Near-Miss in Block R: Pedestrians Sharing the RTG Travel Lane
22:40, berth 6, yard block R. A terminal checker is walking from the reefer rack to the RTG control position to log a damaged door seal. Block R has no marked walkway: pedestrians share the 9 m RTG travel lane, bounded on one side by a two-high stack of 40ft boxes and on the other by the quay edge. The RTG's reversing alarm is the only warning device; the driver sits 12 m up on the waterside leg, and the lane behind him is a blind spot. At 22:41 a prime mover reversing into a straddle-carrier slot passes within 1.5 m of the checker. Neither saw the other. The prime mover's reversing bleeper had been reported faulty the previous shift, but no defect tag was raised and the unit stayed in service. Two contract cleaners, inducted at 21:00 that day, are working 30 m away without an escort. The checker's hi-vis vest is worn under a dark jacket. Lane lighting was last measured at 22 lux.
1. Apply the hierarchy of control to block R. What would you eliminate, what would you engineer, and what would you only then manage administratively?
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Eliminate first - remove the reason to be in the lane. The checker's task was to record a damaged door seal. That can be done by radio or tablet to the control room, by a camera on the RTG, or from the landside before the box is lifted. An RTG cab 12 m up on one leg is inherently incompatible with a person in its travel lane, so the design answer is to stop the person entering, not to warn them better.
Substitute / engineer
- A marked walkway on the landside, 1.5 m clear, with rigid barriers and pedestrian gates at each end of the block - physical separation, not paint alone.
- RTG pedestrian detection or proximity system giving an in-cab alarm and an automatic slow-down or stop.
- Reversing camera, and a bleeper interlocked to the reverse gear so the unit cannot be driven backward with a dead alarm.
- Convex mirrors at the reefer rack corner, and lighting measured and maintained for traffic lanes (a maintained target of around 50 lux is a common design figure) rather than 22 lux.
Administrative - only after the above: a defined exclusion zone around a working RTG (at least the load radius plus a walking margin), a radio call-in protocol before entering a block, one-way truck routing, escort rules for contractors, and a shift briefing on this near miss.
PPE last. Class 3 hi-vis worn outermost - never under a jacket, which is exactly how this one failed.
Reasoning to show: three independent defences failed at once - no walkway, no working bleeper, no line of sight. Fixing only one leaves two live.
2. The reversing bleeper had been reported faulty on the previous shift and no defect tag was raised. How should that be investigated, and who is accountable?
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Treat it as the most serious finding in the file - a known defect on a moving vehicle in a shared lane is a system failure, not a bad luck story.
Lines of enquiry
- Who reported it, to whom, at what time, and in what form - verbal to a supervisor, or written in the defect book?
- What did the shift handover record say, and did the incoming supervisor read it?
- Does the pre-use check sheet actually list the reversing alarm and bleeper, and was it signed that night?
- Is there a defect tag system, is it accessible at 22:40, and is there a quarantine bay where a tagged unit can be parked?
- Is this an isolated unit, or does the fleet audit show the same defect on others - a culture indicator.
Accountability
- Driver: a duty to check before use and to report and refuse an unsafe unit. If he knew and drove anyway, he has a share.
- Supervisor / shift manager: the dominant failure. Once the defect was reported, deploying the unit was a decision to run an unsafe vehicle.
- Terminal maintenance regime: if the tag system is hard to use, or if the informal norm is 'keep it moving till shift end', the defect is designed in, and the finding belongs at management level.
Fix: a pre-use check with sign-off for every unit each shift; a defect tag register with a quarantine bay; a rule that a unit with a failed reversing alarm is parked, not 'used carefully'; and a supervisor audit of tags opened and closed. Record the outcome in the same file as the near miss so the two findings are linked.
3. Two contract cleaners were inducted at 21:00 and left unsupervised. What must a site-specific induction cover, and what supervision is proportionate for their first night shift?
Read the worked answer
Induction content - site-specific, not a generic slideshow
- Block layout, RTG and prime mover movements, blind spots, and the exact no-go zones for their task.
- Segregation rules: where they may walk, pedestrian gates, radio call-in before crossing any lane, and who authorises entry.
- Traffic rules for the units they will meet, including straddle carriers and reversing prime movers.
- Emergency arrangements: muster point, alarm sound, who to call on the terminal radio, first aid.
- PPE standard for the task, including that hi-vis is worn outermost and what to do if it is torn or covered.
- Night-shift specific risks: lighting levels, fatigue, reduced supervision.
- Reporting: near misses count, and how to raise a defect.
Delivery and evidence: in a language the workers understand, with a comprehension check rather than a signature alone; attendance recorded; MBST card sighted and checked for validity and course type; the cleaning contractor's own risk assessment co-ordinated with the terminal's.
Supervision: two workers inducted at 21:00 and working unescorted 100 minutes later is not proportionate. For a first night shift in a live yard, a named escort or a supervisor with no other duty, contact at defined intervals, and a check before any movement into a new area. A permit or access authorisation tied to the block, not just a gate pass.
Reasoning: the terminal controls the premises, so it cannot rely on the cleaning contractor's induction alone; induction transfers knowledge, supervision verifies behaviour. Both are needed on night one, when the lighting, traffic mix and fatigue are at their worst.