Lessons learned: Establish proper safe work procedures

The incident

The Deceased and a co-worker, who worked for a river cruise company, reported for their night shift duty to berth and charge the electric boats at the jetty. While the co-worker was doing his rounds, he saw the Deceased resting onboard a boat. About two hours later, the co-worker could not locate the Deceased. The police were notified after failed attempts to locate the Deceased.

The Deceased’s body was found about 16 hours later, floating near the location of the boat where he was last seen.

The Deceased could have slipped and fell into the water when he was making his way from the boat back to land. He could either be climbing from the boat to the pathway or climbing from one boat to another to access the landing point located near the ticketing booth.

Probable cause

• Failed to ensure that employees don life jackets when working near water, no RA was conducted for the activities of berthing and charging of boats, no proper means of access or egress between boat and land, no measures to prevent employees from falling off the edge of the pathway into the water or onto the deck of boats.
• The Deceased did not know how to swim, was not wearing a life jacket, and fell into water.
• The Deceased likely exited the work area through an unsafe path that exposed him to risks.

Lessons learned

• Conduct a proper RA before any work commences, in particular for all activities on a boat or near a body of water to control any foreseeable risk that may arise during work. The RA should include slip, trip and fall hazards along access routes, falling hazards while getting on or off a boat, rescue plan in the event of emergencies, health condition of workers and assessment of workers’ ability to swim.
• Establish proper safe work procedures for works near bodies of water.
• Brief workers on the risk of working near bodies of water. Topics should include visibility while at work and the use of proper PPE such as anti-slip safety shoes.
• Ensure that there are safe means of access to and egress from shore-to-boat or boat-to-shore, and when moving between boats. This can be achieved, for example, through the provision of a jetty and gangway.
• Check access routes regularly to confirm that the walk path and the steps on the vertical ladder are in good condition and safe for use. Remove any visible contaminations (e.g. oil, mud) as soon as possible as these can lead to slip and fall incidents.
• Provide adequate general and task lighting at specific work areas (e.g. the battery charging area in this case) on the boat and on shore. This is especially important for works carried out during hours of darkness and at times of reduced visibility. Use portable lamps or light-mounted headgear for task lighting at an outdoor location.
• Ensure workers undergo adequate safety and health training in relation to their specific roles and responsibilities and that they are aware of the hazards associated with the work activity and work environment.
• Deploy workers who can swim for work on boats or near a body of water.
• Conduct daily toolbox meetings prior to work commencement and shift-handover to communicate all relevant information and instructions concerning safety and health.
• Closely supervise all workers who are new to the work activity or work environment until they are fully aware of the site-specific risks and are competent for the assigned task.
• Equip each boat with life-saving equipment (e.g. life buoy with rope) for use in the event of an emergency. Mount life-saving equipment at easily accessible locations along the shore where the boats are berthed.