Source · Prevention of Future Deaths
Gerome Reyes
Ref: 2017-0012
Date: 3 Feb 2017
Coroner: Grahame Short
Area: Southampton and New Forest
Responses identified: 0 / 2
View PDF
There is no confirmation that recommended safety upgrades, such as installing door limit switches on goods lifts, have been implemented, posing a continued risk on this and potentially other ships.
Date
3 Feb 2017
56-day deadline
31 Mar 2017
Responses identified
0 of 2
Coroner's concerns
There is no confirmation that recommended safety upgrades, such as installing door limit switches on goods lifts, have been implemented, posing a continued risk on this and potentially other ships.
View full coroner's concerns
_ (1) The Deputy Commissioner of Maritime Affairs for the Republic of the Marshall Islands made recommendations for the relevant goods lift on MV Moonray not to be brought back into service until door limit switches were installed . There has been no confirmation that this recommendation has been acted upon: (2) It appears to me possible that other ships of the same design may also have goods lifts installed without door limit switches installed and so there is the potential risk of injury or death if they are operated in similar circumstances There is no confirmation that Marine Safety Advisory No. 20-13 issued on 26 May 2016 has been implemented: Coroner' $ Office; Castle Hill, The Castle; Wiuchester; S023 8UL Tel 04962-667884 Fax 04962-667893 The being
Report sections
Investigation and inquest
On 25/05/2016 commenced an investigation into the death of Gerome Baon Reyes, 26. The investigation concluded at the end of the inquest on 12 January 2017. The conclusion of the inquest was Accidental death: determined that at about 11.20 (GMT 2 hours) on 22 May 2016 whilst on board MV Moonray sailing across the North Sea approximately 25 miles east northeast of North Foreland and in international waters messman Gerome Reyes was alone in the galley unloading a goods lift when he activated the lift whilst its door was open and was dragged up as the lift ascended, as a result of which he sustained traumatic multiple injuries_ No door limit switch was fitted to the lift so that it could be operated whilst the door was open: He died as a result of Head and Trunk Injuries
Circumstances of the death
death would not have occurred if the door limit switch had been fitted to the goods lift being operated by the deceased.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you Primebulk Shipmanagement Limited andl or Mirage Finance Incorporated have the power to take such action.
Similar PFD reports
Related inquiry recommendations
Scottish Hospitals Inquiry
Uniform policy for obtaining technical advice
Scottish Hospitals Inquiry
Streamlining NHS construction quality procedures
Scottish Hospitals Inquiry
Information on common construction errors
Scottish Hospitals Inquiry
Independent validation of hospital construction
Post Office Horizon Inquiry
Clarify whether HCRS and OCS assessment processes differ
Cranston Inquiry
MAIB publication of implementation measures
Grenfell Tower Inquiry
Reconsider Phase 1 recommendations in light of Phase 2
Grenfell Tower Inquiry
Reconsider LGA Guide paragraph 79.11 advice
Grenfell Tower Inquiry
Add legal requirements warning to statutory guidance
Grenfell Tower Inquiry
Include academics on statutory guidance advisory bodies
Report details
- Reference
- 2017-0012
- Date of report
- 3 February 2017
- Coroner
- Grahame Short
- Coroner area
- Southampton and New Forest
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 31 Mar 2017.
Sent to
- Mirage Finance Incorporated
- Primebulk Shipmanagement Limited