Lessons learned: Always conduct risk assessment when using rope ladders

The incident

Bunkering operations were in progress between a bulk carrier and a bunker vessel. The Injured was climbing up a rope ladder from the bunker vessel to board the bulk carrier when the Deceased descended the same ladder from the bulk carrier to board the bunker vessel at the same time. The rope ladder broke and caused both men to fall.

The Deceased landed on the forecastle deck of the bunker vessel, while the Injured struck against the same deck before falling into the sea. Both men were rescued by a passenger craft in the vicinity and sent to the hospital, where the Deceased passed away.

Probable cause

• Both men did not notice each other when using the rope ladder at the same time. Both were also not wearing life jackets at the time of the accident.
• There were no means of control and communication when using the rope ladder. According to the International Convention for the Safety of Life at Sea, an accommodation ladder shall be used in conjunction with a pilot ladder whenever the freeboard is more than nine metres (the freeboard between the two vessels was more than 12 metres).
• The rope ladder had degraded due to wear and tear.

Lessons learned

• Conduct a risk assessment (RA) to mitigate all risks associated with the usage of rope ladders on board vessels. Recommended risk control measures should include providing safe access on the vessels and the donning of personnel flotation devices.
• Establish a safe work procedure (SWP) for using the rope ladder and communicate the SWP to all levels. The climb up a rope ladder should not exceed nine metres. An accommodation ladder should be used in conjunction with a pilot ladder whenever the freeboard is more than nine metres.
• Ensure that only one person is using the rope ladder at any one time. Work should be planned to minimise the need to travel between vessels.
• Check rope ladders on board vessels on a regular basis to ensure that it is in good condition. Inspection of equipment should include, but not be limited to, wear and tear of side ropes, missing wedges and damages on the steps.
• Establish proper work coordination and communication prior to and during work execution.
• Provide adequate safety and health trainings, including in-house trainings, to generate awareness of the hazards associated with the work activity and specific work environment.