Fatal Man Overboard While Rigging The Pilot Ladder


  • The bosun on board the Maltese registered bulk carrier Navios Amitie fell into the sea while rigging a combination pilot ladder. It was dark and the vessel was making way to the pilot station.
  • The MSIU has issued two recommendations to the Company designed to enhance safety when the crew members are tasked to rig the accommodation and pilot ladders to the ship’s hull.

Transport Malta MSIU issued an investigation report on a fatal man overboard incident, involving a crew member while rigging a combination pilot ladder onoard the bulk carrier Navios Amitie, in February 2020. At the time of the accident, the crew member was not wearing a safety harness. It is very likely that he drowned because he had no lifejacket on.

The incident

In the early hours of 05 February 2020, the bosun on board the Maltese registered bulk carrier Navios Amitie fell into the sea while rigging a combination pilot ladder. It was dark and the vessel was making way to the pilot station.

Information available to the safety investigation indicated that the bosun was alone on the accommodation ladder’s lowest platform. None of the crew members witnessed the events which led to the bosun falling off the ladder.

It seems likely that the crew member fell into the water whilst lashing the accommodation ladder to the vertical pilot ladder.

Probable causes

At the time of rigging the combination pilot ladder, the vessel was experiencing rough seas with winds gusting at 50 knots and a wave height of between two and three metres. There was reportedly no rolling or pitching.

Therefore, it was unclear what caused the bosun’s fall from the accommodation ladder since none of the crew members tasked with the rigging witnessed the actual fall.
As noted above, the environmental conditions were severe. The probability of the waves buffeting the underside of the lower platform or its upper surface being wet from sea spray was not excluded by the safety investigation. Therefore, it seemed most likely that the bosun may have lost his balance and / or slipped while securing the lower platform to the pilot ladder.

Although he had donned personal protective equipment (overall, safety shoes, gloves and helmet), he was wearing neither a life jacket nor a safety harness. In any case, if the bosun did survive any physical injuries, it was very likely that he would have immediately suffered from the severe effects of cold-water immersion and hypothermia. His chances of survival were probably very slim. At the time of the fall, the temperature of the sea was 13°C and the bosun was not wearing any thermal protective clothing.


  • It is very likely, the bosun lost his balance while lashing the gangway to the vertical pilot ladder and fell into sea.
  • The bosun was not wearing a safety harness and he may have possibly drowned because he was not wearing a lifejacket.
  • The SMS required that overside working is undertaken neither when the ship is underway nor during ship’s rolling. Since, combination pilot ladder is rigged when arriving or leaving port, the crew members could not comply with this requirement.
  • No formal risk assessment and no permit to work overside had been filled in.
  • Consequently, weather conditions and vessel’s movement were not considered.
  • Preparing a combination pilot ladder was seen by the crew members as normal routine work.
  • The crew may have perceived the use of a safety harness and life jacket as impeding the task of rigging and securing the combination pilot ladder to the ship’s hull.


Kleimar NV is recommended to:

  • Review and revise the SMS procedure for working over the side to rig combination pilot ladders. The work permit and risk assessment forms should specifically identify this task taking account of vessel’s movement and weather conditions.
  • Ensure that a formal risk assessment and permit to rig combination pilot ladder overside is carried out and ensure that relevant PPE is worn by the crew.

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Source: Transport Malta