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In 2014, eight months before the incident, the cab on one of the company's two coal unloader jetty cranes was replaced. Soon after, the cab started sticking as it traversed the runway beams. Clydeport and the company that fitted the new cab - and which originally installed the two unloader cranes - tried to identify the problem while the faulty crane cab remained in service.
Maintenance engineers had to free the cab each time it stuck. Some climbed on top of the cab - 42m above the ground - and forced it past the sticking point using a pull-lift (also known as a ratchet lever hoist, it is used for lifting, pulling and holding loads). Others opted to use brute force.
The sticking became so frequent that a maintenance fitter was required to sit in the cab with the crane driver all the time the crane was operating. On 15 February 2015, 22-year-old Craig Logan was the maintenance fitter appointed to the task. He had worked for the company for around five years and only recently had been time-served.
Just before 10pm, when the changeover of personnel would have taken place, the cab stuck on return to its home position. Logan climbed out to free it but discovered the pull lift had been moved and wasn't available. One was requested but during the intervening period Logan is thought to have got the cab moving again. Logan became trapped between the motor on top of the cab and the cross beams on the boom of the crane and was crushed to death.
After the incident the cab was found to be 600 kg out of balance. Today it runs smoothly along the runway beams after a weight was fitted to bring it back in line.
"There was a lack of risk assessment leading to a completely unsafe system of work. In fact, the system of work they [Clydeport] had adopted was horrific -¦ I'm absolutely amazed they got away with it for so long," said Russell Berry, an inspector for the HSE. "I think the company agreed the circumstances were so awful that an early guilty plea was the best course of action." Clydeport admitted to breaching Section 2(1) of the Health and Safety at Work Act and fined £300,000. The fine started at £450,000 but the early guilty plea meant it was reduced by a third.
The HSE served three enforcement notices during its investigation. The first was a prohibition notice preventing anyone from accessing the top of the crane cab or the adjacent work platforms when the cab was switched on and liable to move. The second, an improvement notice, was to ensure the crane, including the cab, was well maintained and kept in efficient working order, and the third required Clydeport to implement systems to ensure the safety of its employees carrying out work at height.
Clydeport has instigated "robust" and "significant" changes, Berry said. These include hiring new health and safety personnel (the health and safety manager working at the time Logan was killed took retirement) and a detailed evaluation of the safety and health management systems is currently underway.
A new cab was also earmarked for Clydeport's second unloader crane, though this is yet to be realised. The ongoing closure of coal-fired power stations in the UK means operations will start to slow at the Hunterston Coal Terminal in the coming months.
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