Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0012, written 3 Feb 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Feb 2017 |
|---|---|
| Reference | 2017-0012 |
| Deceased | Gerome Reyes |
| Coroner | Grahame Short |
| Coroner area | Southampton and New Forest |
| Category | Accident at Work and Health and Safety related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
Grahame Antony Short
Senior Coroner for Southampton & New Forest
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Primebulk Shipmanagement Limited
CORONER
lam Grahame Antony Short, Senior Coroner for Southampton & New Forest
CORONER’S LEGAL POWERS
| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (investigations) Regulations 2013.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http:/Avww legislation.gov.uk/uksi/2013/1629/part/7/made
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
The death would not have occurred if the door limit switch had been fitted to the goods lift being
operated by the deceased.
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In my
opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it
is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. —
(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 being 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's Office, Castle Hill, The Castle, Winchester, S023 8UL
Tel 01962-667884 { Fax 01962-667893
6 | ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you Primebulk
Shipmanagement Limited and/ or Mirage Finance Incorporated have the power to take such
action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
31 March 2017. |, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.
8 COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
Embassy of the Republic of the Philippines and Mirage Finance Incorporated. | have also sent it
to the Republic of the Marshal! Islands who may find it useful or of interest.
lam also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He
may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response, about the
release or the publication of your response by the Chief Coroner.
9 Dated 03 February 2017
»,
Signature__¢ Mer
Senior Coroner for Southampton & New Forest
Coroner's Office, Castle Hill, The Castle, Winchester, S023 8UL
Tel 01962-667884 | Fax 01962-667893
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