Improvised Lifting Operations Led to Serious Injury

The New Zealand Transport Accident Investigation Commission (TAIC) has released its findings into the serious injury that occurred on the bulk carrier, Thor Nitnirund, in the Cook Strait on March 20, 2025.

The Commission’s report highlights the need for effective safety management systems, proper planning of lifting operations, and vigilance around high-risk areas during deck work.

In March 2025, the bulk carrier was drifting in Cook Strait while waiting for a berth in Wellington. Heavy weather in preceding days had washed two cargo lashing chains over the ship’s side. To recover them, the crew improvised a lifting system powered by a mooring winch.

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

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

The crew did not identify the consequences of a failure under load and underestimated the risks of the improvised lifting arrangement. The task was not properly planned, risk-assessed or supervised.

The ship’s safety management system required risk assessments and toolbox meetings, but these were not applied effectively to this task, and audits by the operator did not identify the gap. A toolbox meeting was held, but it was in the cargo office not the worksite, so the crew had less opportunity to visualize the operation, identify hazards and consider safer ways of doing the work.

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

• Stay clear of danger zones: Never stand in the bight of a line or lifting system. If equipment fails, serious injury can happen fast. Identifying and monitoring this risk should be part of pre-task planning and supervision during the work.

• Plan the work: Plan, risk-assess and supervise lifting operations before work begins. Non-routine jobs can introduce hazards that are not immediately obvious, and crews may miss risks or use equipment and methods that are not suitable for the task.

• Hazard-control equipment: Know what equipment is covered by the safety management system, and ensure it’s inspected, maintained and documented. Equipment outside these controls can remain in service with hidden defects and fail when it is needed most.

• Make it real: Senior officers must actively implement the ship’s safety management system. Audits and compliance checks should test how procedures are applied on board, not just whether forms have been completed. Gaps between the system and day-to-day practice can leave serious risks unmanaged.

The Commission issued no new recommendations. The operator, Thoresen & Co (Bangkok) Limited, showed that it had taken action to address the safety issues identified in this inquiry. This included stronger lifting gear inspection and maintenance procedures, unique identification of lifting equipment, color-coding, inventory controls and standardized fleet-wide management processes. It also strengthened requirements for worksite toolbox meetings, task supervision, risk assessment procedures and auditing of onboard practices.