Lessons Learned: Crew Suffer Fatal Injuries


  • The Bahamas Maritime Authority (BMA) has published a marine investigation report to draw lessons learned from two fatal injuries.
  • Recommendations: Conduct a full review of its onboard procedures with particular attention to casualty reporting, verifying that the vessel is prepared for sea, deck access and movement of personnel, task scheduling and communication.
  • Review of its risk assessments to ensure they align with work as done and reflect current guidance and industry best practice.

The Bahamas Maritime Authority (BMA) has published a marine investigation report to draw lessons learned from two fatal injuries that took place on the afternoon of 30 June 2023, aboard the vessel Beluga Reefer, reports Safety4sea.

What happened

On the afternoon of 30 June 2023, Beluga Reefer was on passage from Durban to Port Elizabeth, South Africa, and was making way during a period of adverse weather.

Four crew members were at the forward mooring station to secure mooring lines when the vessel was struck by a series of large waves, washing the four crew
members off their feet, and propelling them into the ship’s structure and deck machinery. Of the four crew members, two suffered fatal injuries, one sustained
minor injuries and the other required emergency medical assistance ashore.

Why it happened

On departure from Durban, the master requested that all deck machinery and lines be secured for sea due to adverse weather conditions being forecasted. Due to a lack of rest, the bosun reported the forecastle was secure but decided to leave the mooring lines with a plan to complete the task later that day.

Whilst the bosun and crew slept, conditions deteriorated but no measures were put in place to control access to the deck. When the bosun and crew returned to the deck, no-one was aware of their movements and they were found by chance by the chief officer who was on deck and exposed to the same risk whilst completing a routine task.


The purpose of the analysis is to determine the contributory causes and circumstances of the casualty as a basis for making recommendations to prevent similar casualties occurring in the future.

Due to initial misreporting, the BMA investigation team could not travel to the vessel to gather evidence and conduct interviews until several weeks after the casualty, impacting the quality of the information gathered for analysis.

Heavy weather preparations

Prior to departure the weather forecast showed a deep low pressure frontal weather system in the Indian Ocean approaching the coast of South Africa. Wind strength of force five to six, occasionally gale-force eight from the southeast, veering to southwest had been forecasted, with a swell height of three to four metres from the southwest. The planned passage was into the wind and swell.

Due to the forecast, the chief officer held a shipboard safety meeting with all crew present on the 29 June 2023. The wind direction, strength as well as predicted wave heights was shared along with an emphasis on crew duties during “bad weather.”

Despite the safety meeting and intervention from the master to reduce slamming, no action was taken to restrict access to the deck. The Company’s Heavy weather checklist (CL-12) identified the need to ensure access to the deck was avoided as well as ensuring all deck machinery was to be secured prior to sea, but the checklist was not used as there was no identified thresholds for what constituted heavy weather.

Human Factors

The bosun’s misreporting that the forward mooring station was secure for sea when departing Durban was a situational violation. This decision – to leave securing the forward mooring station until after their rest period – was informed by fatigue, onset by the change in working patterns as the vessel worked along the coast. Normally in between port calls the bosun and deck crew would have been operating a set eight-hour day work pattern, allowing for sufficient uninterrupted rest. Prior to the casualty, work and rest periods had been adjusted for eight consecutive days to accommodate port arrivals and departures and for cargo operations. This meant that the deck crew were operating staggered hours of work and rest which affected their sleeping patterns. At the time of departure – the bosun had been working since 20:00 the evening before and was scheduled to end his shift at 04:00 to commence with rest. The bosun’s normal rostered hours of work were between 08:00 and 18:00 with scheduled breaks in between allowing for lunch.


The bosun and an able-bodied seafarer were killed and a further two seafarers suffered injuries when they were washed clear from the forward mooring station when a series of large waves engulfed the forecastle. The deck team were on the forecastle to secure mooring lines and equipment which they had reported as
completed on sailing – they had left the work unfinished in order to take overdue rest. The vessel was experiencing slamming into the building sea and swell and steps had been taken to mitigate but at no point had the officer of the watch or master considered using the Company’s heavy weather checklist or restricting access to deck.

The chief officer missed an opportunity to discuss mitigating measures for the forecasted adverse conditions at a shipboard safety meeting the previous day.

Action taken and Recommendations

Acheon Akti Navigation Co. Ltd. (the Company) has:

Enforced a programme of change with regards to “Stop-The -Job” interventions and risk management.

Requested refresher training of the following Company procedures with all officers and ratings who could be involved in works on open decks:

  • Navigation under Various Conditions
  • Navigation in Ocean Waters
  • Navigation in Heavy Weather
  • DRA 1 Navigation in Heavy Weather
  • Instructed its fleet to affix warning signs at the exits of accommodation blocks that entry to the weather deck during adverse weather is prohibited.

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Source: Safety4sea


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