Poor Risk Assessment Led Deadly Fall

Credit: Vessel Crew via MCIB report

Transport Malta’s Marine Safety Investigation Unit issued an investigation report on the fatal fall of a crew onboard the bulk carrier. The investigation found that the crew member lost his footing and grip whilst carrying out repairs on the ladder.

The Incident

While carrying out repairs in cargo hold no. 3, the third engineer fell approximately six meters from the cargo hold’s ladder, just under the cargo hold’s access ladder lower platform, to the tank top. One of the crew members who were in the cargo hold raised the alarm. 

The injured crew member was attended by the chief and fourth engineers, who were on the main deck near cargo hold no. 3. Paramedics boarded the vessel sometime later, but the injured crew member was pronounced dead.

It was established that the third engineer had fallen off from the sloping section of the forward cargo hold access ladder, just below the lowest platform to the cargo hold tank top.


  • Although the ladder was in a good condition, it was not excluded that the third engineer lost his footing as he negotiated the different angles of the ladder on his way down to the tank top;
  • The plastic band was rigid and not elastic, and considering that the safety helmet fell off, it has been concluded that the safety helmet had not been secured to the chin;
  • Rather than an appropriate fall arrestor, the third engineer was wearing a safety belt;
  • A five-point fall arrestor was available on board but not used during the repair works inside the cargo hold;
  • The type of fall preventer used by the third engineer was not of the best design for vertical movements;
  • The safety investigation did not have evidence of toolbox meetings being carried out prior to the repair works being initiated in the cargo hold no. 3;
  • The officer responsible for the overseeing of the tasks was engaged in the engine-room workshop, cutting the material to size, in preparation for the welding process;
  • No other officer had been appointed to oversee the work inside the cargo hold and flag out any actions or inactions which could have become potentially dangerous;
  • The crew members’ perception was that the risks involved were well under control and which did not require extraordinary efforts to mitigate;
  • A perceived ‘safe’ task could have led to the acceptance of higher risks;

Actions taken

During the course of the safety investigation, the company:

  • Conducted a fleet-wide review of safety harnesses, with either upgrading or replacements carried out where necessary;
  • Distributed a fleet safety circular, highlighting the issues of risk/hazard assessment, rigour to work permit systems and appropriateness/condition of PPE;
  • Painted the top of the lower stool yellow to highlight the change in the ladder’s inclination and distinguish it from the cargo hold tank top;
  • Reviewed its ISM internal audit and marine inspections’ scope and process in terms of rigour, objectivity and frequency;
  • Amended the SMS in order to further formalize the work inside cargo holds (in terms of height and hot work). Working procedures have been added, including provisions for risk assessments, work permits and general HSE considerations. Visual aids have been included;
  • Reviewed and updated the risk assessment template;
  • Briefed all crew members on this accident;
  • Reviewed its senior officers’ familiarization process, to include topics on risk assessments and safety culture in general;
  • Issued safety bulletins on this accident.


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Source: MCIB


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