The Incident

After shore leave at night, some crew of a Hong Kong registered bulk carrier went back onboard. The two crew on security watch at the shipboard access point on main deck assisted those crew in need in boarding the vessel and returning to their cabins. The access point was therefore left unattended.

The electrical engineer tried to board the vessel by taking a shortcut in an attempt to climb to the upper platform of the accommodation ladder at main deck level from the quayside. However, he failed to land on the upper platform and fell into the sea unnoticed. His body was found at sea two days later.

According to the investigation, the main factor that contributed to the fatality was that the electrical engineer, perhaps under the influence of alcohol, took an improper route to board the vessel by climbing directly from the quayside to the accommodation ladder upper platform.

The investigation also resulted to the following safety issues regarding the implementation of the shipboard Safety Management System and the Ship Security Plan:


  1. the safety net was not rigged to cover the entire length of the accommodation ladder;
  2. the accommodation ladder had not been manned at all times in accordance with the Ship Security Plan. As a result, the attempted climb and the fall of the electrical engineer were unnoticed.

Lessons Learned 

The note highlights that

It is important that all crew members should strictly follow the requirements and procedures of the Safety Management System and the Ship Security Plan.

Accordingly, it is avised that:

  1. the safety net should always be rigged properly to cover the entire length of the accommodation ladder between the ship and the quay to minimize the risk of injury from falling;
  2. the consequences of alcohol consumption during shore leave as stated in the policy/guidelines of the Safety Management System should be reiterated;
  3. the manning of access control points during port stay period must be maintained at all times.