Faulty Position in Closing Ventilation Louver Board Kills Crew




The vessel was safely moored alongside at the port of Pago Pago, discharging its cargo of containers.

The second mate was the duty officer at the time, overseeing the cargo operation. At about 0235(LT), whilst on deck, he tried to close one of the ventilation flaps of the hatch covers.

During his actions, he lost his balance, fell on the side railings of the vessel and eventually overboard on the jetty side. Medical assistance was provided to the crew member, who was eventually transferred to a local hospital. Notwithstanding the medical care received, the second mate succumbed to his injuries.

The safety investigation revealed that the incorrect position adopted by the crew member to close the ventilation louver board was the immediate cause of the accident.

Taking into consideration the safety actions adopted by the managers in the aftermath of the accident, no recommendations to the Company have been issued by the MSIU.


Actions Taken

During an on board meeting held on 05 April 2015, the operation of the cargo hold’s ventilation louver board was discussed. Crew members were reminded that the cargo holds’ ventilation louver boards have to be opened / closed from the main deck with the safe use of a ladder. It was also reiterated that the operation of the cargo holds’ ventilation louver boards from above (i.e. by standing on top of the cargo hatch covers) was strictly prohibited.



  1. Management has highlighted to all Company’s seafarers the importance of safety on board in accordance with Company’s Policy. A circular letter was sent to all ships, defining the objective target of zero accidents onboard and ashore; 
  2. A Cargo Operation Booklet was compiled, enabling the recording of potential cargo operations-related hazards and / or high-risk operations identified prior to the start of each cargo operation. Guidelines on the opening and closing of the cargo holds’ ventilation louver boards as well as notices prohibiting the access to the cargo hatch covers without Master’s authorization were also included; 
  3. The internal audit checklist has been amended with the addition of a supplementary item, requiring the internal auditor to carry out a risk assessment on safe working practices after observing cargo operations in real time; 
  4. Notice boards, indicating the proper practice for the closure of the ventilation flaps, have been placed at both gangway entrances of container vessels in the fleet; 
  5. High caution areas have been marked, as symbolic barrier systems, at the edges of the hatch covers of the entire container fleet, eliminating the risk for the personnel to fall overboard; 
  6. The deck and operation manual for container vessels has been amended with particular reference to the control of hatch covers access. It is now being required that access is only granted following specific instructions and with adequate supervision during cargo operations.



  1. The crew member sustained fatal injuries after falling from the cargo hatch cover to the quay on the vessel’s starboard side while attempting to close a cargo hold’s ventilation louver board.
  2. The position adopted by the crew member to close the ventilation louver board was not appropriate.
  3. The MSIU was unable to exclude fatigue as a contributing factor to the fall of the crew member.
  4. The crew member was not wearing a fall restraint system.
  5. This initiative taken by the crew member to close the cargo hold’s ventilation louver board, allowed for a one-person error situation to develop.
  6. Once the support bracket had been freed, the weight of the louver board would have to be carried by the hinges and the crew member. This was considered to be a significant weight, taking also into consideration the less than optimal position of the crew member holding to the louver board from above.
  7. An uncalculated risk had been accepted by the crew member. The fact that the crew member was on his own, precipitated into a situation where the opportunity for the accompanying crew member to flag and limit the additional risk (through monitoring) had been frustrated.
  8. Symbolic barrier systems were not present on the cargo hatch cover.


Taking into consideration the safety actions already adopted and implemented by the Company, no recommendations have been issued.

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Source: Transport Malta


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