Mars Reports 2013
The Nautical Institute has issued Mars Report No 43 as follows (official report edited from BDU 415/10) :
During operations, an O/S climbed onto the 2.2 metre hatch coaming and used the guard rail for foot support. Presumably, as there were no direct witnesses, he lost his footing and/or handhold, fell backward onto the deck and struck the guard rail with his head causing fatal injuries. He was wearing size 10 mixed fabric (cotton/rubber) gloves and a protective helmet. An examination of the work rest schedule of the victim did not reveal fatigue as a factor.
No ladder was located in the immediate vicinity of the accident; there were only three permanently installed ladders along the whole of the hatch coaming. It would have been possible to safely stand on the hatch coaming with such a ladder as an additional handhold and backfall preventer is offered by the rail above each ladder.
The official BSU report found that the accident was the result of structural defects and inappropriate protective equipment, amongst others. Had more ladders been installed on the hatch coaming then it is very likely that the accident would not have happened because controlled operation with additional protection (in this case, a backrest on the coaming) would then have been possible.
For more information, please read Mars Report No43 by The Nautical Institute