Fatal Fall Overboard! Risk of Working Aloft


A reconstruction to show how the aluminium ladder had been rigged


On 28 April 2016, the Maltese-registered ship Seagull was at anchor outside Trincomalee port, Sri Lanka, awaiting supply of bunkers. In order to read the draught marks, a ladder was rigged above the starboard marks.

At about 1730, the chief mate read the draught and while on his way up the ladder, he fell into the sea. The deck-boy, who was standing-by on the poop deck, threw the nearest lifebuoy and raised the man overboard alarm. The chief mate managed to grasp the lifebuoy but before long, his body became limp.

The deck-boy and two crew members jumped into the sea and kept his face out of the water. They managed to administer CPR, however, he was declared dead upon arrival at the hospital.

Cause of the Fall

Although the microscopic analysis of the lungs during the initial post-mortem examination indicated factors compatible with drowning, there was no information on what has led to the fall from the ladder2. Thus, on the basis of the deck boy’s observations, the safety investigation did not rule out ischemia (restriction of blood supply to heart) and momentary loss of consciousness.

The subsequent trauma caused by the sudden immersion (albeit in
relatively warm water) and the strenuous effort to reach the lifebuoy, may have gravely debilitated the chief mate’s physical strength and cardiac function.

Actions Taken

Following the accident and the internal investigation carried out by the Company in terms of Section 9 of the ISM Code, the DPA attended all Company vessels to highlight the importance of safety management system procedures.


  1. The chief mate may have suffered from a medical condition which caused his fall overboard;
  2. The aft draught gauges in the control room were faulty;
  3. On-board assessment of risk for the reading of draught marks was not usually carried out;
  4. The rescue boat was not used to read the draught marks since it was considered inappropriate for the task;
  5. The chief mate saw no other option but to improvise a way to read the aft draught marks;
  6. The improvisation by the chief mate was carried out without a clear mental model of the risks involved, but with the intention to complete a step as part of the bunkering procedure.

The ship’s rescue boat


Blue Seas Shipping S.A. is recommended to ensure that, where fitted, the draught gauges are operational, in order to minimise the exposure of crew members to the risk of working aloft.

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Source: Transport Malta


  1. 5. The chief mate saw no other option but to improvise a way to read the aft draft marks;

    If that was the case , the Chief Mate should have used safety harness or belt according to Company’s SMS Procedures mentioned probably in Chapter 7.

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