Fall Overboard While Securing Pilot Ladder Combination Arrangement


Transport Malta’s Marine Safety Investigation Unit has issued an investigation report on the fall overboard and subsequent loss of life of a crew member while securing a pilot ladder combination arrangement for the Maltese-registered oil and chemical tanker.

The incident

Mariner A departed in a loaded condition from the port of Novorossiysk, Russia, in the early morning hours of 05 February 2023. The vessel was bound for the port of Samsun, Türkiye, and was expected to arrive in about 16 hours. After the pilot disembarked, the master instructed the bosun, via a portable radio, to secure the pilot ladder – accommodation ladder combination arrangement.

The bosun and two ordinary seafarers were carrying out this task, with the bosun down at the bottom (platform) of the accommodation ladder that was still inclined and the two ordinary seafarers assisting with the task from the deck. During the task, the bosun fell overboard. The crew members immediately responded to the emergency and the local authorities were contacted for assistance in recovering the bosun from the water. The bosun was eventually recovered in an unconscious state by a pilot boat and was transferred to a shore hospital. He was pronounced dead on arrival at the hospital, and the death certificate stated the cause of the bosun’s passing away as drowning.


The purpose of a marine safety investigation is to determine the circumstances and safety factors of the accident as a basis for making recommendations, to prevent further marine casualties or incidents from occurring in the future.

Cause of Death

The death certificate determined that the cause of death was drowning. The bosun fell overboard at around 0351, after which, the two OS saw him and heard him call for help. They further stated that the bosun was unable to swim towards the lifebuoy which they had thrown towards him. Shortly after, the crew members lost visual contact with the bosun.

The crew members were unable to recall the exact time at which they lost visual contact with the bosun. However, considering that the cause of the bosun’s death was drowning, the safety investigation did not exclude that by the time the crew members lost visual contact, the bosun had already started drowning. By 0431, when the crew members regained visual contact, the bosun was floating face-down in the water, and it was highly likely that the bosun may have already drowned by this time.

Probable cause of the fall overboard

As none of the crew members witnessed the bosun’s fall overboard, the safety investigation was unable to determine the exact dynamics, leading to the fall. As the crew members found that the bottom platform was angled downwards and its securing pin, while being in one of the slots, was not securing the platform in position, it is highly likely that the bottom platform of the accommodation ladder suddenly slipped out of its intended position at one point. The loud metallic-like sound heard by the two OS, before the splash in the water, may have been that of the accommodation ladder’s bottom platform striking the roller beneath it, after the platform slipped down from its position.

Considering that the pilot had just disembarked without any reported issues, using the combination arrangement, the safety investigation was of the opinion that the bosun had intentionally removed the securing pin of the bottom platform in preparation to hoist the ladder. Crew members clarified that the bottom platform’s securing pin had to be removed and the platform dropped so that after the ladder is hoisted up and turned inwards, the platform would not interfere with the securing of the ladder. However, it was stated that this was usually done once the accommodation ladder was hoisted up and brought closer to its securing position. While the exact reason for the bosun to release the platform prior to it being hoisted remains unknown, the safety investigation could not exclude the possibility that he may have done so from the following perspectives:

  • from past experiences, he may have found the inclination of the platform and / or the removal of the securing pin to be difficult when the accommodation ladder was closer to its securing position; and
  • having joined the vessel only a couple of weeks prior, the bosun may not have been aware of the possibility of the platform being inclined after bringing it closer to its securing position.


Immediate causes of the accident

  • The bosun drowned after he fell from the accommodation ladder, while preparing the pilot ladder – accommodation ladder combination arrangement for recovery.
  • The bosun may have drowned due to cold shock and subsequent superficial tissue cooling, shortly after falling into the water.
  • The bosun may have fallen overboard either while trying to adjust the accommodation ladder’s bottom platform with one hand, after placing the securing pin in the slot, thereby shifting his centre of gravity towards the edge platform and overside, or he may have slipped on the ladder shortly after the pin was placed into the slot, due to the ice accretion.

Conditions and other Safety Factors

  • The bosun was neither wearing a safety harness nor a working life vest / life jacket, while working on the accommodation ladder.
  • It is possible that the bosun may have perceived a life jacket and a safety harness as a hindrance to performing the task.
  • The bosun accepted the risks associated with not wearing a working life vest / life jacket and a safety harness.
  • Data available to the safety investigation suggested that the task was not being monitored by other crew members.
  • The lifebuoy with a self-activating smoke signal and a self-igniting light, which was located on the port side bridge wing, was not released. The absence of a helmsman / lookout required the master and the OOW to improvise over their duties specified in the muster list, and this may have led to them to overlook the release of the lifebuoy.About 40 minutes after the bosun fell overboard, he was seen floating facedown in the water, and it was highly likely that he had already drowned by that time.
  • The bosun was only recovered about 1.5 hours after he fell overboard. Taking into account the low temperature of the water into which the bosun fell, the safety investigation believes that the delay in the recovery of the bosun was a contributory factor to his death.

Actions taken

Following the occurrence, the Company took the following safety actions:

  • an accident notification / safety flash was immediately disseminated amongst its fleet and, on completion of the Company’s internal investigation report, the report was promulgated to its fleet and also discussed during the Company’s management review meeting;
  • online conference calls were carried out with its seafarers, those who were on board as well as ashore, to identify the practices that were being followed for the rigging and securing of the combination arrangement, the seafarers’ risk perception and awareness relating to this task, and the adequacy of the work plan for this task;
  • informed its crew manning agencies about the accident and instructed them to provide a safety notice on this matter, during the pre-joining briefings of all seafarers joining from their offices;
  • updated inventories of PPE required for the rigging and securing of combination arrangements were collected from all vessels, and arrangement were made to replenish missing PPE where required;
  • retractable fall arresting devices were supplied to all vessels in its fleet;
  • using the example of the practice on board Mariner A, the Company advised all vessels to have a dedicated storage box for PPE required for the rigging and securing of pilot and accommodation ladders;
  • all vessels in its fleet were instructed to post warning signs near the accommodation ladders, to remind crew members to don a working life vest / life jacket and a safety harness when working overside, and that the work is to be continuously supervised by other crew members;
  • a safety campaign was launched across its fleet to verify and assess the safe working practices followed for the rigging and securing of pilot and accommodation ladders;
  • the causes of the accident and the lessons learned, as identified by the Company’s internal investigation, were added to the agenda of the Company’s annual senior officers’ conference;
  • a shore-based training organization was contracted to organize a webinar and refresher training for its seafarers, to address safety culture, awareness, and behaviour;
  • provided new coveralls to all crew members, affixed with a safety badge to serve as a continuous reminder on the importance of safe actions and behaviour;
  • the Company’s procedures, work permit and risk assessment, relating to working overside were reviewed and revised to provide additional emphasis on the required precautionary measures and the severity of the consequences in the case of non-compliance;
  • the Company’s computer-based training (CBT) program was upgraded to include, amongst others, modules on the use of PPE, slips, trips and falls, human behaviour, safe gangway and ladder operations and safety culture;
  • the crew manning agencies were instructed to verify that all newly promoted bosuns completed the CBT modules on the use of PPE and safe gangway and ladder operations, prior to joining the Company’s vessels;
  • introduced monthly cause analyses of reported near-miss cases, aimed at identifying signs of hidden / less-obvious risks which could compromise onboard safety, with the results being promulgated across its fleet;
  • aimed at improving the key performance indicators for the Managers’ Safety leadership visits of eight per year and promote safety culture during the visits through the formal safety meetings with all the available crew members; and
  • commenced emphasizing the Company’s procedures for working overside, to all masters and deck officers, during their pre-joining briefing.


In view of the conclusions reached and taking into consideration the safety actions taken during the course of the safety investigation, no recommendations were issued by the MSIU.

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Source: Transport Malta