Man Overboard While Rigging a Combination Pilot Ladder in Position

Summary

On the morning of 16 March 2015, an able seaman (AB) on board the Maltese registered bulk carrier CY Thunder fell into the sea while rigging a combination pilot ladder. It was dark and the vessel was underway to embark a harbour pilot for Port Sudan.

Post-accident inspection indicated that the gangway’s platform was unrestrained and swinging with the motion of the vessel. At the time of the accident, the AB was alone and none of the crew members witnessed the events.

It is likely that the AB lost his balance, fell into the water because he was not wearing a fall preventer device, and drowned because he had no lifejacket on.

As a result of the safety investigation, the MSIU has made three recommendations to the ship managers, to develop procedures and supervise the rigging / un-rigging of the combination pilot ladder, to conduct risk assessments, and improve on man overboard drills.

Immediate cause of the fall overboard

Although none of the crew members witnessed the actual fall of the crew member from the gangway into the water, it was not excluded that the AB lost his balance while rigging the gangway, and consequently fell into the sea. It was confirmed, however, that he was not using a fall prevention device and he may have possibly drowned because he was not wearing a lifejacket.

The crew members’ report of a sighted light signal believed to be coming from the AB, was very likely to have been the flickering light of the lifebuoy under the action of the sea waves. The MSIU could not identify the source of the whistling sound that the bosun had reportedly heard and which had attracted his attention.

Conclusions

1. In all probability, the AB lost his balance while rigging the gangway and fell into the sea.
2. The AB was not using a fall prevention device and he may have possibly drowned because he was not wearing a lifejacket.
3. The safety investigation was unable to confirm whether or not fatigue was a contributing factor to the accident. However, the evidence did not indicate that the behaviour manifested by the crew member was suggestive of fatigue issues.
4. The AB may have overestimated the extent to which he could control the risky situation.
5. The safety management system had no safe working procedures to mitigate the hazards that were inherent in the rigging of the combination pilot ladder over the ship’s side.
6. No risk assessment or toolbox meeting had been conducted before the task was initiated.
7. There was no teamwork dynamics manifested between the team members – to the extent that the combination pilot ladder was being rigged without having the necessary safety barrier systems first installed.
8. By the time the lifebuoy was released by the master and the reciprocal course completed, significant distance had been covered and time had elapsed, presenting an enormous task for the crew members to locate the missing AB.
9. The crew’s actions suggested that there was a lack of exposure to realistic man overboard drills.
10. A Williamson turn would have been more appropriate than the Anderson turn manoeuvre that was initiated and completed.

Recommendations

• establish procedures and checklists for risk assessment related to rigging and unrigging of combination pilot ladders.
• ensure that a responsible officer always supervises the rigging and unrigging, and that the relevant PPE is used.
• ensure that crew members are thoroughly familiar with man overboard drills and with the procedures to save VDR data.

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Source: MTI

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