Tornado incident at the

Freeport Container Port

Grand Bahamas

on 29 March 2010

Independent Investigation

Jacques Obadia

Occupational Safety

and Health Expert                                                                         15 June 2010

Introduction

1.      Following a tornado incident at the Freeport Container Port (FCP) on 29 March 2010 an independent investigation was commissioned by the Ministry of Labour and Social Affairs of the Bahamas to review the incident in the light of existing information gathered by the FCP and by the Freeport Department of Labour Inspectors. This investigation was carried out during the period 10 to 14 May 2010 by Mr. Jacques Obadia, former official of the International Labour Office (ILO) and expert in occupational safety and health (the Expert). His services were provided graciously to the Government of the Bahamas.

2.      The general terms of reference for the investigation were to review the different aspects of the incident that resulted in three occupational fatalities and six injuries, two of them serious. This included an analysis of the sequence of events, factors that might have affected the outcome of the storm passage through the port and the level of emergency response preparedness prior to the incident. The management and staff of FCP cooperated fully during the investigation by arranging meetings, making available all the information and documents requested by the Expert, and opening the whole Terminal for inspection. The Expert was provided with an office with telephone and computer facilities. A list of the references provided by the FCP and the Ministry of Labour is provided in Annex 1.

3.      All employees were given the opportunity to arrange for a private interview with the Expert and a few took advantage of this possibility. Due to time limitations, the interviews were carried out in an office at the FCP site. The Expert declined to meet and interview the two seriously injured employees. He considered that, in the light of possible legal implications, such questioning would be best conducted in the context of a coroner’s inquiry.

4.      The signed interviews of 35 employees and docked vessel crew members who witnessed the incident, carried out by the FCP in the days following the event, were made available to the Expert. It is assumed that these employees made their statements freely and in good faith, and without any pressure. The table in Annex 2 summarizes the information provided in the signed employee statements as well as the interviews conducted by the Expert. The observations in the table focus on the sequence of events related to the passage of the storm formation through the Terminal and on other safety and health aspects

5.      Freeport Container Port (FCP) is a privately owned and operated port of Hutchison Port Holdings (HPH), a subsidiary of Hutchison-Whampoa Limited. HPH operates 49 ports in 25 countries throughout Asia, the Pacific, the Middle East, Africa, Europe and the Americas. Freeport Container Port is located on Grand Bahamas Island. The FCP was officially opened in July 1997 and presently comprises a total land area of 3,400 ft (1,036m of berths) with 15.5m depth alongside; 10 Super Post Panamax Quayside Gantry Cranes and 2 Gottwald Mobile Harbour Cranes; 3 Empty Container Handlers; 75 Straddle Carriers; 1 Megaport Straddle Carrier (Radiation Detection Unit); A Navis Computerized Port Operating System; and 49 Hectares/118 acres of Stacking Area. It has an annual capacity of 1.5 Million TEU[1]. The total workforce at the FCP is 713, with 490 involved in Terminal operations and 109 in engineering (maintenance activities). The port operates on a 24 hrs basis (3 x 8 hr shift rotation).

FCP OSH programme 

6.      The main elements of the current FCP OSH management structure include a trained Safety and Security Manager reporting to the Operations Manager, a Safety Committee comprising representatives from all departments and disciplines, an Accident Investigation Committee, and the Safety Committee of the Employee Council. References concerning the FCP Safety, emergency response and operational manuals are provided in Annex 1.

7.      The FCP started in 2007 an OHS improvement programme aimed at reducing drastically the Lost Time Injury Frequency Rate and bring the Terminal at a higher level of emergency response preparedness. A good part of the OHS improvement activities, particularly the training of employees, were implemented in 2009 with the technical assistance of the Health and Safety Department of the container port of Felixstowe (United Kingdom), the FCP’s sister port. The main measures and actions taken as part of the programme, prior to the incident, include:

·         The revision and distribution of the Safety manual to all employees in 2007.

·         The recruitment in 2009 of a trained Safety and Security Manager who reports directly to the Container Port Director.

·         The establishment of a Safety Committee comprising representatives from all departments and disciplines. The Committee meets on a monthly basis. The Safety Committee has attended a two day training course on accident investigation and emergency response procedures.

·         The setting up of an Accident Investigation Committee composed of representatives of the Safety, Operations Engineering and Human Resources departments, as well as an instructor from each of these Departments. The Committee meets with the employee(s) involved in an incident to understand all aspects of the event and take corrective action to prevent a reoccurrence.

·         The implementation of a new traffic management system.

·         Upgrading the Crane Operator Training Program in 2009 through the installation and use of a new Ship-to-Shore and Mobile Harbour Crane Simulator. Operating much like an aircraft flight simulator, the simulator produces a realistic 'virtual offshore environment' and moving sensation in which the crane operator uses standard crane controls to move various simulated loads between offshore installations and supply vessels, as well as train and test operators on their reaction to emergency situations in ways which are not feasible in a real crane.

·         The review and updating in 2009 of the FCP Emergency Response Manual in consultation with the Government of the Bahamas.

·         Training and certification of ten Supervisors by the Institution of Occupational Safety and Health[2] (IOSH) in Managing Safety in Ports.

·         Attendance by all Supervisors of a two day safety seminar on causes of accidents, accident prevention, the Health and safety at Work Act, and reasons why employees may neglect safety.

·         Safety Orientation provided to all new employees and contractors.

·         Giving Safety refresher classes to operations personnel (discipline specific).

·         Training groups of employees in First Aid and CPR.

·         Participation of a number of employees in training on Environmental Responsibility.

·         Attendance of approximately 150 employees in a one-day training course on Causes and Costs of Accidents and on Accident Prevention.

·         Training of groups of employees in the use of fire extinguishers. This included how to inspect, classes of fire, types of extinguishers, and practical exercises. Employees participated also in a two week training course on basic fire fighting, hose handling, chemistry of fires, tactics and techniques, internal fires response (demonstration and practical) etc…..

·         A Radiological/Nuclear Awareness Hazardous Material Training Course given to employees from the safety, security, operations and engineering departments.

·         Sponsoring by the FCP of a Health and Safety Fair for all employees with participation from the local fire department, public hospitals authority, and the Royal Bahamas Police Force.

·         Implementation of a procedure for the boarding and inspection by Safety Officers of vessels calling at FCP. This includes completion of vessel condition, any areas of concern addressed with vessel captain/chief officer and contents relayed to operations supervision and communicated to FCP ship working personnel.

·         All departments must carry out monthly safety drills. A monthly “Safety Hour” has been established during which the Terminal shuts down for one hour to allow safety meetings to be held in all departments in order to bring safety information to employees and to address employee concerns and suggestions.

·         Production and implementation of a revised safe system of work for straddle carriers/berth operators working under cranes (push/pull twist lock bins in tire lanes).

·         A number of employees went to the United Kingdom for training and certification from the National Examination Board for Occupational Safety and Health (NEBOSH). Certifications were received in occupational health and safety, controlling workplace hazards, practical application of health and safety measures, and the management of health and safety at work.

·         The installation of a terminal air quality monitoring system with several monitors placed at critical locations around the site.

·         Working towards the British Standards Institution (BSI) Occupational Health and Safety Audit System (OHSAS) certification for the FCP facility. This certification ensures that the FCP implements a systems approach to the management of OHS.

The tornado incident

8.      The incident at issue occurred on the 29 of March 2010 in the  FCP. A number of videos[3] and photographs[4] taken close to the harbour and available on the internet show clearly a funnel cloud moving towards the port. These and the employee statements confirm that the FCP was struck by a tornado. The Williams Town, Fortune Bay and Port Lucaya areas also sustained tornado damage to property but fortunately without loss of life.

9.      Based on employee statements and available meteorological data[5], it is established that the weather on 29 March 2010 in the Grand Bahamas area was very bad all day, with rain and thunderstorms with intermittent wind gusts and even some hail. There is a good consensus on the fact that a serious worsening of the weather with very heavy rain and increasingly high winds started at about 11:00 hrs. Lifting operations had been stopped a few times because of low visibility. From all accounts  the first cranes on the south side of the quay started  being pushed by high winds at about 11:20 hrs and by 11:30 hrs the tornado had swept the quay at full force  and vanished in no more than two to three minutes.

10. Within those few minutes, one crane was pushed over a 100 m and four other 1000 ton cranes were sent crashing together into the last crane at the end of the gantry tracks, toppling it to the ground. This very short duration was confirmed by the Captain of the vessel MSC Diego who also estimated it at no more than 3 minutes with wind speeds at over 90 mph. The impact of the tornado was strong enough to break the stern mooring lines of two of the docked ships and push them in a near perpendicular position to the quay. Apart from broken stern mooring lines, the docked vessels did not sustain any damage.

11. The report written by the FCP Safety and Security Manager following the incident provides a concise description of the aftermath following the tornado passage over the Terminal, including rescue operations and a preliminary inventory of damages sustained by the cranes, a straddle carrier and containers. A diagram made by the FCP shows very clearly the positions of the 10 gantry cranes; the Gottwald crane and the two vessels before and after the tornado passage (see Annex 4).

Preparedness issues

12. A number of issues raised by employees concerning the level of emergency preparedness at the FCP prior to the incident and their possible influence on the outcome of the incident are reviewed below. This includes access to meteorological information at the FCP, rescue operations, high wind procedures, sound alarms, radio communication systems and lifting operations.

Meteorology

13. Based on employee statements, work started very early in the morning under intermittent heavy rain and winds. According to News reports, the Bahamas Department of Meteorology (BDM) was aware that day of thunderstorms moving across the island. It seems however that the risk of tornado activity was detected only very shortly after the Department issued a severe weather alert for Grand Bahamas. The FCP report on the incident indicates that news of possible tornado activity on the island reached the port at approximately 11:17 hrs. Information about the sighting over the sea near the harbour of a cloud formation resembling a tornado was radioed at approximately 11:15 hrs to the Quay Office by a number of employees working at the South side of the Terminal. A general call to stop all operations was sent shortly after. It seems that there was just enough time to secure the two most southerly cranes (C1 and C2) before the full force of the tornado swept the Terminal.

14. The Expert visited the Freeport airport meteorological facilities[6] on 10 May 2010. The airport has a recently installed an Aviation Automated Weather Observing System (AWOS 900 3) with one meteorologist on site. The system meets the requirements of the US Federal Aviation Administration (FAA), the International Civil Aviation Organisation (ICAO) and the World Meteorological Organisation (WMO) for use at airports[7]. On the day of the incident, the airport station was aware early in the morning of severe storm activity susceptible to reach Grand Bahamas. The information was seemingly transmitted to the BDM in Nassau but not directly to the FCP or any other facility. The Expert was told that only the BDM had the authority to issue public severe weather advisories and alerts.

15. Prior to the incident, the FCP did not have any onsite weather monitoring system that might have provided advance information on the nature of the incoming storm, and possibly more time to prepare for its impact. However, based on the current level of related technology and science, tornado forecasting is still very difficult. According to the US National Oceanic and Atmospheric Administration (NOAA) the current average lead-time for tornado warnings is 13 minutes[8]. Research has shown that it is also extremely difficult to predict whether a detected storm formation will spawn tornadoes or not. These can form, land and disappear in a few minutes[9].

16. The emergency preparedness and response systems in the Caribbean region, and thus the Bahamas, are rather geared to hurricanes than to tornadoes. A strong “hurricane safety culture” exist at all levels in the country and sensitive facilities such as ports and airports have sufficient lead time – in terms of days – to get prepared. The FCP Emergency Response Manual, prepared in consultation with government authorities, provides a very comprehensive procedure defining specific responsibilities and measures to be taken in case of a hurricane to ensure the safety and health of personnel and property[10]. Terminal work during relatively bad weather and fluctuating wind speeds is a common occurrence. The presence of a weather monitoring system at the FCP at the time of the incident might have detected an incoming storm system but not necessarily its capacity to generate tornadoes.

17.  The Freeport (Airport) historical weather data[11] for 29 March 2010 in Annex 5 indicates that the weather was overcast all day with thunderstorms, rain showers and even hail but with fluctuating wind speeds below the limit for triggering crane shutdown and terminal operations. This information concurs with that given by employees in their statements. The data indicates also that the tornado was a much localized event as the maximum wind speed at the airport was 23 km/h. The airport is located only one or two miles from the Terminal.

Rescue operations

18. Emergency response after the incident was rapid and coordination of rescue efforts was efficient. External services were contacted immediately and responded very rapidly (hospital ambulances, Fire department, Freeport Harbour Control, Airport Crash team, etc.).  Several of the employees who were working on the Quay at the time of the incident were the first to reach the injured and provide first aid where possible. Assistance was also provided by companies nearby. Following a Terminal evacuation order, a head count was conducted at the Staff Cafeteria and all personnel not involved in emergency operations sent home.  

19. It should be noted that the Company ambulance had a flat tire when it arrived on the quay and thus could not be used. However a sufficient number of external ambulances reached the Terminal rapidly. The very detailed description of the rescue in the FCP Incident Report is corroborated by the employee statements.

Alarm and communication systems

      High wind procedures

20. Sections 13 and 14 of the Safety Manual define high wind procedures for securing cranes and straddle carriers. Terminal superintendents are the nominated competent persons with the responsibility of starting the process of securing the cranes, terminating lifting operations, arranging for the cranes to be secured at their anchor positions (13.1.1-13.1.3) and keeping Terminal Management advised as to the decisions taken.

21. Each gantry crane must be fitted with its own wind speed indicator in the operator’s cab. The indicator may comprise two light signals, amber and red, and a repeater light panel fitted to the external structure of the crane (13.2.1). The amber light illumination indicates that the wind has reached a speed 5 mph below the recommended maximum operating speed for the crane (45 mph). It requires the Superintendent to monitor closely wind speed levels to determine if they are reaching a stable level allowing continuation of activities, or increasing towards maximum operating speed. In this case, crane securing procedures should be started.

22. A red light illumination indicates that wind speed has reached the maximum operating speed for the crane (50 mph). The superintendent should order cargo operations to cease and to bring ship working personnel ashore. In addition, in wind conditions in excess of 55 mph, the crane rail clamps are set automatically to disable the gantry motion. This can be overridden by the driver to allow moving the crane to a pin down position[12]. The clamps are also triggered by a power loss. The heavy damage observed on the gantry drive boogies of a number of cranes may have resulted from the triggering of the rail clamps by wind speeds exceeding the 55 mph limit or by the Terminal power outage, or by both. In any case, the winds were definitely higher than the braking capacity of the rail clamps.

23. As described in Section 14 of the FCP Safety Handbook, straddle carriers do not have wind speed indicators on board and drivers must rely on information and instructions provided to them by the Terminal Superintendent and their own assessment of the difficulty in controlling the vehicle. High wind operational limits are the same as for the cranes.

24. These safety rules are evidently designed for situations where average winds are increasing steadily, thus giving the decision maker sufficient time to have the cranes secured properly and personnel brought back to safe areas. This was not the case at the time of the incident where decision making time was much shorter. It is noted that Section 13 of the FCP Safety Handbook does not specify nominally the amber and red light wind speed limits for Quay cranes while Section 14 specifies them for straddle carriers. In the same way the wind speed limits are not mentioned in the Crane Operator’s Manual (see Annex 1).  

25. A Memo sent by the Terminal Coordinator to the Duty Operations Manager, dated 30 March 2010, states that the wind meter in the Quay office was out of order. The 26 April 2010 Ministry of Labour Report on the incident, indicates also that a number of operators, speaking on the condition of anonymity, alleged that wind meters on cranes had been disconnected to prevent stopping work when high winds reached the alarm and shut down levels. The FCP denied these allegations and gave instructions to determine whether the safety mechanisms had been tampered with. It should be noted that if the crane rail clamps were triggered by wind speeds in excess of 55 mph and not by the power outage, this would indicate that the wind speed indicators were functioning.

26. Two employees mentioned in their statements taking readings from a wind speed indicator at their job station. A speed of 23.7 mph was read in the machinery house of C 6 by a painter after 07:00 hrs. A speed reading of 61 mph was observed after 11:00 hrs by a welder at the Engineering building. While  the Captain of the MSC Diego estimated the peak wind to be well over 90 mph at the time of the tornado passage, he and his crew were too busy responding to the emergency created by the breaking of the vessel’s stern mooring ropes to take a wind speed reading. None of the employees who were on the cranes reported any wind speed readings or visual warnings prior or during to the tornado passage. It appears therefore that some wind meters were operational, at least on one crane and the Engineering Building. It should be noted that the power outage at the Terminal at the time of the incident may have affected the crane wind speed indicators.

Sound Alarms

27. Section 3.8.1 of the Safety Manual indicates that fixed sound alarms systems are installed throughout the Terminal. The alarm sounds three types of warning tones: Wail (Stay alert listen to instructions), Steady (Evacuate the Terminal) and Westminster chimes  (All Clear). The available information indicates that at the time of the incident the alarm system was not triggered. There were indications from the interviews that the terminal alarm system was not operational. The system seems to be intended for specific situations  such as hazardous materials leaks requiring rapid evacuation rather than weather related emergencies.

       Radio Communication systems

28. The FCP uses a multi channel radio communication system that links crane operators and personnel on the Quay, straddle drivers, maintenance personnel and duty personnel the Quay Office. The use of radio communication units, particularly in the case of emergencies, is defined in Section 3.10 of the Safety Manual. In addition, the Shipworkers Training Manual details the “Speak Code” rules for effective Radio communications for work and for emergencies.

29. Radio warnings of the incoming tornado were sent by employees on specific channels but seemingly not relayed on all channels. Although one of the channels is reserved for emergencies, it seems that there is no comprehensive overriding mechanism to transmit emergency warnings, instructions or alert codes on all channels to all personnel working on the Quay at the same time.

Lifting operations

30. At the time of the incident four cranes were operating (C1, C2, C7 and C9) and were thus not pinned down. According to available information C1 and C2 had been pinned down just before the tornado hit the quay with full force. However, the pin down status of C3, C4, C5, C6, C8 and C10 at that time of the incident remains unclear. A table indicating the pin down status of the cranes and their movement prior to and during the incident is provided in Annex 3. Based on the FCP Damage report and the diagram in Annex 4 it seems that the path of the tornado was such that wind pressure on cranes C1-C4 was not as high as on the other cranes. The employee statements indicate that all cranes were affected by the winds and moved northward, but some stopped rapidly afterwards while the others continued on a collision course toward the next cranes. This seems to confirm the evaluation in the FCP report.

31. It is probable that cranes C1- C4 were subjected to lower wind pressures and only for a very short duration, while cranes C5 to C10 sustained the full force of the tornado. The fact that C5 was pushed with the rail clamps set down close to 100 m before stopping is a good indication of the force of the winds. In a Memo appended to the FCP incident report, the Terminal Coordinator states that a number of crane repositioning was made before 6:00 hrs in preparation for the morning shift work. Cranes C3 to C6 were not scheduled for use, C10 was being prepared for maintenance work and C8 was out of service. In order to free access for C9 to the holds of the MSC Bahamas, C6 and C7 were positioned further back south near the MSC Diego, and C8 was positioned between MSC Bahamas and MSC Diego.

General OHS

32. The FCP Safety, Emergency and equipment operations Manuals (See References in Annex 1) were reviewed and, apart from the sections relevant to high wind procedures, found to be clear, comprehensive and maintained up to date. However, comments were made that the safety training over the past two or three years was insufficient. Improvements made in this area following the incident are described below.

33. In the employee statements, a number of specific OHS aspects were raised, such as the difficulties in communication between employees and management, deficiencies in the checking and maintenance of emergency response equipment such as the company ambulance (flat tire) and fire truck, and lack of safety and health related training and drills in the past two or three years.

OSH improvements following the incident

34. Following the incident, the FCP has decided to undertake a number of improvements related to OSH. These include:

·         Counselling sessions related to the psychological impact of the incident are offered to all employees, and will continue to be offered as long as needed.

·         Employees have now the possibility, through a Suggestion Box installed in the Cafeteria, to voice their concerns anonymously and directly to the Chief Executive Officer.

·         Safety briefings are being held with team members prior to the start of each shift led by Supervisors to reinforce safe working practices.

·         A general meeting dedicated to safety issues is held monthly to communicate updates and discuss safety initiatives with all team members.

·         The high-wind amber alarm threshold has been lowered to 35 mph from 45 mph to improve capacity to secure cranes and straddle carriers before reaching the Terminal shut down level.

·         The Terminal’s general alarm system is now located in the quay office, and all duty managers have been instructed in the use of the system.

·         A TELVENT weather monitoring system dedicated to the forecast and tracking of weather systems has been installed with displays at engineering, quay, safety, and planning offices. A large video monitor was placed in the cafeteria for all employees to view weather information. Familiarization and training in the use of the system was conducted by a local meteorologist.

·         Tie down drills for quay cranes and straddle carriers are being held more regularly.

Conclusions

35. The following elements have been retained by the Expert as a basis for formulating conclusions regarding the consequences of the incident:

a)      The extreme brevity of the tornado incident.There is a good consensus that on the day of the incident a serious worsening of the weather with very heavy rain and increasing winds started at about 11:00 hrs and that lifting operations were stopped a few times because of low visibility. From all accounts cranes on the south side of the quay started being pushed at various speeds by high winds at about 11:20 hrs and by 11:30 hrs the tornado had swept the quay at full force and vanished in no more than two to three minutes.

b)      The lack of experience with tornado incidents The FCP report on the incident indicates that news of possible tornado activity on the island reached the port at approximately 11:17 hrs and that a general call to stop all operations was sent shortly after. The fact that Terminal work during relatively bad weather and fluctuating winds is a common occurrence may have affected the time taken to assess the seriousness of the situation.

c)      The absence of an on-site weather monitoring system. At the time of the incident, the FCP did not have in place an internal weather monitoring system and had to rely on external information sources. The presence of such a system might have helped in detecting an incoming storm system but not necessarily its capacity to generate tornadoes. The available weather historical data indicates that winds for that day were below the lifting plants operational limits and that the tornado was a much localized event. This information concurs with that given by employees in their statements.

d)     Post incident emergency response. Emergency response after the incident was rapid, efficient and carried out according to rules. Coordination of rescue efforts was good and external services were contacted immediately and responded very rapidly. The Terminal was evacuated rapidly after a head count.

e)      Deficiencies in the maintenance of the emergency equipment. It is noted that the company ambulance arrived on site with a flat tire and that a number of employees alleged that checking and maintenance of emergency response equipment were not effective. However, as multiple ambulances reached very rapidly the Terminal, these issues did not seem to have had a significant impact on the rapidity of the assistance provided to the injured.

f)       The extremely high level of wind speeds at the time of the incident. While it cannot be conclusively determined whether wind speed indicators were operational at the time of the incident, it probable that at their highest point, wind speeds exceeded the operating limits of the gantry cranes and straddle carriers. The fact that C5 was pushed with the rail clamps set down close to 100 m before stopping is an indication of the force of the winds.  It could not be determined that all wind speed indicators were operational. However, at least two wind speeds were read, one on a crane early in the morning and the other at the Engineering building at the time of the incident. Given the brevity and severity of the incident, it is probable that crane operators were not in a position to think about reading wind speeds. It is also possible that wind speed indicators were affected by the power outage. In response to wind speed indicator tampering allegations, it is understood that the FCP intends to investigate the operational status of all wind speed indicators at the time of the incident.

g)      The safety rules were not designed to cater for brief and violent events such as tornadoes. The safety rules related to wind speed alarms and limits are evidently designed for situations where average winds are increasing slowly and steadily, thus giving the decision maker sufficient time to have the cranes secured properly and personnel brought back to safe areas. This was not the case at the time of the incident where decision making time regarding the ceasing of lifting operations was much shorter. It is noted that the amber alarm threshold has been lowered to from 45 mph to 35 mph to improve capacity to secure cranes and straddle carriers and allow personnel to descend from the cranes safely before the red alarm is triggered.

h)      There was no overriding mechanism to communicate radio alerts on all channels. Radio warnings of the incoming tornado were sent by employees on specific channels but not relayed automatically on all channels. Although one of the channels is reserved for emergencies, it seems that there is no comprehensive overriding mechanism to transmit emergency warnings, instructions or alert codes on all channels to all personnel working on the Quay at the same time.

i)        The apparent practice to leave cranes unpinned appears to be related to a concomitant need for efficiency and lack of awareness of the seriousness of certain storms and the potential they may have to develop into tornadoes. Based on the fact that several cranes were repositioned before 6:00 hrs on incident day in preparation for the morning shift in order to allow working cranes to service a berthed vessel and be repositioned rapidly according to needs. The Expert concludes that in all probability, none of the cranes were actually pinned down at the time of the incident. Lack of knowledge about the seriousness of the storm and productivity constraints may have played a role in the decision to keep the cranes unpinned during the shift so that they could be moved to service the berthed vessels. This is particularly the case for crane C8.

j)        Tornado trajectory. It is probable that cranes C1 to C4 moved only a short distance because they were subjected to lower wind pressures and only for a very short time, while cranes C5 to C10 sustained the full force of the tornado. This may be explained by the trajectory of the tornado when it swept the Quay.

k)      The FCP Safety, Emergency and equipment operations Manuals were reviewed and, apart from the sections relevant to high wind procedures, found to be clear, comprehensive and maintained up to date. However, comments were made by some employees that in actual practice, the safety training over the past two or three years was insufficient

36. In conclusion the Expert notes that,

a)      While hurricanes and thunderstorms are not infrequent in the region, the formation of tornadoes such as the one at issue appears to be a comparatively rare event. Furthermore, according to current meteorological knowledge it is apparently extremely difficult, if not impossible, to determine the capacity of thunderstorms to spawn tornadoes and to detect and predict their strength and path. Moreover, as demonstrated by the incident on 29 of March 2010, the formation of tornadoes is typically a suddenly occurring event during which wind speeds of extreme levels may develop and pass by in the span of a few minutes. In the case at issue, the emergency preparedness and the FCPs safety organization were geared to cater for extreme weather conditions in the form of hurricanes and other storms and not for sudden events such as the tornado incident at issue. Among the facts that the Experts has been able to determine as a result of the investigation, reference is made to the absence of an efficient system for detecting and relaying adequate and appropriate information to the workers in the FCP regarding the relevant weather conditions. This is regrettable and should be remedied. However, and due to the unpredictable nature of the tornadoes in question, it is the view of the Expert that it is improbable that the existence of a more efficient weather relaying system could have had a significant impact to prevent the events on the 29 of March 2010 in the FCP port.

b)      The Expert has determined that according to prescribed safety procedures, the conditions were such that the cranes should have been pinned down. It has not been possible conclusively to determine whether in fact the required pinning down procedure had been followed. With the possible exception of C1 and C2 (who in any event do not appear to have been hit with the full blast of the tornado) it is probable that none of the cranes at issue had been pinned down. Several reasons related to convenience and required efficiency of operations, as well as lack of awareness of the seriousness of the weather conditions were noted as to why this requirement may not have been adhered to. However, given the unpredictability of tornadoes, the Expert considers that it is impossible to determine whether the outcome of the incident would have been less or more severe in terms of injuries to employees and property damage if all or at least cranes C8 and C10 had been pinned down.

c)      The Expert has determined that: there were certain shortcomings in the communications systems, the emergency response equipment was partially deficient, and all required safety training apparently had not been carried out. These shortcomings need to be addressed as a matter of urgency, as they may have an incidence on the general level of emergency preparedness in the port. In the case at issue, however, it is the view of the Expert that, due to the brevity of the incident, these shortcomings did not have any significant impact on the outcome.

37. The Expert notes that the above conclusions are based on the information that was gathered during the investigation at the FCP in Grand Bahamas and from the other referenced sources. Other investigations, such as engineering investigations that may have been or are being carried out by the FCP and possibly other bodies such as insurance companies may identify other issues related to and relevant for the incident. These should be taken into account in any overall evaluation of the preparedness and response to the incident.

Recommendations

38. Although it may be difficult to increase significantly the level of preparedness for a tornado passage and to mitigate its impact, a strong emphasis on prevention may significantly improve the Terminal’s safety level under normal or less extreme weather conditions. The availability of a focused and well promoted regulatory framework, as well as the establishment of effective social dialogue, the provision and effective carrying out of OSH training, the development of skills, and timely access to reliable knowledge are critical elements in a successful management of OHS and the building of a safety culture, both at the national and enterprise levels. The following recommendations, which reflect the basic principles in relevant ILO instruments, are focused on areas which, in the view of the Expert, could benefit from improvements to enhance the enterprise and national OHS systems and to maintain the incidence of occupational accidents and diseases at the lowest possible level.

At the enterprise level

39. These recommendations address principally the operational and general OSH issues identified by the Expert. A number of these recommendations have already been or are in the process of being implemented by FCP. 

       Operational issues

a)      It seems that reliable information on the nature and severity of the incoming thunderstorm reached the FCP with insufficient time to fully secure the Terminal. While it is noted that a full weather monitoring system was installed shortly after the incident, the FCP should seek to further improve its communication channels with the Bahamas Department of Meteorology and, to the extent possible, with other key Meteorological Centres in the region.

b)      The general maintenance schedules of wind speed indicators should be further investigated. All appropriate measures should be taken to ensure that these instruments are not disabled by power failures and work at all times. One possible solution is the installation of alternative emergency power sources such as rechargeable batteries. It might also be useful if wind speed data could be transmitted and pooled in a central location such as the Quay Office to monitor and map speeds, as well as indicator functionality. In the same way, if not already done, the Terminal’s sound alarm systems should be modified to run on batteries or other independent power sources in case of a general power outage. In the event the procedure is not already in place, a record of functionality checks and maintenance work should be established and kept up to date for all equipment that are critical to the safety and health of workers.

c)      Instructions in the Safety Handbook and the crane and straddle carrier operator’s manuals regarding high wind procedures should be clarified regarding limited response time emergencies and harmonized. In the same way, the Emergency response manual should also include a specific section on high wind and eventually other limited response time emergency procedures. Moreover, the procedures in Section 3.8 of the Safety Manual should be reviewed and clarified as to its uses. The feasibility of using the Sound alarm systems in the case of very short lead time emergencies should be considered, and the logical decision steps and responsibilities for triggering the system should be defined.

d)     The radio communication system and its use should be re-evaluated and the necessary improvements made to ensure that alerts and instructions regarding serious emergency situations can be transmitted immediately on all channels and to all personnel using radio units. It is understood that the FCP is addressing this matter.

e)      Pin down procedures should be reviewed and clarified particularly in relation to rapidly developing emergency situations such as rapidly increasing winds. The rules under which the crane’s automatic rail clamping system can be overridden should also be reviewed and clarified in relation to emergency situations.

            General OSH issues

f)       Effective social dialogue, including communication and cooperation between management and employees regarding safety and health at work is an essential tool in reducing significantly occupational accidents as well as property loss. It is also an effective basis for improving labour relations within the enterprise. This is even more essential in high hazard operations such as container ports. Workers should feel that they can raise genuine safety and health issues to their management without fear of undue consequences and that their concerns are acted upon rapidly. The establishment and effectiveness of communication and consultation mechanisms is the best and most practical means to build over time a preventative safety and health culture in the enterprise. While the human losses and injuries are incalculable, the cost of implementing a good occupational health and safety programme is orders of magnitude lower than the costs of property losses sustained by the Terminal.

g)      The sharing of information, best practices and technical expertise in the area of OSH are essential to the management of OSH and the building of a safety culture at the enterprise level. The Hutchison Port Holdings Company should consider establishing a global OHS network linking its different sites to facilitate the exchange of technical information and best practices between its OSH specialists. Given the size of the company and the number of ports it manages, it should also consider establishing its own auditing team to ensure periodic evaluation of the sites as to effectiveness of OHS implementation and maintain the global OSH performance of the company as a whole at the best possible level.

h)      In relation to comments made concerning the insufficient level of health and safety training over the past two or three years, a well organized and continuous training and skills certification programme is essential for ensuring maintenance of skills at the level necessary to understand and address effectively the ever changing occupational hazards and working conditions and environment. Given the hazardous nature of port work, particular emphasis is needed on emergency response training and the handling of hazardous materials. It is noted that the FCP has started a promising programme of training in the area of OHS.

At the national level

40. In relation to the problem of timely public communication of severe weather related alerts, the process and rules for issuing such alerts should be reviewed and to the extent possible improved.

41. Occupational safety and health in the Bahamas is legislated under the 2002 Health and Safety at Work Act. While the Act provides a good general framework and defines all the important principles and responsibilities in this area, its full implementation could be strengthened and facilitated by the development of regulations, codes of practice and technical standards designed to address the specific needs of different economic sectors. Consideration should be given to the strengthening of the National OHS system and more particularly its Labour Inspection capacities in the area of occupational safety and health. In order to ensure an effective application at the enterprise level of the provisions in the Act, consideration should be given to the strengthening of the national OHS system by:

a)      Giving consideration to amending the Act in a number of areas to in order to reflect more closely the provisions of the ILO Occupational Safety and Health Convention (No. 155), 1981, particularly those concerning the protection of workers removing themselves from a work situation presenting an imminent danger to their life or health.

b)      Initiating the formal process leading to the ratification of the main ILO OSH standards, including the OSH Convention (No. 155), 1981 and its Protocol of 2002 related to the recording and notification of occupational accidents and diseases, and the Promotional Framework for Occupational Safety and Health Convention (No. 187), 2006.

c)      Developing and endorsing at the highest level of government an OSH policy as well as a time bound strategy defining objectives aimed at strengthening the national OHS system.

d)     Developing a set of technical regulations defining OHS requirements for specific undertakings, occupations and hazards.

e)      Endorsing and promoting the use by enterprises of OHS related internationally recognized Codes of practice such as those of the ILO, and technical standards such as those developed by international, regional and national standardization bodies that are relevant to the various aspects of OHS.

f)       Strengthening and expanding the OHS training of the labour inspectorate so it may provide guidance to enterprises in implementing effectively the requirements of the national OHS regulatory system.

g)      Promoting the establishment and implementation at the enterprise level of a systems approach to the management of OHS, based on the principles of the 2001 ILO Guidelines on OSH Management Systems, or other similar internationally recognized technical standards.

h)      Participating in regional OHS networking systems designed to facilitate exchange of information and best practices.

i)        Promoting the professional certification of OHS practitioners in order to ensure that skills and experience in this area are updated periodically through recognized evaluation mechanisms. The provision of diplomas and degrees in the area of OSH by the National education system should also be considered.  

j)        Preparing a national OHS profile designed to assess the strengths and weaknesses of the national OHS system, identifying areas, and serve as a baseline for measuring future improvements made through national programmes developed to address these areas.

Annexes

Annex 1. References

1.      Freeport Container Port Safety Department - Tornado Incident Summary, March 29, 2010

2.      Freeport Container Port Safety Handbook. Amended June 2007

3.      Freeport Container Port Emergency Response Manual, 2009.

4.      Freeport Container Port Shipmaster Information and Emergency Procedures Guide, November 2006

5.      Freeport Container Port, Operator’s Reference Manual for the OMG and HHI Cranes, Quayside Gantry Cranes, Version 3.0, 2006.

6.      Freeport Container Port, Straddle Operator Handbook

7.      Shipworker Training Manual, amended December 2007

8.      Memorandum by the investigating Labour inspector to the Deputy Director of Labour, Department of Labour, Freeport, Bahamas, concerning the Tornado incident, 26 April 2010.

9.      Act to make provisions relating to health and safety at work and for connected purposes, Enacted by the Parliament of the Bahamas, 2002.

Annex 2. Summary of employee statements and interviews

 Annex 3. Crane pin down status and movements on 29 March 2010

Legend:          PD: Pinned Down; NPD: Not Pinned Down; SFW: Scheduled for work;    NSFW: Not scheduled for work.

Annex 4. Terminal situation before and after the tornado passage

Annex 5. Historical Weather data for 29 March 2010. 

Hourly observations at Freeport Airport