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SAFETY4SEA

Lessons learned: Improvised plans can produce bad consequences

by The Editorial Team
October 31, 2024
in Accidents
Lessons learned

Credit: Shutterstock

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The Nautical Institute draws lessons learned from an incident in which two deck crew were painting a stairway when one used an unapproved A-frame ladder, leading to a fall overboard after the vessel rolled. 

Two deck crew had been directed to paint the underside of the external stairway landings at bridge deck level. They were working from the boat deck and had been instructed to use a telescopic rod connected to a roller brush to reach the area to be painted several metres above. After starting the task, one of the crew decided to install a portable A-frame ladder (stepladder) to assist in the job.

Some time later, the vessel changed course and started rolling due to the change in angle across the swell when suddenly, the ladder tilted towards the sea. The crew member on the ladder grabbed the drainpipe under the stairway landing with one hand to keep his balance. At the next roll, the ladder tilted again and this time both the crew member and the ladder went overboard. 

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The remaining crew member ran to the port side and threw the nearest lifebuoy towards the victim in the water as the vessel continued to steam ahead. He then raised the alarm with the bridge team. 

Lessons learned:
  • Improvised plans can produce bad consequences. In this case the victim decided on a whim to use a step ladder, yet this tool required a permit to work (PTW) before use. The PTW, an administrative protection, would probably have ensured the proper installation of the ladder, thus saving his life.
  • This company had a very innovative system to help crew initiate a ‘stop work’ effort; a whistle and STOP sign on a lanyard for each crew member. Yet, in this case it was not used. To facilitate a stop work initiative, not only must crew have the right tools, but they must be given proper training in their use and an environment of trust must be established.
Lessons learned: Improvised plans can produce bad consequencesLessons learned: Improvised plans can produce bad consequences
Lessons learned: Improvised plans can produce bad consequencesLessons learned: Improvised plans can produce bad consequences
Tags: lessons learnedThe Nautical Institute
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