crossing and entering 04 Charlie, as I have to use my horn in order to alert any equipment that possibly crosses over
Did -Are
you receive
training
insequence
how to door
the
involved:
YES NO
you low
working
untask
sequence
manner
tion vessel ,it was a feeder
with
levelwith
,after
I done 3 moves
and went
to take? the 4th container to cha
Experience:
1 years
When exactly you noticed
movement
before or
after passing 04 Charlie?
I was
wasRTG
working
sequence
manner
his moment the sill
beam
limit
switch
activated
and
disconnect
trolley
,dueYES
to suddenly
stopped the
Are
you
aware
of
the
rules
/
procedures
related
to
this
work:
NO
movement
after
i
passed
over
half
of
container
block,
so
i
noticed
it
in
front
of
me
(from
his
blind
point
side
not
from his
the wharfflippers
controller
noticed
that there
a defect
inyou
the
crane
hoist
right
sea the
side
and sofallen
he told
the
-Did
theit Wharf
controller
inform
that you
going
to discharge
twin
? onsea
touch
which
leadwas
to impact
and
damage
in are
one
and
other
inme
the
.channel to
was a cut in the wire as heYes
toldhe
medid
and. so we called ENG team .
If you wereIf succeeded
in
avoid
being
hit
by
RTG,
what your
you
were
toNO
do after that?
required,
were
you
wearing
the
PPE:
YES
Did
you
work in
blind
point correct
from
side ?going
-did
you
notice
the
spreader
in
twin
mode
?
When
did
thisworking
incident
take
place ?
n between RTG boundary by making TRhead
to
about
half ofon
the
container
Nobe
, I was
the
deck . in the Gulf row then my truck will be in a
Yes,
I saw
the
piston
of twin dawn
.
In
the
2ndany
hour
from
mywork?
work.
Did
you
face
during
Did you receive
supervision
in problem
the
laststarting
1hr ofyour
your
work: YES NO
No
, QC
was working
well
.
How
do
you
thinkhad
this
incident
could
be avoided
in
future?
1.
I
thing
that
RTG
operator
to
check
for
its
direction
before
deciding
to gantry.
Did you face any problem with spreader TLS during
your
working
hours?
2.
RTG
gantry
siren
need
to
be
louder
in
order
to
be
clearly
noticeable
-Beforespreader
made
bypass
theto
twin
lamp
lighted
not?
Didayou
a you
pre-shift
safety
talk:
YESsame
NO withorthe
No, as I adjusted
TLSreceive
on are
the
Trimcheck
position
be the
vessel position .
I didnt check it, I give all my attention to the lock lamp.
Abo-elenen
ID: 305
Direct
Supervisor:
Name:
Hany
Samir
ID: 512
Did you
receive
training inName:
how
to Mohamed
do
the task
involved:
YES
NO
Department: OPS

the
what
was
your trolley
speed
Experience:
4?years
Department:
Ops
Position:
YSV YES NO
Are you
aware
of
rules
/
procedures
related
to
this
work:
didRTG
you
activated
the bypass
(TTDS
wer , I reached the stop
sign working
and-Why
stopped
I had speed
checked
the way
container
blocks
I was
with
theafter
normal
because
Ibetween
wasbypass)?
loading
from
laneand
2 . there wasnt an
I
thought
that
I
lifting
twin
unit
and after I passed the firstIf blat
on the
land
, I surprised
by correct
TR
obstruct
way NO
so I stopped immediately .
were
Are you
this
happened
it before
required,
wearing
the
PPE:? my
YES
-How couldYes
you
make
itbut
accept
lock command
?
two
time
in different
bay
Did
he/she
give
a
pre-shift
safety
talk:
YES
NO
What
was your
before
you
started
I spreader
activated
TTDS
bypass
. limit
Didyou
receive
supervision
inmode
the
last
1hr
of
your
work:moving
YES ?work
NO ?
What
was
your
action
in each
time
when
the
switch
It
was
20ft
mode
as
our
SOP
.
How dowas
you think
this
incident
could be
avoided
in
future?
make
agantry
safe
adjust
hoist
. persons work
you
Did the
siren
was by
working
When was the last Itime
spoke
to distance
or
witnessed
the?involved
What is the safe distance between
the sill beam and the spreader?
Yes , it was
-What is the
instruction
which
you
received
instopped
the
training
using
bypass?
About
1
meter
, the
the
limit
switch
distance
Did
you
check
the
way
after
RTG
on
the about
stop
sign
?
Wetness:
Name:
Eshaa
ataa
abd
el-malak
ID:
535
Direct
Supervisor:
Name:
Ehab
Mohamed
Nageb
Sadek
ID:
1176
Didnt
use
the
bypass
till inform
supervisor.
No , because I checked
theto
way
before
andthe
I the
didnt
any equipments.
It is safe
close
theI stopped
flipper
over
sillnotice
beam?
Whythe
youflippers
didnt use
emergency
button
? VSV
Yes, I can
close
after
get out
from
the
vessel .
Department:
Ops
Position:
Department:
Ops
Position:
RTG
Operator
I surprised by TR and
I didnt
make
any cabin
thing , give
just I you
keepamy
hand
away from the controller keys .
Are the
glass
clear
visibility?
Did the
you supervisor
face like this
situation
before
-Did you inform
or
ask the
deck? controller?
yes
Experience:
7 years
No
, ita was
first
time
. YES NO
No Ithe
didnt
Did
he/she
give
pre-shift
safety
talk:
In
your
opinion
why
the
accident
happened?
informed the attach operator that he
will load
twin
container
, however he was know this information but
When
almost
this
accident occurred?
I Itdont
know,
may
be
fault
in .hoist.
was spoke
the first
my rotation
When was
the last
time
you
to hr
or in
witnessed
the involved
persons
-Where
was
the
Dock
controller
at
the
time
of accident
? work
How
can
we
avoid
this
accident
to
repeated
?
Did
you
feel
any
exhaustion
before
this
incident?
Did you have SOP
for training
the new
attached operators ?
Working
on
another
QC13.
We
can
close
the
flippers
on
TR
direct
,
or
make
more
safe
distance
but ID:
it well
effect
on productivity.
No,
at
all,
I
was
well.
Witness:
Name:
Ahmed magdy
mobark
1847
mately 3 or 4 blocks
, in the 1st block
I monitored
his moves
and
confirmation
on
the
system
step by step
Name: Ayoub Ibrahim Salman

Department: OPS
ID: 3706 ( Sinai )

Position: TR driver
G ( one of them on the right side and the other in the left side from me ) and also there were the fuel TR behind the RTG
TR but after I directed my TR , I noticed that the distance will be critical , so I reverse back again and took my way after I
1- Did you notice any sound during the TR hit the container ?
- No , TR motor sound was very high .
2- Did you close your cabin glasses ?
- Yes , I was closing the cabin from all side .
3- Did you have the awareness about the prohibition of reversing back without guide?
- No. Gomaa Hassan Ali ID: 1158
Involved Person: Name:Mohamed
Department: OPS Position: QC Operator
Experience: 2 Years
h cover land side ( Under deck ) , and suddenly the (MV/CMA CGM LYRA) moved forward and found my crane cabin abov
it was free , I changed mode from 40 feet to 20 feet and switched off twin mode in the same time but unfortunately , the
1- Did you notice any
abnormalities
move (Elsayed
Trim or Hassan
list ) from
(MV/CMA
Involved
Person:orName:
Elmasry
ID: CGM
1049LYRA) during work ?
- No , everything was in a good condition .
2- Did
you face any
problem
during
work?
Department:
OPS
Position:
QC your
Operator
- No , QC was work well .
Experience: 1.5 year

to another bay to discharge 3 single moves ,but they were between two rows both of them was 7 tier ,after finish discha
down command one flipper didnt respond so I inform my Vessel supervisor and ENG team for inspection.
-last time you used the flipper ,Did you notice any abnormalities in its performance ?
No, it was all in good condition
-What was your hoist down speed ?
It was slowly
-Where was the Dock controller ?
He was working with me .
-while you enter between the two 7 tier rows ,did you collide with any container or your spreader made any sway ?
Just little sway while entering between the two row with 7 tier.
YES
NO
- All TR drivers must follow the instructions by waiting the RS/EH operator signal to enter under the spreader.
Direct Supervisor: Name: Hany Samir
Department: Ops
ID: 512
Position: Ops SV

Involved Person: Name: Ashraf Abd El Azeem Akl ID: 3355
Mohamed
Hamed Mohamed ID:
1285 TR driver
Department:
Ops (Campbell)
Position:
Experience:
years
Position: QC 2.5
Operator
s there and after it attach the OHF, it was stopped as standby position, then I started to move with TR to get under OHF
any horn, signal or microphone and while I was entering under OHF, I heard a sound of crash I looked back, I saw the da
Experience: 2 Years
1- What is your instruction for safe entrance under RS ?
tch and the middle hatch
was closed and loaded with 4 tiers so I have to hoist up to exceed these tiers th
- The RS operator must give a signal by hand, RS horn, or microphone.
topped and the wires make spring2-movement
and follow
the container
collide with cell guide .which make the da
Why you didnt
these instructions?
-What
the weight
of athe
twin?position.
- Because
I saw was
him stop
moving as
standby
About
69that
tonwhat
& weyou
used
workentering
slowly in
thisRS?
case.
3- Did
traintoabout
under
- No, I trained that-What
I didntwas
enter
till the
RS down
operator
gave me a permission.
your
hoist
speed?
4- Did he give
you any
alarm
even
after you
start
enter
under the RS?
It was
slowly
due
to heavy
load
oftothe
twin.
- No.
-after the hoist stopped
,What was your reaction ?
Department: OPS
witch the crane off then on andDid

hoist
up again then adjust my position
using trolley and enter the cell guid
you receive a pre-shift safety talk:
YES NO
-If you stopped the hoist before the hatch by safe distance ,does this damage will took place ?
May be
yes to
& do
may
no.
in how
thebe
task
involved: YES NO
-When this accident take place ?
Are you aware of the
/ procedures
related
to this work: YES NO
Inrules
my second
working
hour
tried to close the distance

between
twin containers
to Zero position
Involved
Person:the
Name:
Hisham Mohamed
Samir but I found it not responding
ID: 1122 because the twin co
0.5 meter I stopped hoisting down
to give a chance
for the TR driverPosition:
to adjustYard
himself
under the RTG, but the TR didnt m
Department:
OPS
Supervisor
ners on the TT, and when the landed lamp was light up, I started toExperience:
unlock the spreader
3 years from the containers and started
he back edge of the trailer and cause a leaking of the internal cargo, I stopped and called the YSV, then while I handling a
again
of anotherof
TRberth
causing
a leaking
the
cargo.
Mohamed
Mustafa
Mohamed
ID:ofto
846
work at the end of berth
05 on
andthe
theedge
beginning
04
F,I
thought
re containers
adjust my car
position in the road betwe
1What
was
your
procedures
while
handling
a
twin
containers
on
a
TR?
eached to the road I started to back reverse again with maneuvering like (S) suddenly I notice that I hit something I stopp
- While I handling a twin containers
on the TR
concentrate
on the TR side and back edges.
Department:
OPSI must
Position
:QC Operator
2- Did the
thatroad
happened
in this
case.
-Did you checked
when you
revers
back by PU?
- I do concentrate on the side edge only
but
I
didnt
make
attention
to the back edge.
Yes ,I did Experience: 6 Years
While handling
twin containers,
should
close
the
distance
between
them
to zero
position?
planned to 3discharge
4 single
units
(20
while
discharging
fourth
one
I heard
abnormal
sound
from wires, then
-Did
youaheard
anyFeet)
horn alarm
or you
notice
anythe
light
coming
from
another
PU?
but if not happened I should take them
as single
container
by one),
that take a long time, so I handling them o
out from
pulley
,weNo
call
ENG
team
for and
inspection.
, I(one
didnt
4- Did
that
in the
training?
wasyou
thetake
under
bay
structure?
-your car -What
windows
was
open
ordock
close
when
the accident happened ?
No, but I care
about
the
work
in
short
time. bay 01 and it was clear .
It was sea side hatch and I -discharge
bay 02
& It
03finalize
safely
then
I
start
to discharge
was closed
Was your
mind
with
internal
or external
problems?
-while5-working
,Did
you busy
hit or
collide
with
containers
Vessel
?
-Are
there
any
problems
in your
mirrors or
and
glassbody
?
Normal
things
as
I
prepared
for
marriage.
der dock moving inside cell
nowas
possibility
hit the headblock
and the
was
No,guide
Mirror
in goodto
condition,
and the glass
giveWharf
me a controller
clear vision
. working with me and n
6Did
you
suffer
from
any
illness
and
took
any
medicines?
-Did you complain
un clear
operator
cabin glass ?
-Did youfrom
use Crane
the cardefect
mirroror
when
you start
maneuvering?
I
made
a
surgery
and
took
an
antibiotic
but
I
stopped
for
3 weeks to
ago.
it was
No , I did use it I depend on my first check & NO
I was
give perfect.
my attention in this moment
monitoring the work .
Acc.
towas
youryour
rotation
,When
place ?
-What
speed
whenthis
theaccident
accidenttack
happened?
Did
you
receive
a
pre-shift
safety
talk:
YES
After 30 min
fromnormal
starting
my second
working
hours
It was
speed
it less pair
thanor20
km. NO
in how
do the
YES NO
- Did
youto
wear
the task
seat involved:
belt?
yes.
Are you aware-what
of theabout
rules the
/ procedures
related
toplace?
this work: YES NO
illumination
in this
It was no good.
If required, were you wearing the correct PPE: YES NO
-Did you sleep well?

Did you receive supervision in the
last 1hr of your work: YES NO
Yes
How
do any
you problem
think thiseffected
incidenttocould
avoided in while
future?
-Are you
have
your be
performance
driving?
No
Direct
Supervisor:
Name:
Mohamed
Hamdy it in theID:
1298 ?
-What was the instruction which you received
training
hile maneuvering specially Reverse drive, avoid people error, keep a safe distance between me and any TR use the car m
Department: Ops
Position: Ops SV
-What is the precaution that you can take it to avoid it repeated again?
Did double
he/she check
give athe
pre-shift
safety move,
talk: YES
To keep more attention , check and
road before
usingNO
the car mirror all the time.
ring first vessel rope, the

vesselPerson:
teamAhmed
down
Abd
the ELaal
vessel
rope with
ID
: 1725
increase ID:
length
and with operating the v
Involved
Name:
Ali
El Ahmed
Shahat
hassanen
1264
y supervisor requested steel bar from the vessel to free the rope from the fender so they threw the bar for
Department:
OPS pull thePosition:
RTG
Operator
- After I finished,
the
vessel
worker
rope
and
the
rope
tied in the bollard.
Department:
Ops
Position:
RTG
operator
- My supervisor asked me to go up the vessel with him to deliver the steel bar to the vessel worker.
Experience: 2 Years
we
went
up
the
vessel
gangway,
the
gangway
was
on
the
rope
which was moved
attached
in the
bollard and on t
Experience:
yearstrolley
3 H 58 then I moved to bay 62 , after I catch the reefer unit from TR
,I hoist up and 2
forward to enter betwe
- During going down the gangway,
the
vessel
were itmaking
modification
for the gangway position.
the
last
tier in team
row E make
falling down
.
denly
thetovessel
slipped
the
quay
and
theand
rope
and
hitinthe
and
I felltech
down
o move
02 H gangway
which contain
twofrom
order
one
in bay
the
2nd
bayvessel
66?sostrongly
I wait the
reefer
toin
-Did you
handle
any
move
in 10
this
bay
before
the
accident
I swam
and phone
climbed
to
the me
quay
the
fender
then
Yes
I discharge
one
unit in
same
bay
2
tech contact with- me
by RTG
and
ask
if
Ithrough
have
an
order
in Bbay
10I Itook
said first
yes aid.
in B tier 1 but there
-Did you
pre handling
check
theme
baythe
? confirmation for this reefer in
and he said wait my hand sign after
un make
plugged
the cable
andfor
give
cently
so authorized
I thought
it was
only
4 tiers
and
I hoist
up to
safe
distance
to pass
4t
1-ranges,
Are
to go
up
the so
vessel?
EX
TR we
butdidnt
the Astack
was54tiers
tier in
sothese
I must
re you
handle
two container
again
I wait
him
contact
with
me over
or give
-What
your time
vision
RTG
cabin
andto
RTG
? for any connected cabl
- No,
myabout
supervisor
who
authorized
only
goperformance
up the
vessel.
lso ,I started to lift it slowly
,in
the
same
Ifrom
was
looking
from
my
cabin
seeking
Vision was clear and no abnormalities in RTG performance .
2- Why
go socket
up the was
vessel?
me from-Do
theyou
mega
phone
and told me
that did
theyou
reefer
broken due to the plug was connected
have any work related problems or personal problems affect your attention while working ?
- My supervisor askedNome to go up with him.
3- Are you trained about safety for vessel gangway?
- Yes.
-What is the instruction which you
reserved before handling any reefer ?
What is thethat
safety
vessel
it the reefer tech to give me the4confirmation
thefor
reefer
un gangway?
plugged and didnt lift any reefer Only
- Gangway
must
be stableand
on the
quay
safety
netsystem
must be
with his
knowledge
check
all and
reefer
on the
in installed.
this bay.
5- -Did
Why you
did you
gothis
up unsafe
vessel
gangway?
follow
instruction
in this
bay(66)?
Towas
finish
my
No, I didnt I waited the reefer tech but -he
late
sojob.
I afraid for delay and I took the decision to lift
6- How we can avoid
repeated
again
-Doesthis
thecase
screen
system
workin? the future?
- I must ensure that vessel gangway is
safe before going up the vessel.
Yes
-Did you have a confirmation on your system regarding to this reefer ?
Did you receive a pre-shift No
safety talk:
YES
NO
-why you didnt call the reefer tech by using the megaphone on the RTG?
Did you receive training in how
do the
task involved: YES
NO
It to
didnt
work
- Did you informed your supervisor about it?
NO
Norelated to this work: YES
- When the reefer tech was late why you didnt call your supervisor by using the phone cell?
If required, were
you wearing
correct
PPE:time
YES NO
My phone
cell wasthe
broken
in this
-In which hour the accident take place?
Did you receive supervision
the last
your
work: YES NO
In the lastinhour
after1hr
theof2nd
break.
When he out Involved

from his TR
and started
give me
a hand
sign toID:
lift 3708
the reefer again.
Person:
Name:toHassan
Yasser
Salama
-Does your Cabin glass

clean & provide
clear
vision?
AndCo.)
whatPosition
about the
in this place?
Department:
OPS Out
Source
(Sinai
: TRillumination
Driver
Involved
Person:
Name:
Mohamed
Ahmed
el-sodany
ID:
1263
Yes, I have a clear vision. And the illumination was good.
-Are the EX TR position was right
while you put
it?
Experience:
10 month
Department:
Operations
RTG Operator
roller inform me to move
for discharging
by QC 13 Yes.
which have noPosition:
TRs .I moved
forward but QC 13 was go
unfortunately I hit the trailer of the TR in front of me
Experience:
years
-Did you know about TR moving
in front of2you
?
-What
down
speed?
Yes ,Iwas
sawyour
my hoist
college
Bassem
andle 1st reefer container
(according
to my
work)
byspeed
adjusting
spreader
using
Normal
and I slow
down
my
when
I put
it on the
TR. side-shift in both direct
-Why
you
hit
him
? the
sted on the
bay,
thencontainers
i took the did
container
and
directed
toward
thehappened
reefer bayspecially
but while
wasTRs?
hoisting dow
-How
many
youI was
done
before
the
accident
oni EX
looking
at
VMT
screen
and10
phoned
my direct
containers
and 1yard
reefer.
o you have any instruction immediately
from yourAbout
supervisors
or OPS
trainers
to supervisor.
monitor the VMT screen while driving
No, but It is my habit to check the screen while drive .
Did you apply any gantry
movement
handling
theshift?
container from the Ext. truck?
- did
you -What
sleptbefore/after
well
coming
was before
your TR
speed?this
No, ivery
just low
use speed
the spreader
side-shift
mechanism.
did
It was
I Yes
just Istart
moving
from QC 13.
-In which
hourglass
the accident
takeclear
place?
-Did your
TR front
provide you
vision ?
According to your position
on
the
bay,
to
which
direction
the
In the 2nd hourYes
after
. the 1st break. ext. truck was shifted?
e (forward), as in the first
wasnt
able
to takewhile
the container
according
my position, for that i use side-s
-Arei you
attention
handling
this
reefer
container?
Acc was
to you
rotation
,when
the accident
take to
place?
vement) then hoisted up
re-adjusting
spreader
side-shift
to my
thefirst
left-side
before
Yes
In and
my 1st
working hour
at (07:45
am) in
day shift
. hoisting down in the b
-Are
Wasthe
the
RTG
megaphone
working
properly?
training
period
wasslept
enough
for you?
-How
many
hours
did you
yesterday
?
Yes.
Only Yes
4 hours.
-In your opinion why-Why
the accidents
take place?
?
So,
why
you
didnt
use
it
instead
of
making
the
side-shift?
arp, and may be Iwhen
adjusted
thereason
container
on the
TR sleeping
the distance
which
between
the TT gui
have Isome
family
prevent
myEX
from
more
than I4took
hours
.
As the Ext. truck drivers in general are not rapidly responding to our requests.
Did you recognize the side-shift direction (whether it was on the left or right-side) while hoisting down?
No i didnt,
as it was
so difficult
recognize
while
hoisting
Witness:
Name:
Bassemtofayez
Mahfouz
ID:
3641 down.
Department: OPS Outsource (Sinai Co.) Position: TR Driver
Did you monitor the right reefer (last tier catwalk
handrail)
hoisting down?
Experience
: while
2 years
No, because
onwait
the left
side. TR coming ,once I stopped I
er and in my way to yard ,I stopped
at thei was
end concentrating
of back reach to
another
Why you didnt activate spreaders zero position before hoisting down?
1- Did you noticed that the containers you would handle was a twin containers?
- Yes, I was knowing.
2- Did you turn on the twin mood before handling the containers?
- Yes, I turned it on, but it didnt work.
3- Was there any device show the status of the twin mood if it work or not?
- Yes, there was a twin mood indication lamp, but I didnt look at it.
4- Were you busy or disturbed mind?
system screen as I was trying to confirm the containers and it didnt work properly, and I didnt give attention to the twin
5- what was your rotation hour in the time of the accident?
- It was my 3rd hour on my 2nd hot seat change.
YES NO
YES
NO
NO
NO
- To give more attention and look to the twin mood indication lamp before handling the containers.
- To provide the RTG spreaders with TTDS (Twin Twenty Detection System).
Direct Supervisor: Name: Saad Kamel Ashry
ID: 883

Engineering: Mahmoud
Dorman
HSE: Mohamed Abbas
Ehab Zahran
Ahmed Salah
Ahmed El-Marasy
Operations: Nader Helmy

Engineering: Wael Abd ELfatah
Mustafa Fathy
HSE:
Operations: Ehab Zahran

Engineering:
Mohamed Hadidi
HSE: Ramzy
Maher
Ahmed Hegazy
Ahmed Salah
Ahmed El-Marasy &
Hesham Ismail

Engineering:
Mahmoud Dorman
HSE: Ramzy Maher
Sameh Haggag / Adel

Khedr
Ahmed Salah
Mohamed Abbas /
Mohamed Eltabeey.
Mohamed Hegazy
Amr El Shorbagy
Ramzy Maher
Operations: Mohanad
Rehan
Engineering:
Mahmoud Dorman HSE:
Mustafa Fathy
Ops: Ahmed Hegazy

Eng: Ahmed Shawky
HSE: Hisham Ismail
- Mohamed Seif
- Wael Abd El Fattah
-Ramzy Maher
Nader Helmy
Engineering:
Ahmed Shawky
HSE: Mustafa
Fathy
Walid Elkoraey
Mohamed Hassan
Mohamed Abbas

Engineering: Mohamed Ali
HSE: Hisham Ismail
HSE: Hisham A.Ismail.

Eng: Mohamed Hadidi
Nader Helmy
Engineering:
Ahmed Shawky
HSE: Mustafa
Fathy
Operations : Ehab Zahran

Engineering:
Sayed Abo-Elenieen
HSE: Hisham A.Ismail
Nader Helmy
Mohamed elhenawy
Mustafa Fathy
Ehab Zahran
Amr El Shorbagy
Ramzy Maher
Ehab Zahran
Motaz Hewila
Ramzy Maher
Ehab Zahran
Mohamed Elhadidy
Ramzy Maher
Mohamed Seif
Moataz Hweila
Mohamed Abbas
Nader Helmy
Mohamed Elhadidy
Mustafa Arnous
Hatem Hosny
Mahmoud Dorman
Mustafa Fathy
Sameh Haggag + Mohamed

Adel
Amr Hamza + Ahmed
Salaheldin
Mohamed El-Tabeey +
Mohamed Atef
Mohamed Adel
Mohamed Elhadidy
Mohamed Abbas / Mohamed
Atef.
Khaled hegazy
Ahmed Salaheldin
Hisham Ismail
Khaled hegazy
Ahmed Salaheldin
Hisham Ismail
Ehab Zahran
Ahmed Salah
Ramzy Maher
HSE: Hisham A.Ismail.

Eng: Mohamed Hadidi
Operations: Khaled Hegazy
Hatem Hosny
Moataz Hewella
Mustafa Fathy

Engineering: Motaz Hewela
HSE: Ramzy Maher

Engineering: Ahmed Salah
HSE: Hisham Ismail
Mohamed Seif
Ahmed Salah
Ramzy Maher
Mohamed Hegazy
Hany Maged
Ramzy Maher
Nader Helmy
Ahmed
Shawky
Mustafa Fathy
Adel Khedr
Salah
Ahmed
Mohamed Abbas
Ehab Zahran
Mohamed Hadidi
Ramzy Maher
Ehab Zahran
Amr Shorbagy
Ramzy Maher

HSE: Hisham Ismail

Engineering: Ahmed
Shawky
HSE: Hisham
Ismail
Mohamed Seif
Mohamed El Hadidy / Ibrahim
El Mogy
Ramzy Maher
Ehab Zahran
Hesham Nagy / Amr
shorbagy
Mustafa Fathy / Mohamed
Atef
Nader Helmy
Ahmed Salah
Mustafe Arnous , Ramzy Maher
Emad Salah
Ahmed Shawky
Ramzy Maher

Engineering: Ahmed
Salah/Ahmed Bahaa
HSE: Hisham Ismail

Engineering: Amr Shorbagy
HSE: Mohamed atef

Engineering: Mohamed Hassan
HSE: Mohamed atef
Nader Helmy
Engineering:
Mohamed Hadidy
HSE:
Ramzy Maher
Operations:Ehab Zahran
HSE: Mohamed Atef

Engineering: Ahmed
Salah El deen
HSE:
Hisham Ismail

HSE: Mohamed atef

HSE: Mohamed atef

Engineering: Ahmed Shawky
HSE: Mohamed Atef &
Mohamed El tabeey
Ahmed Abo Rehab

Amr ELshorbagy
Mustafa Fathy & Ahmed
Karawia
Operations:
Adel Khedr
Engineering:
Shawky
Ahmed
HSE: Mohamed Atef /

Mohamed El-tabeey
Operations:
Adel Khedr
Engineering:
Howila
Moataz
HSE: Mohamed Atef /

Mohamed El-tabeey

Engineering: Mahmoud
Dorman
HSE: Mohamed Atef
Operations Khaled
Hegazy/Ahmed Fouad (act SSI)
Engineering: Ahmed
Salahelden
Safety: Hisham Ismail

Engineering: Amr ElShorbagy
HSE: Ramzy Maher

HSE: Ramzy Maher
Operations: Adel Khedr

Engineering: Azmy shata
HSE: Mohamed Atef
Mohamed Adel
Amr Elshorbagy
Mohamed El-Tabeey +
Mohamed Atef
Operations:Khaled Hegazy
HSE: Mohamed Abass
Ehab Zahran
Ahmed Salah
Ahmed Karawia/Mustafa
Fathy
Operations: Hatem Hosney

HSE: Ramzy Maher + Ali
Adel
Operations:
Adel Khedr
Engineering:
Moataz
Hewela
HSE:
Mohamed El-Tabeey
Operations:
Adel Khedr
Engineering:
Ahmed Doma
HSE: Mohamed El-Tabeey
Nader Helmy & Amr Rashwan

Ahmed Shawky
Ramzy Maher + Ali Adel
Adel Khedr
Ahmed Shawky
Mohamed El-Tabeey
Khaled Hegazy
Moataz Hewalla /Amr
Elshorbagy
Hisham Ismail / Mohamed
Abass.
Operations: Mohamed
Elaraby/Mohamed Seif
Engineering: Amr
ELshorbagy
HSE:
Mohamed Abd ElRahman/Mustafa Fathy
Khaled Hegazy
Ahmed Salaheldin
Mohamed Abbas
Ayman Haikal
Mohamed El Hadidy
Ramzy Maher
Hatem Hosney
Mohamd Doma
Mohamed Doma

Engineering: Mohamed Hadidi
HSE: Mohamed Atef
Shift Manger: ahmed hegazey

Investigation completed by:
Operations: ahmed abou rehab
Engineering: ahmed baha
HSE: ahmed karawia
Operations: Hatem Hosney

Engineering: Amr Shorbagy
HSE: Ramzy Maher + Ali Adel
Amr Rashwan
Ahmed Shawky
Mohamed Abd El Rahman
+Ramzy Maher
Operations: Mohamed saiff

Engineering: Essayed Abo
Eleneen
HSE: Ahmed karawia
Ehab Zahran
Amr ELshorbagy
Mustafa Fathy
Operations: Khaled Hegazy.

Engineering: Ahmed Salah.
HSE: Mohamed Abass & Ahmed
Karawia.
Operations: Ehab zahraan

Engineering: amr el shorbagy
HSE: Ahmed karawia

Engineering: Motaz Hewlah
HSE: Ali Adel

Engineering: Ahmed
Shawky
HSE: Mohamed Eltabeey
Operations: Khaled
Hegazy
Engineering:
Ahmed Salahden
Safety: Hisham Ismail

Engineering: Mohamed ElHadidy
HSE: Mohamed Atef
Mohamed Seif
Ahmed Salah
Ahmed Karawia/Mustafa Fathy
Amr Shorbagy
Hatem Hosney
Ramzy Maher
Ali Adel
Operations: Adel Khadr

HSE: Ahmed Karawia
Operations: Hatem Hosny

Engineering: Motaz Hewlah
HSE: Ramzy Maher & Ali Adel

Engineering: Walled El-fouly- El
Zohery Hassan- Hany Maged
HSE: Mohamed Atef

HSE: Mohamed Atef
Mohamed Seif
Moataz Hewella
Mustafa Fathy
Nader Helmy
Mohamed El Hadidy
Ramzy Maher
Mohamed Hamdy (Act as SSI)

Motaz Hewela
Ramzy Maher
Adel Khedr
Ahmed Shawky
Mohamed Atef
Operations: Walid Aly

Engineering: Ahmed
Shawky
HSE: Mohamed Atef

Engineering: Mohamed
ElHadidy
HSE: Ramzy Maher
Operations: Mohamed Sief

HSE: Ahmed Karawia

Engineering: Ahmed
Salah
HSE: Ramzy Maher +
Ali Adel
Engineering: Moataz Howila
HSE: Mohamed Atef

Engineering: Ahmed
Salah
HSE: Ali Adel
Mohamed Seif
Mohamed ELhadidy
Mustafa Fathy

Investigation
by:
HSE: completed
Ali Adel
Shift Manager: hatem act

Operations:
Helmyby:
InvestigationNader
completed
Engineering: Ahmed
Shawky
HSE: Mustafa
Fathy +
Ali Adel saif
Operations:
Mohamed
Shift Manager: hatem act
Engineering:
m. el
Investigation
completed
by:
haddeidy
HSE: ahmed karawia
Operations: Mohamed saif
Engineering: m. el
haddeidy
HSE: ahmed karawia

HSE: Ali Adel
Nader Helmy
Elsayed AboEleneen
Adel
Operations:Nader Helmy
Engineering:Elsayed
AboEleneen
HSE:Ali Adel
Mohamed Hegazy
Ahmed Salah
Mustafa Fathy
Ali
Nader Helmy
Ahmed Salah
Ramzy Maher
Mohamed Seif
Moataz Hewela
Mustafa Fathy
Mohamed Seif
Moataz Hewela
Mustafa Fathy
Hatem Hosney
Mohamed El
Hadidy
Ramzy Maher
Operations: Mohamed siff
Engineering: ahmed shawkiy
HSE: ahmed karawia
Mohamed Seif
Wael Abd Elfatah
Mustafa Fathy
Operations: Ashraf Souidy

Engineering: Ahmed
Salah
HSE:
Ahmed karawia
+ Ahmed Elaraby (Act SSI)
+ Nader Helmy
Engineering: Moataz
Howilla
HSE: Mohamed Eltabeey
Security: Amr Elbana
Heshaim Behairy
M .El Haddeidy
Ahmed Karawia
Mohamed Hegazy
Mohamed Hassan
Mustafa Fathy
Mohamed Adel
Wael Abd El-fattah
Mohamed El-tabeey
Mohamed Atef
Hatem Hosney + Nader Helmy

Amr Hamza + Mohamed El
Hadidy
Ramzy Maher
Revision: R001
Risk Value
Probability ( 5 ) * Severity moderate ( 3 ) = 15
possible 3* minimum 1 = 3
Possible3* Minor 2 = 6
Probability ( 5 ) X Severity will be advised later L17
Unlikely 2 * Minor 2 = 4
Near Miss
Risk= severity(1)*likelihood(5)
Possible 3* waiting
likely* min = 4
Probability 4 ( Likely ) X Severity 1=4
unlikely* min = 2
severity ()*likelihood (3)= to be calculated
min 1*likely 4 = 4
Minimum (1) * Likely (4) = 4
Possible 3 * Minor 2= 6
Possible 3* waiting
Minor* possible = 2*3
1* 3
Probability (3) * Severity ( 1 ) = 3
Probability possible (3 ) X Severity ( 2 ) = 6
Possible 3* Minimum 1 = 3
Min2* possible3=6
Possible (3) * Min 2= 6
Possible (3) * waiting
Severity 4 *(probability 3 )=12
Probability Unlikely ( 2 ) * Severity ( 3 ) (Wire Due )= 6
Likely (4) * Minimum (1)= 3
Severity (2 ) * Probability (2) = 4
Severity ( ) * Probability (3
Probability ( 2 ) * Potential Severity ( 5 ) = 10
likely 4* Minimum 1=4
Risk Value:
Severity (waiting) *likelihood (3)
Risk Value:
Risk Value:
Likely4*Waiting
Risk Value:
Severity (2) * Probability (3) = 6.
Risk Value:
Severity (3)(22.283 EUR) *likelihood (3)=9
Risk Value:
Probability (3) X Severity ( ) =
Minimum 1 * Likely 4 = 4
Risk= Likely (4) * Severity (1) = 4
Possible 3* Minimum1=3
Likely 4 * 4 = 16
Likely (4) * Severity (Waiting cost)
Probability 1* Severity ( Waiting to be advised from WS )
Minor (2) * Likely (4) =8
likely (4) * Severity (Waiting cost) =
Likely ( 4 ) * Severity (1) = 4
Possible 3* minimum 1 = 3
likely (4) * Severity (Waiting cost)
Unlikely (2) * Severity ( waiting medical report)
Near Miss
Likely (4) * Minor (1) = 4
Possible 3* Sverity 2= 6
Likely 4*waiting
Probability (3) X Minimum (1)= 3
Possible 3 * Severity 3 = 9
Probability (3) X Severity (1) =
Probability Unlikely(2) X Severity Minor ( l ) = 2
Probability (2) X Severity 2) =4
Risk= Severity ( ) * likely Possible (3) = 6
Risk= Severity (2) * likely Possible (3) = 6
Probability (2) X Severity ( 1 ) =2
(2 )* Likely (3) =6
possible 3* sevirity 3 + 9
possible 3* sevirity 4 = 9
Possible (3) X Severity (3 ) = 9
Likely (4) X Severity (2 ) = 8
Possible( 3)* Severity( 2)= 3
Possible 3* Severity 1
12
Probability (3) X Severity (Waiting Cost) =
Likely 4
Likely ( 4 ) * Severity ( )
Likely ( 4 ) * Severity ( )
Likely 4* Severity ( 2 ) = 8
Likely 4* Severity ( 2 ) = 8
Likely (3 ) *severity ( 3) = 9
12
Likely (3) * Severity ( 1 ) = 3
Likely(4) *
Severity ( 1 ) = 4
Waiting cost * likely
Possible 4* severity (1) =4
Possible 3* waiting
Waiti
Revision date: 22/06/2011
F-03-02
Corrective Action
Action
Owner-ship
Deadline
1 To provide deck controller with

every deck.
2 To assign deck controller with every
crane with the vessels which famous
by the bad Cell-guide.
Management
Shift Operations
Superintended.
Under process
To be implemented
1- Send the TR driver to the Training

for a one day refreshment sessions
about the instructions and procedures
of traffic.
2- The case to be published for all TR
drivers at the daily safety talks.
Add to TBT to all TR driver to inform TR SV in case of

feeling sleepy of fatigue .
OPS
41294
OPS
January 21, 2013
1-Add this case to TBT and highlighted the importance

of following the procedures of never reversing back
unless in the presence of an observer and with clear
view.
2- Make reassessment to the driver and driving roles
refreshment.
1- ops
2- ops + ops training
January 18, 2012
1- Add this case to TBT and

highlighted the importance of calling
and providing every QC is dealing
with the blind points on vessels with
deck controller.
2- To provide deck controller with
every QC.
1- Ops
2- Management
1- 21/1/2013
2- under process
1 To make a daily random check for

the wrong staking in the yard, then
re-stack in the proper way & to be
reported as observation .
2 To add every observation of bad
stacking in the log file by the name &
ID of the involved operator then to Ops Yard Supervisor
collect the repeated names to be sent
Ops
to Ops training for re-assessing this
Ops
operator.
3 To add this incident to the TBT &
highlight the importance of stacking
in the proper way & to check the
distance between the bays before
handling any container.
Daily ( Starting from

20/01/2013 )
To be implemented
28/01/2013
Make a survey for all the new gutter

covers for standing on its fixation
status on the ground and to start
fixation process.
Prepare MSDS training for gate

service supervisors
Prepare training for gate service
supervisor & subcontractor supervisor
to raise their knowledge about
dealing with IMO container.
Gate dept. to provide chemical set of
PPE (Gloves, full mask) for IMO cargo
inspection
Gate to Modify IMO cargo inspection
SOP
Exclude stevedore workers whom
have any medical history related to
project
waiting project respond
HSE
HSE
Gate
Gate /HSE
Gate
01/02/2013
01/02/2013
15/02/2013
10/02/2013
01/02/2013
1-To be discussed during TBT about the importance of

pre-checking of plug/unplugging reefer sockets.
2-Refreshment for RTG operators about new reefer
socket system.
Ops
2/14/2013
Add this case to the TBT

showing the importance of
1- RTG operator must assure
that the number and the
location of the container in
the yard is identical to the
number and location of the
container in the system.
2- If the RTG operator visibility
is not good, he must call the
yard supervisor to help him
ops
February 5, 2013
1-ENG TS to paint new stop sign at the end of J

block same like phase II
2-Involved Driver get out of OPS Rooster till reassessment
3-TR Supervisor to highlight our traffic rules &
traffic priority during daily TBT
ENG TS
OPS -Training
OPS - Execution
1-Waiting TS advice
2-Already done 07/02/2013
3-15/02/2013
1 Add this incident to the daily TBT &

highlight the importance of following
the safe handling procedures & the
importance of reporting any defects.
2 To assign the RTGs which working
with reefer to be fully equipped by the
communications devices.
Ops
15/02/2013
Ops
07/02/2013
To add/highlight on TBT the case and

inform all drivers about the
importance of following the correct
SOP.
Ops
12/31/1899
Refreshment to be done for the

operator
regarding new reefer system.
Refreshment to be done during safety
talk to discuss all issues may effect
the work.
1-Involved driver out of OPS rotation

till reassessment
2-Add this case to TR driver TBT and
highlight the hazard &consequence of
breaching SOP.
Ops
2/18/2013
1-OPS Training
2-OPS
10/02/2013
16/02/2013
1-Highlight in TBT for all RTG

operator
about the importance of double
checking
before handing any containers.
(visual checking before rely on
signals).
2-To fix all light indicators inside all
RTGs operator cabin (lock-unlocklanded)
Ops
Eng
1-3-2013
1-4-2013
1-Reefer to include Gate loading in LOG system ASAP

2-Add to RTG operator TBT to wait confirmation from
reefer before handling Gate units till LOG modification
done
Reefer
OPS
February 20, 2013
1- Make a refreshment to the RTG operator

about the
reefer load system procedures
2- Add this case to the TBT showing the
importance of
a) Follow the reefer load procedure.
b) RTG operators must call the reefer
technician for check the status of the reefer
connection in doubt condition, or in system
failure and never depend on live vision
Add this case to the TBT showing the

importance of checking the position of the
4 flippers before loading on vessel.
ops
ops
14/2/2013
21/2/2013
ops
February 22, 2013
1- To add this case to the TBT & to highlight

the importance of safe working operations.
2- To let the deck controllers make a survey
on the vessel structure which may affect on
the operations & I case of deck absence it
will be the responsibility of the vessel
supervisor.
1- ops
2- ops (VSV)
20/3/2013
20/3/2013
Add to all driver TBT :

1-report any abnormalities ,feeling fatigue
or snooze to direct supervisor .
2-Importance of seat belt and explain
consequences of misuse
ENG WS to start applying the modification

for all DUTCH LANKA trailer as sample
trailer 118
OPS
ENG WS
March 20, 2013
1 Send the involved operator to training

department for re-training.
2 Add this case to TBT and highlighted that
1. All RTG operators must use the screen
for check process during operation and
inform the Yard supervisor about any
defected screen.
2. All RTG operators must use slow trolley
speed in case of 5 tier.
3. All RTG operators must ensure that
spreader in zero position before trolley.
3 Add new modification for all RTG that in
case of hoist level above 3 tier, the trolley
speed will be slow automatically.
4 Detect the places in which the same
incidents happened during the last year in
order to study the reasons behind these
kind of incidents (RTG hit containers).
OPS-Training
OPS
ENG - OPS
Safety - OPS
15/03/2013
17/03/2013
Under test
Under study
1- To add this case to the TBT & to highlight

the importance of following the safe
working procedures .
Ops
April 1, 2013
Add to TBT the importance of keeping

a safe distance
between trucks especially with
loading
twin containers with heavy weight.
Ops
3/25/2013
1-A special tool has been requested

from Eng. Dep. To be used instead of
human hand to be easily accessible
for work purpose.
2Add to TBT about the importance of
using PPE all the time as this tool
might fall on somebodys head.
Eng.
19-04-2013
31-03-2013
1-Reassessment of the driver

2-Add to the TBT the importance of never
taking the risk and get maneuvering in
such situation.
1-ops training
2-ops
1-21/3/2013
2- 24/3/2013
Recommendations to provide with

each QC one deck controller
to ensure safer handling steps.
Adding to the briefing
Give instructions for QC operators to
reduce speed hoist up while handling
in blind points.
Ops
waiting
14-04-2013
1-Exclude this TR Driver from OPS

rooster till reassessment
2-Add to TR Driver TBT Traffic rules
refreshment
OPS
4/15/2013
Add to the TBT the importance of giving

more attention in such situations and be
more careful while handling in such
environment, and always taking in
considerations the un expecting changing
in circumstances
OPS
April 11, 2013
To add to TBT the importance of

keeping an adequate space between
the truck and containers before start
maneuvering.
To add to TBT dont start
maneuvering unless you have clear
and enough space for turning your
truck wheel gradually.
Add this case to the TBT and instruct the

VSVs whose
in charge of sailing any vessel
to notify all VSV to take more care
while operating the surrounding vessels.
OPS
4/20/2013
ops
April 19, 2013
Add this case in the TBT and highlight the

importance of never
reversing back in the blind points and if
necessary the
TR drivers must asking for a helper (TSV) to
help TR
Add
to all
TBT back
not to
start
drivers
forD&W
reversing
safely
operation before insure that deck

controller inspect all working bays
and report any abnormalities
ops
4/19/2013
OPS
230/04/2013
1 Involved person to be re-inducted about

how to take the right decision & to ask the
direct supervisor about any critical
situations.
2 To add this case to the daily TBT &
highlight the importance of following the
work procedures & the safe working rules.
Eng.
5/6/2013
1-Reassessment for the TR driver

2-Add this case to TBT and highlight the
importance of
- Never to take maneuvering with TRs in
such area between the waiting area & the
beginning the Mike (main drive way).
- Never move the TR on the tire rim directly
(when the rubber tire is exploded).
1- ops+ops training
2- ops
1- waiting
2-26/4/2013
1-Add this case to the TBT and highlight

the importance of
- Never leave the equipments in unsafe
area (make a safe distance away from the
RTG lane).
- Never hoist down the RTG spreader to be
close to the ground.
- In such cases and the area under the RTG
was crowded, the RTG operator must
confirm that he will move.
2-- Collect the RTGs without microphones
for fixing them
3-- Draw a red line beside the RTG gantry
line to define the safe area to stop the
equipments
ops
CHE
TS
4/5/2013
Under process
waiting
Add to TBT the Importance of having

sufficient time for sleeping before
start work and never take the risk for
driving or working in case of feeling
tired/fatigue, and ask your supervisor
to take rest if needed.
Eng.
5/15/2013
Add to TBT a good and clear way of

communication must be established
between QCs operators and Wharf
Controller and ensure that the all
messages have been delivered
clearly.
Refreshment to Wharf controllers to
ensure the proper position during
gantry movement for QCs.
Ops
5/15/2013
1- Add this case to the TBT and highlight

the importance of pay more attention
on the way while gantry and never depend
only on the anti collision sensors
2- Provide the RTGs with log file system to
facilitate knowing the faults and bypass
actions.
1- Ops
2- CHE
1- 20/5/2013
2-Waiting the CHE response
about the capability of build
up the system log file
1-Making a contract with a glass

subcontractor specialist to make a full
inspection for all cabins glass.
2-Making periodic inspection by a
professional subcontractor on the
operator cabin regarding glass frames
3-Adding this case to TBT as in case
of any abnormality discovered by the
operator should be readily reported to
the direct Supervisor.
1-Engineering
2-Engineering
3-Operation
1&2 waiting ENG feed

back
3- 01/06/2013
1- Add to the TBT of TR drivers that in case

of doubt about waiting in a safe position
between two close nearby QCs, they must
ask the wharf controller if the distance
between the two QCs is safe to wait in or
not.
2- Add to the TBT for the wharf controller to
pay more attention for the TRs traffic and
positions under QCs.
3- Re-assessment to be done for the TR
driver
4- Insuring that the TBT must be done for
all ops stuffs.
1- ops
2- ops
ops training
3- ops
1- 5/6/2013
5/6/2013
3- waiting
5/6/2013
Add this case to the TBT and highlight the

importance of
- In case of feeling fatigue or drowsiness ,
the drivers must stop driving, inform TSV to
get sufficient rest.
- Incase of taking any kind of medicine, the
drivers must tell the SV in the beginning of
the shift and go to the clinic for evaluating
if the medicine will effect in their safety
during work or not.
ops
June 14, 2013
To provide Deck controller for each QC as

1.Add
this casefor
to QCs
TBT operator
regarding:
truck
its essential
while
drivers have to bay
more attention while
handling
across
container
blocks
and
look
todriving
give clear
status
with cell
guide
and
ship
aside at both directions
especially
at
cross
structure.
routes inside the yard.
2.Truck driver need to be sent to the
training sector in order to be re-assessed,
and during this period of time he should be
out of working rotation.
3.A Standard Operating Procedure

need to be presented regarding: how to
control external trucks in special cases and
especially in areas where there is an
interfering between gate operations and
normal operations.
4.Safety Awareness Program need to be
held to ext. truck drivers in order to be sure
that all drivers are aware about our safety
instructions regarding driving instructions
inside the terminal.
Management
1- ops
2- training/roster
3-gate
4-- Safety
1- 25/06/2013
2- 20/06/2013
3- waiting
4- waiting
1. Add this case to TBT regarding: truck

drivers have to check for any abnormalities
noticed inside truck cabin before operation
and pay more attention for the extinguisher
position and report that to their direct TR
supervisors.
1- ops/training
2- ops
2. Broad survey
should be performed to all TRs inspecting
the presence/absence of extinguisher
stands and sending the defected TRs to
Workshop in order to fix new stands.
1- 25/06/2013
3- waiting
1- QC operator must gave a training

session
about the safe handling procedures
and the correct inspection to assure the
safe handling
2- - Add this case to the TBT showing the
importance of following the safe inspection
procedures after incidents and when doubt
they must stop the operation till full
inspection
3- - Provide a deck controller for each QC
1-Ops training
2-ops
3- ops and
management
1- waiting
2- 24/6/2013
3- in progress
1. TR Driver to be sent for training

department in order to be re-assessed and
during the re-assessment period he should
be out of rotation.
2.Add
this case to TBT highlighting that: TR
drivers during passing within blocks in the
yard should look around for any crossing
equipments and didnt take the risk of not
following safety traffic standards.
3-Add this case to TBT
highlighting that: RTG operators while
crossing through blocks they should stop at
the Stop sign and check for any passing
vehicles.
Add to TBT to RTG operators and all

stuff in case if they have any personal
issues/lack of rest they should inform
their supervisor.
1- Ops-Training/OpsRosters
2/3- ops
1- 25/06/2013
2/3-1/07/2013
Ops
7/1/2013
1.Add this case to TBT: regarding that

Deck controller should be in place
while opening HC and give that the
highest priority.
Ops
2.Add this case to
TBT: regarding that all QC operators
should ask for a confirmation from the
deck controller that HCs are ready
before opening them.
7/1/2013
To provide Deck controller for each QC in

order to provide full monitor on the
handling process.
Management
Waiting
Add to TBT for all RTG operator

1- never handle severe deviation
alone .
2-Report any abnormalities to avoid
sudden failure in equipment.
OPS
7/15/2013
Truck driver need to be sent to the

training sector in order to be reassessed, and during this period of
time he should be out of working
rotation.
Add this case to TBT and highlight
that TR drivers must follow safety
regulations for traffic inside yard: they
should stop at the Stop sign and
stand away from RTG lane and didnt
take any decision seemed to be hard
to perform and may lead to a
potential of an accident.
Ops-training
Ops-roster
OPS
July 18, 2013
Installing some sort of buzzer related

to twin sensor on the RTG spreader
inside the operator cabin to alert the
operator if the twin mode wasnt
activated before twin move get lifted
on 40 feet spreader mode.
Eng.
July 18, 2013

that RTG operators must be more
attention especially when trying to
press twin-telescopic store button so
as not to press any other button
instead like twin-up button.
OPS
deck controllers have to made a preinspection starting from the bays that
within operation process and then
check for other bays with no current
operation.
2.Providing
Deck controller for each operating
crane to maintain safe operation
process.
3.Refreshment /
awareness message sent by VSV for
each working QC operator during
cargo operation (especially after each
handover)regarding the status &
history of the vessel and also VSV
have to monitor deck position on
board.
4.For
such vessel: Cargo operation
shouldnt be planned by maximum
cranes: by providing 2 operating
cranes
at most
in order
tooperators
maintain
Add to safety
briefing
for QC
vessel
stability
during while
operation
to pay
more attention
dealingand
decrease
spreader
withthe
twinpotential
containersofand
monitor their hoist speed.
stuck.
1/3. Ops
2. Management
4.Ops
OPS -Execution
OPS -Execution
1&3 :25/07/2013
2&4 :waiting
16/08/2013
26/07/2013
1-The involved person was terminated from

entrance the terminal again.
2-Add this case to the TBT and high light
the importance of
- Checking the low bed stopper bars before
using it and the defect ones must be
prevented from use
- Give more attention while entering the XRay area.
3-Random stuff (Subcontractors & SCCT)
sampling for drug test to be done
continually
1- HR
2- OPS
3- HSSE
1- 17/7/2013
2- 25/7/2013
3-25/7/2013
1. Safety instructions refreshment to be

done for the two drivers
2 .Add this case to the TBT and high light
the importance
1- Fasten the seat belt all driving time.
2- Keep the safe distance between TRs.
ops
1.Waiting
2. 3/8/2013
1.Send the Involved RTG operator for

refreshment about the importance of
using reefer log system.
2.Add this case to TBT and
highlight that RTG operators must be
more attention and check on the
Reefer log system or check with the
reefer technician before lifting any
reefer container.
Ops-training
OPS
1. 1/8/2013
2. 7/8/2013
2 Add this case to TBT and highlight that

TR drivers must be more attention to his
road and inform TR supervisor for any
defected seat belt. 26/07/2013 OPS
OPS
July 26, 2013
1 Add the inspection of the hoist set

point of the limit switch the PM.
2 To modify the process of pre-task
check of the crane operator, to be the
1st move of every crane the pre-task
check by working in the safe way & to
check the functions .
3 To add this accident to the TBT & to
highlight the importance of following
the safe working procedures & to
inform the supervisor & the
colleagues about any faults in the
equipments
Eng
Ops
Ops
8/10/2013
1-Add to all QC operators to ask for

assistance from dock controller in
case of handling in blind points or
when get confused from unclear
situation before activate any bypass
2-OPS Dept to make survey for
system screen in all QCs .
3-After finalize a/m survey ENG&IT
Dept. to repair all defected screens
(Power/system errors)
OPS
OPS
ENG/IT
17/08/2013
17/08/2013
30/08/2013
1 - Add to the SOP that in case of working

in a blind area the operator must call the
deck controller as a guide .
2 - Add to the TBT the importance of to be

care while working on blind point .
Add this case to TBT and highlight that
QC operators must check flippers status
before charging or discharging on vessel.
8/18/2013
OPS
8/20/2013
OPS
1 Add this case to TBT and highlight that all

TR drivers must follow safety traffic rules.
2 Sent the involved driver to training
department for reassessment
19/08/2013
18/08/2013
OPS
OPS training
1- Claim the vessel for the mentioned

damage
2- A clear instructions to be written in the
SOP for taking the safe position (behind
lane 3) while berthing the vessels even in
driving position & to publish it in the TBT.
1- claims
2- Ops
19/8/2013
28/8/2013
Add this case to TBT and highlight that

QC operators must be more attention and
must adjust the spreader on the container
1well
Engineering
write
before downdepartment
the flipper to to
prevent
the
adequate
SOPflipper
for this
& to be
collision
between
andjob
container.
Ops
August 28, 2013
sent to HSE department to be

approved for the concerned safety
parts.
2 A- Engineering team to prepare the

Risk assessment for this task & to be
1-Eng
communicated with HSE department
2-Eng / HSE
for reviewing it
B- To review all routine / non routine
3-Ops / Eng
jobs risk assessments which located 4-HSE / HR relations
in Eng library.
3 To add this accident in the Tool Box
Talk & to highlight to operations team
that no one is allowed to operate any
equipments without authorization.
4 To share this accident via all notice
boards
25/08/2013
A- 25/08/2013
B- 15/09/2013
01/09/2013
26/08/2013
1 Potential punitive action with QC

Operator
2 Re-assessment of QC Operator
3 Review of SOP handling, escalation
and communications
HR
HR
Scott
(pending HR
consultation)
(pending HR
consultation- ASAP)
13/8/2013
Add this case to the TBT in order to

highlight the importance of being
more attention while working close to
another RTG and didnt depend on the
censor
OPS
August 1, 2013
* Reassessment must be done for the

TR driver about his safe working
instructions
- Add this case to the TBT and
highlight the importance of insuring
that the spreader was in a safe height
1- Ops training
2- ops
1- waiting
2- 2/9/2013
1- Risk Assessment to be issued for this

activity
2- Add this case to the TBT and highlight
the importance of following the safe
instructions while working in the blind point
with guide
ops
1- 6/9/2013
2- 3/9/2013
Add this case to TBT regarding: all SV should

pay more attention while maneuvering, especially
while driving around working sites and pay more
attention for barriers places.
ops
September 10, 2013
1- Add this case to TBT and highlight that

TR drivers must be more attention to his
road and take save distance between two
vehicle 15/09/2013 OPS
2- hold awareness campaign about the
dangerous of driving to close to vehicle in
front
OPS
5-Sep-13
1- Add the safe procedures of dismantling the lash

bars to the lashing manual.2 - Add this case to the TBT and highlight the
importance of taking care while dismantling the
lash bars.
3 - Study changing the type of the lashers gloves
to be impact resistant type
4- Make lashers aware of thier surroundings , and
take more care in the working area.
08/09/2013
Ops (Lash)
Ops
08/09/2013
Ops + HSE
Under study
Add to the TBT that all drivers must

stuck with the traffic roles and give all
attention and concentration on their
way while driving
HSSE
9/18/2013
ENG WS
10/1/2013
Add this case to TBT regarding: all

Eng. & operator should be more
attention while maneuvering. All pick
up while adjustable tire air pressure
entering in reverse position with a
guide to avoid any impact.
Putting some reflective tape on the
workshop shelter support.
Reposition the spotlight by
coordination with TS
Adding TR movement in tires
1 -Add to all TR driver TBT to avoid sharp

maneuvering near hatch covers
2- Add to D& W controller TBT to secure all
hatch cover with cones once opened
3 -TR Driver will directed to OPS-Training for
reassessment
OPS
September 25, 2013
1 To make an adequate ashtray outside the cabin.

2 To fix all fire extinguishers of the crane
operators cabin in one place at all cranes, this to
be visible to all crane operators.
3 To communicate this incident with the 3rd party
which is responsible for cleaning process & the
importance of keep the good level of
housekeeping.
4 Add to QC operators check list a point of Fire
Fighting equipments are in place.
Eng
HSE Fire
Eng
Ops
10/10/2013
10/10/2013
25/09/2013
01/10/2013
1.Add this case to TBT regarding: all crane

operators should be more attention and
follow sop while charging and discharging
containers (take a safe distance ,ask the
dock controller for a help if needed)
Ops
September 27, 2013
2.Add this case to TBT regarding: all lasher

guys check them workplace on the vessel
and reported any abnormal situation to the
supervisor, and follow sop.
1.Provide deck controller for each Quay

Crane
2.Add this case to TBT and inform
operators ( Deck Controllers , Crane
operators and lashers ) to report any
abnormalities occur to take our precautions
to avoid unsafe (Action&
Conditions )
Ops
Ops
In Progress
06.10.2013

that
TR drivers must check TT leg support
before driving and inform TR
supervisor about any defect in the TR.
Provide additional D&W controllers to

be with each QC operator.
Add this case to TBT regarding: All

Supervisors should follow the traffic rules
inside terminal regarding driving speed not
to exceed: 25 KM/H.
Add this case to TBT regarding: All
Supervisors have to make a pre-task check
1atAdd
to time
all D&W
TBT Ops-PUs
to inform
each
theycontroller
handed over
the themselves
ENG team full
details
anyshift
among
within
theabout
working
circumstances
place before
start
in addition to take
the normal
inspection
handling
any
.
between shifts
in order
tofault
discover
sources
2 Add
all QCbefore
operator
TBT never
handle
of to
hazard
it becomes
risky.
any spreader stuck before arrival of ENG
team.
Ops
Mng
10/4/2013
wating
OPS
October 2, 2013
OPS
10/15/2013
Add to the TBT that call the deck controller

if any abnormalities happened
while handling the containers specially in
the blind areas.

that RTG operators must be more
attention during working on bays and
make sure that the RTG position is
right before starting work ( check &
double check) also while making
trolley and ensure that the hoist in
safe level before making trolley.
Sent the involved operator to training
department for reassessment.
October 4, 2013
Ops
07/10//2013
Ops
Check list for the critical points on the

spreader/ head block to be formed by ENG
& OPS departments to check the spreader
every hot seat change for the wharf
controller
Survey to be done for the safe guard of the
pulley of the hoist wire
Add this case to TBT and inform our
operators ( Crane operator , Deck and
wharf controller )to report any hit or
abnormalities to ENG team
Add this case to TBT and highlight that: QC
operators havent to increase their hoist
speed while discharging under deck and
pay more attention in case of containers
found to be improperly stacked and
1.Send
the handling
Involved process
RTG operator
for
arrange the
with deck
reassessment.
controller.
2. Repair defected Twin activation button
on the console.
3. Add this case to TBT and highlight that:
RTG operators must pay more attention
while activating spreader twin mode by
visual inspection on the spreader and by
noticing twin activation lamb on the
spreader or in the operator cabin.
ENG & OPS
12.10.2013
ENG
03.10.2013
OPS
10.10.2013
OPS
October 15, 2013
Ops Training
12.10.2013
ENG
11.10.2013
OPS
15.10.2013
1-Prohibition for all SCCT PUs to wait

in standby lane & use designated
parking( at M-Block) .
only in case of heavy tools required
they should confirm with wharf
controller before discharge their tools
then wait in M-Block
2-OPS Training to Issue RA for vehicles
reversing back
1-OPS/ENG
2-OPS Training
10/20/2013
1- Ops
2- Ops
3- ENG
1- 21/10/2013
2- 21/10/2013
3- Waiting
1- Add to the TBT the importance of

giving more attention while driving the
equipments with prominence.
2- Instruct all Ops SVs to avoid Washing the
RTGs cabins glass in the reefer stands
blocks
3- Putting a reflective tabs & paint the RTG
cabins glass washing equipment by
shining colors (yellow & Black)
*Reassessment to be done to the RTG

operator specially on the reefer containers
handling instructions
*Add this case to the TBT and highlight the
importance of following the procedures and
must check the unplug system first
*A survey on the phones of all RTGs must
be done and select the defect ones to
report it to the TPM system for repairing.
1-ops training
2- ops
ops +engineering
1- waiting
2- 21/10/2013
3- Waiting
Add this case to TBT: highlighting the

necessity of reporting any accident
happens immediately, in order to
define the root causes and to get the
required corrective actions to prevent
its re-occurrence.
OPS
10/25/2013
Provide refreshment session for the

involved trainee concerning
containers safe handling procedures.
No one of trainers is allowed to stand
closely while handling process and to
stand in a safe place away from the
containers handled. 23-10-2013
OPS-training
10/23/2013
Engineering department to study a modification to

the trolley cat walk locks to prevent falling down.
Eng
October 31, 2013
1. Add this case to TBT and highlight it to

RTG operators must be more attention
especially when handling tank container or
IMO container and follow sop about it and
make sure that.
2. Also add this case to TBT and highlight it
to all TR drivers must be more attention
especially
when for
theyall
working
under RTG
Make survey
megaphones
onor
QC
and
didnt
usecollect
the cellthe
phone
will work
the
RTGs
and
defect
for
and follow SOP and
every one see anything
repairing
wrong stop it.
3 Study to paint all BOSCER TT sharp edge
by yellow color to be clear for RTG
operators.
4. TR driver will sent to training to
reassessment
1& 2 Ops
(1,2&4) 01-11-2013
ws
7-11-2013
ops-training
Waiting
OPS + ENG
1. Sending
Involved
operator of
for:
Add
to the TBT
, the QC
importance
re-assessment.
1. RTG operator
never to load any
2.
Add this case
todoubt
TBT, regarding:
all
containers
if they
that the TRs
QC
operators
should
follow
about
in wrong
position,
and
wait SOP
till the
TR
OPS
working
below
deck
and
to
ask
for
the
get in completely right position.
1. Ops-training
deck
controller
anything that
2. If you
noticehelp
any for
abnormalities
in
Ops
could
be
a
source
of
doubt
and
never
your equipment , call ENG team
made any
sudden movement
immediately
to fix it . without
coordination with deck/Engineering
member.
2. 1. 26/10/2013
29.10.2013
30/10/2013
2.
1.Add this case to TBT and inform our

operators ( Crane operator , Deck and
wharf controller )to report any hit or
abnormalities to ENG team
immediately
1 Reassessment for RTG Operator

2 TBT for all RTG Operators to ensure right
position of RTG before handling/checking
the bay
3 Add to new hire training program for
each equipment the historical accident
analysis and how to avoid it
OPS
OPS -Training
OPS Execution
OPS Training
06.11.2013
November 10, 2013
r SOP ( MakeOPS
sure Training
that the way
is clear ,SOP
priority
OPSequipment ) and take
13.11.2013
their attention specially durin
to initiate
forpass
Newfor the largest
operators illustrate duties &

responsibility for attached &trainer .
New operator directed to HR to
finalize Working under influence of
drugs
Add this case to
OPS,HR
TBT, regarding: all QC

operators should take a safe distance while
moving above the sill beam .
OPS
November 10, 2013
Add to all QC operators to ask for

assistance from dock controller in
case of handling under deck or when
get confused from unclear situation
before activate any bypass and return
to his supervisor if he want to activate
bypass.
OPS
11/14/2013
d them to be more careful while handling the containers specially OPS

under deck and reported
any abnormalities immediate
20/11/2013
1 Add this case to TBT and inform our TR

drivers that they must be reverse back with
guide .
1.Add this case to TBT and inform our VSV

to report to all VSV on the berth about any
vessel makes mooring or sailing during the
operation .
2.Make risk assessment for the mooring
and sailing process for ships
Add to all QC operator TBT to give extra

care while entering between higher tiers on
dock
Ops
16.11.2013
Ops
OPS
20/11/2013
Add this case to the TBT and highlight that

all drives follow his instructions by not
entering under the RS till
the operator give him a permission by
hand signal, RS horn or microphone
Ops
30/11/2013
Add to All QC operators to stop the

hoist before enter the cell guide by
safe distance to adjust the position
Ops
February 12, 2014
ENG Dept. to study possibility of installing

additional guard to protect wire from get
out of pulley
ENG
15/12/2014
1-Following up the operator case as

positive drug test.
2-Add this case to the TBT and highlight
the importance of:
-The importance of working with full
concentration and following the SOP of
handling the twin containers.
-The consequences of working under
influence of drugs.
3-Review the progress of the project of
Add
thisacase
tomarks
TBT and
that
making
visual
on highlight
the trailers
to all
be
PU
drivers
must
be
more
attention
to
his
clear for the RTG operators while stacking
road andthe
take
save distance
the
containers
on thebetween
TTs
vehicle also while reverse back with
maneuvering .
1- HR
2- Ops
3- Ops & WS
1- ----2- 8/12/2013
3- Waiting
Ops
25/12/2013
Add to All RTG operator to hoist max and

give more attention when handling in
reefer ranges
Add to the TBT the importance to

following SOP about handling reefer
to all RTG operator and didnt take
any decision need authorize from
Make contact between terminal
them supervisor without knowledge.
security manager and mooring
Always return to your supervisor.
company to discuss the availability to
prevent mooring team to go up vessel
or not.
Until having final decision from
security manager, Mooring SV only
will have authorization to go up the
vessel under supervision from
security SV.
Make awareness for all mooring team
that they mustnt go up any vessel
before taking confirmation from
OPS
15/12/2013
OPS
21/12/2013
Security
12/15/2013
Add to TBT: all RTG operators to take

extra care and to be more attention
while handling the reefer container.
1 Add to TR Drivers TBT ,Give more

attention while driving and never
concentrate with anything while
driving
2 Reassessment for TR 54 Driver
Add this case within daily shifts TBT:

regarding that all RTG operators
before handling their 1st move inside
bays, they should adjust their position
firstly by taking the first snapshot
using empty spreader inside the bay.
OPS
31/12/2013
OPS
30/12/2013
OPS
29/12/2013
1- all RTG operator must give more

attention while handling the twin
containers in the yard and must
2- insure that the twin mood lamp is turned
on before lock the spreader twist lock.
Ops
ENG+OPS
1 - 1/1/2014
2- under study
Waiting monitor result in 19/01/2012
Status (open/ New Penalty Code

closed)
(if applicable)
ID Number for
sanction receiver
Open
Open
New
new
new
Open
Open
New
open
New
New
New
New
New
New
New
New
new
new
New
New
New
New
New
new
new
New
new
New
new
new
New
Opened
New
New
New
New
New
Open
New
Open
Open
new
Open
Open
Open
Open
New
open
New
New
New
New
New
New
Opened
New
New
New
New
Opened
NEW
New
closed
New
Open
closed
Opened
New
Opened
closed
Opened
Closed
Opened
New
New
New
New
Open
Open
OPEN
Open
closed
closed
closed
closed
closed
closed
closed
New
closed
new
New
New
Open
New
New
New
New
New
Open
Shift Manager Resposability
Management
Salah Abd Elaziz
Sameh Haggag
Josh
Sameh Haggag
Josh
Amr Rashwan
Mohamed Elaraby
Amr Rashwan
Amr Rashwan
Mohamed Elaraby
Salah Abd-elaziz
Amr Rashwan
Salah Abd-elaziz
Amr Rashwan
Josh
Amr Rashwan
Amr rashwan
Sameh Haggag
Mohamed Elaraby
Mohamed Elaraby.
Amr Rashwan
Amr Rashwan
Josh
Amr rashwan
Amr rashwan
Sameh Hagag.
Amr Rashwan
Josh
Salah
Hany Mustafa
Amr Rashwan
Amr Rashwan
Salah
Salah
Mohamed El Araby
Amr Rashwan
Mohamed El Araby
Josh
Ehab Zahran
Amr Rashwan
Amr Rashwan
Hatem Hosny
Amr Rashwan
Amr Rashwan
Amr Rashwan
Salah abd Elaziz
Josh
Salah Abd Elaziz
Hatem Hosny
Hatem Hosny
Josh
Josh
Josh
Salah AbdElaziz
Hatem Hosny
Amr Rashwan
Mohamed El Araby
Salah Abd Elaziz
Salah Abd Elaziz
Amr Rashwan
Salah Abd El-Aziz
Hany Mustafa
Mohamed Elaraby
Salah Abd Elaziz.
Amr Rashwan
Mohamed Adel
AHMED ABOU REHAB
Mohamed Adel
Amr Rashwan
Mohamed Adel
Hatem Hosny
Amr Rashwan
Amr Rashwan
Salah Abd Elaziz
mohamed el araby
Salah Abd Elaziz
mohamed el araby
Amr Shorbagy
AMR RAShwan
AMR RAShwan
Salah A. El-Aziz
Ehab Zahran
Amr Rashwan
Amr Rashwan
Mohamed ElAraby
Ehab Zahran (Acting)
Ehab Zahran
Mohamed Elaraby
Ahmed Hegazy (Act As)
Hatem Hosny ( Act as OSM )
Salah Abd El-Aziz
Ehab Zahran ( Act as OSM)
Amr Rashwan
Amr Rashwan
HATEM HOSNY
HATEM HOSNY
Amr Rashwan
Salah Abd Elaziz
Salah Abd Elaziz
Ehab Zahran
Ehab Zahran
Mohamed Elaraby
Mohamed Elaraby
Mohamed Elaraby
Mohamed Elaraby
Nader Helmy
MOHAMED EL ARABY
Nader Helmy (Act)
Amr Rashwan
Amr Rashwan
Amr Rashwan
Mohamed El araby
Sccot
Amr
Rashwa
n
Amr
Rashwa
n
Yasser
Ausam
a
Yasser
Osama
Scott Selman
Sameh
Haggag
Mohamed El Araby
Mohamed Adel
Amr
Rashwan
Sameh Haggag
Amr
Rashwan
Amr Rashwan
Motaz Ali
Hany Mostafa
Item
1
2
3
4
5
6
7
8
9
10
11
Time Of
Incident
Related to
Corrective/Prev
Type
Number
Corrective/Preventive Action follow up (ro
Case Explanation
rrective/Preventive Action follow up (rolling document)
Root Cause
(As per preliminary
ng document)
Preliminary
Investigatio
n By
Risk Value
F-03-02
Corrective Action
Action
Ownership
Deadline
New
Status Penalty
(open/cl Code (if
osed) applicabl
e)
ID Number for sanction receiver
Date
Item
Date
Time Of Related
Incident
to
Equipment (if
applicable)
Type
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Number
Case Explanation
Corrective/Preventive Action follow up (rollin
Root Cause
(As per
preliminary investigation findings)
Preliminary
Investigation By
Risk Value
F-03-02
Corrective Action
Action
Ownership
Deadline
New
Supervis
Status Penalty
or
(open/cl Code (ifSYNERGY NO
responsi
osed) applicab
bility
le)
Amr Rashwan
M. Abu Omar
Scott
Scott
Yasser Oussama
Yasser
Moataz
Yasser Yasser Yasser Yasser Yasser Yasser

M.
Osama
Osama Osama Osama Osama Osama
AbouElF
arah
Yasser Yasser Yasser Yasser Yasser Yasser Yasser Yasser

Osama Osama Osama Osama Osama Osama Osama Osama


Yasser Yasser Yasser Yasser

Osama Osama Osama Osama
STS
RTG STS Spreaders RTG Spreaders Tractor Trailers
CQ01
CQ02
CQ03
CQ04
CQ05
CQ06
CQ07
CQ08
CQ09
CQ10
CQ11
CQ12
CQ13
CQ14
CQ15
CQ16
CQ17
CQ18
CR01
CR02
CR03
CR04
CR05
CR06
CR07
CR08
CR09
CR10
CR11
CR12
CR13
CR14
CR15
CR16
CR17
CR18
CR19
CR20
CR21
CR22
CR23
CR24
CR25
CR26
CR27
CR28
CR29
CR30
CR31
CR32
CR33
CR34
CR35
CR36
CR37
CR38
CR39
CR40
CR41
CR42
CR43
SQ01
SQ02
SQ03
SQ04
SQ05
SQ06
SQ07
SQ08
SQ09
SQ10
SQ11
SQ12
SQ13
SQ14
SQ15
SQ16
SQ17
SQ18
SR01
SR02
SR03
SR04
SR05
SR06
SR07
SR08
SR09
SR10
SR11
SR12
SR13
SR14
SR15
SR16
SR17
SR18
SR19
SR20
SR21
SR22
SR23
SR24
SR25
SR26
SR27
SR28
SR29
SR30
SR31
SR32
SR33
SR34
SR35
SR36
SR37
SR38
SR39
SR40
SR41
SR42
SR43
TR01
TR02
TR03
TR04
TR05
TR06
TR07
TR08
TR09
TR10
TR11
TR12
TR13
TR14
TR15
TR16
TR17
TR18
TR19
TR20
TR21
TR22
TR23
TR24
TR25
TR26
TR27
TR28
TR29
TR30
TR31
TR32
TR33
TR34
TR35
TR36
TR37
TR38
TR39
TR40
TR41
TR42
TR43
TT01
TT02
TT03
TT04
TT05
TT06
TT07
TT08
TT09
TT10
TT11
TT12
TT13
TT14
TT15
TT16
TT17
TT18
TT19
TT20
TT21
TT22
TT23
TT24
TT25
TT26
TT27
TT28
TT29
TT30
TT31
TT32
TT33
TT34
TT35
TT36
TT37
TT38
TT39
TT40
TT41
TT42
TT43
CR44
CR45
CR46
CR47
CR48
CR49
CR50
CR51
CR52
SR44
SR45
SR46
SR47
SR48
SR49
SR50
SR51
TR44
TR45
TR46
TR47
TR48
TR49
TR50
TR51
TR52
TR53
TR54
TR55
TR56
TR57
TR58
TR59
TR60
TR61
TR62
TR63
TR64
TR65
TR66
TR67
TR68
TR69
TR70
TR71
TR72
TR73
TR74
TR75
TR76
TR77
TR78
TR79
TR80
TR81
TR82
TR83
TR84
TR85
TR86
TR87
TR88
TT44
TT45
TT46
TT47
TT48
TT49
TT50
TT51
TT52
TT53
TT54
TT55
TT56
TT57
TT58
TT59
TT60
TT61
TT62
TT63
TT64
TT65
TT66
TT67
TT68
TT69
TT70
TT71
TT72
TT73
TT74
TT75
TT76
TT77
TT78
TT79
TT80
TT81
TT82
TT83
TT84
TT85
TT86
TT87
TT88
TR89
TR90
TR91
TR92
TR93
TR94
TR95
TR96
TR97
TR98
TR99
TR100
TR101
TR102
TR103
TR104
TR105
TR106
TR107
TR108
TR109
TR110
TR111
TR112
TR113
TR114
TT89
TT90
TT91
TT92
TT93
TT94
TT95
TT96
TT97
TT98
TT99
TT100
TT101
TT102
TT103
TT104
TT105
TT106
TT107
TT108
TT109
TT110
TT111
TT112
TT113
TT114
TT115
TT116
TT117
TT118
TT119
TT120
Reach Stacker
Empty Handler
RS01
RS02
RS03
RS04
RS05
EH01
EH02
EH03
EH04
Forklift Over Height frame

FL01
FL02
FL21
FL31
FL32
FL33
FL34
FL35
FL51
FL52
FL53
FL54
FL55
OHF01
OHF02
OHF03
OHF04
OHF05
Manlift Terminal Pickup

ML01
ENG-PU-01
ENG-PU-02
ENG-PU-03
ENG-PU-04
ENG-PU-05
ENG-PU-06
ENG-PU-07
ENG-PU-08
ENG-PU-09
ENG-PU-10
ENG-PU-11
ENG-PU-12
ENG-PU-13
OPS-PU-01
OPS-PU-02
OPS-PU-03
OPS-PU-04
OPS-PU-05
OPS-PU-07
OPS-PU-08
OPS-PU-10
OPS-PU-11
OPS-PU-21
OPS-PU-22
OPS-PU-30
OPS-PU-40
OPS-PU-50
OPS-PU-60
OPS-BU-05
OPS-BU-06
SAF-PU-01
IT-PU-01
OPS-PU-19
OPS-PU-20
OPS-PU-09
OPS-BS-02
OPS-BS-01
5072
5073
5074
528
529
NO
Sub Contractor
1
2
3
4
5
6
7
BANAMA JACK
CAMPBLE
ONYX
EL-KOTBY
IBRAMAR
MARTEC
EGYPT REEFER
OBV 1
OBV 2
OBV 3
OBV 4
OBV 5
OBV 6
OBV 7
63
May 30, 2013
10:00
red
QC
QC 16,
TR 91,
TR 107
80
June 22, 2013
17:40
White
QC
15
,while
you?
as we with
there to Lack making
No,
he
checked
of
was 20
was
my
with
attentio
working
feet
pass(hoi
nroster
from with QC
containe
please During
st down
they
16.
the
TR
r
was
specify discharg mention +trolley)
driver &
attache
the
ing
twin ed there Was
I it
the
d
with
your first Nader
contract left on was less surprise
wharf move on
another
or Co.
truck
by TR Helmy
that 7 d
controlle
the
bay? Ahmed
of the
name; if 107
hit Deck waiting
r of TR No, it was
discharg
the
an
in
controlle
thelane
last Salah
107
ed
involved empty rs and move
02 but
for
waiting
containe
person containe
unfortun
me
as
I Mustafe
13
position.
r
(from
was
going
is the
r on
ately
I Operatio
Arnous ,
Wharf
2Not
bay
21)
ns:
Ehab
to
make
a
responsi truck 91 on shift. couldnt Ramzy
followin
handover.
from
ble (his leading
stop the Zahran
Maher
g
below
Enginee
mistake) to fall
collision.
Did you
procedu
by
a
ring:
for the down on Working notice
1- Did
the
res
from
closed
Ahmed
incient the
first environ attached
you
the
TR
twist
container
noticed Salah
ment:
driver
lock
HSE:
while
TR
in
about
handling
from the
02 Mohame
As
there lane
making
the
twin
right
107) d atef
was
an (TR
move?
a
safe
side
No,
obstruct before
corner distance because
you
ion
casting between discharg
of my
(Twist
his
TR vertical
and
Lock) in e the
suddenl and the visibility
?
theTR Twin
front
which
y the
Yes I
corner prevent
below about 3 noticed
casting me from
containe meters observing
his
of
the
away
r fall
the
below
presenc
fallen
(after container.
down
containe e but I
from a entering thought
r which
height between itWhen
was
played a
and rest the two exactly
out
theof
role he
in
QCs
in
my
container
the
between knew started
to
spreade
attachm
that
the
the
fall down?
r
ent of
distance
Once
I
vessel
pathway
the
and between lifted. the
containe
seaside the two 2- twin
When
move
I
r with
QC cell QCs was found
did
you
the
the
beam. close to spreader
notice
lifted
each
shifted
the
TR
containe
other,
toward
107
sor.he the bridge
position
and I
tried to
?
be more thought
While I
close to that the
vessel
was
at
the TR
was
lane 02
in front moving.
but I
Risk Value:
ask the
wharf
controlle
r if the
distance
between
the two
QCs is
safe to
wait in
or not.
2- To
Add
provide
to the
Deck
TBT
for
controlle
the
r
for
wharf
each QC
controlle
in
order
r to
pay
to
more
provide
attentio
fullthe
n for
monitor
TRs
on
the
traffic
handling
and
process.
position
s under
QCs.
3- Reassessm
ent to
be done
for the
TR
driver
4Insuring
that the
TBT
must be
done for
all ops
stuffs.
15/6/201
1- ops
3
2- ops 5/6/201
3-ops
3
training
34-- ops waiting
5/6/201
3
12th
Manage
Nov.
ment
2013
Open
Open
Mohame
d El
Araby
Amr
Rashwa
n

Corrective-Prevention Actions Follow Up 2013

Caricato da

Informazioni sul documento

Descrizione originale:

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Corrective-Prevention Actions Follow Up 2013

Caricato da

Copyright:

Formati disponibili

Corrective/Preventive Action follow up (rolling document)

Equipment (if applicable)

Employee statement summary

Corrective/Preventive Action follow up (rolling document)

Equipment (if applicable)

(As per preliminary investigation

Employee statement summary

Involved Person : Nam e: El-Sayed M ohame d El-Abot y

People cau se:

Add t his cas e t o TBT a nd highligh ted th e follo wing:

1- Did yo u sle ep well?

Ope rat ions : H atem Ho sny

Involved Pers on: N ame: N ader m oss y Mo hamed ID: 92 0

Add the case to TBT

Op erat ions : M ohame d Ad el

OPS - OPS tra ining

Probability ( 3 ) * Severity (1) = 3

January 20, 2013

Salah Abd Elaziz

January 21, 2013

January 18, 2012

H ow do you th ink this in cid ent could be avoided in future?

Immed iate caus es

D id you s aw the da maged cell-gu ide b efore han dling ?

D id you receive tra ining in h ow t o do the t ask invo lved:

Operation s: Moha med Adel

Probability ( 5 ) * Severity moderate ( 3 ) = 15

1 To pro vide de ck co ntro ller with eve ry deck.

Did yo u receive su pervision in t he las t 1hr of you r work: YE S NO

Immed iate caus es

Und erline caus es

Moh amed Mo hamed E lfeeky

Driving in b ad weath er (very cold and rain y )

Immed iate caus es

January 12, 2013

Th e T R d river was harryin g up.

En gin eering : Moham ed

Add t o T BT t o a ll TR driver to inform TR SV in case of feeling s leep y of

D id you receive a p re-sh ift safe ty talk:

1- Sen d the TR driver t o t he Tra ining for a on e d ay refres hmen t

De partmen t: OPS out s ource(Kotby) Position : TR Driver

D id you receive tra ining in h ow t o do the t ask invo lved:

January 14, 2013

Expe rie nce: 18 mont hs

Involved Person : Nam e: Moh amed N asr N asr ID : 13 62

January 15, 2013

Immed iate caus es

1- Wa s it th e fi rs t move in th is b ay ( 5th row s ea side)?

Immed iate caus es

January 19, 2013

2 - To p rovid e d eck cont roller with every QC.

D id you receive tra ining in h ow t o do the t ask invo lved:

If required , were you wearin g the correct PPE : YE S NO

Sa meh Hag gag / Ade l Kh edr

Probability ( 5 ) X severity (3) = 15

1 To make a da ily ra ndom check for th e wrong st aking in th e ya rd, then

Ops Yard Sup ervisor

D aily ( St art ing from 20/01 /201 3 )

waiting project respond

1. Ad d this ca se to TBT and h igh lig hted t he followin g:

2. S end th e involved TR driver to t rainin g for re-a sses sme nt

OPS train ing