The Nautical Institute has issued Mars Report regarding an accident in which the victim did not adhere to the practice of removing the outermost lashing only once the vessel was at berth.
The Incident
A container ship was underway under pilotage in a confined waterway en-route to a berth. Some crew were removing the lashing rods in preparation for discharge once berthed. One of the seamen removed the outermost long lashing rod (4.7m long) and was seen balancing with it upright in his hands. He was briefly in balance, but then both the lashing rod and the seaman went over the side.
A crewman who had witnessed the event quickly threw a lifebuoy with light into the water, then called the bridge to announce a man overboard (MOB). Shortly, more lifebuoys were thrown in the water and emergency MOB procedures initiated. Less than 20 minutes later the vessel had made a turn and was close to some of the buoys that were floating in the water, but the victim could not be seen. The rescue boat was launched and other small craft in the area also assisted in the search.
The crew member who fell overboard was never found and is presumed drowned.
Apparently, it was a regular practice on board, although not written down in procedures, to remove the interior lashings before berthing but not the outermost ones. It is unknown why the crew member did not adhere to this practice.
Lessons learned
- When working close to the side or at height, always wear a safety harness.
- If there is a risk of falling overboard, wear a lifejacket.
- Unwritten work practices should be formalised into written procedures and the relevant risk assessments carried out to ensure risks are as low as reasonably practicable (ALARP).
Comment by the Editor of the Mars Report
In this casualty the victim did not adhere to the practice of removing the outermost lashing only once the vessel was at berth. That practice, albeit unwritten, was a barrier (or defence) to reduce risk. Yet, even if he had adhered to this practice and all other factors remained the same, he would have fallen overboard nonetheless. The lashing, at more than 4m in length and quite ungainly and heavy, was situated in a dangerous position near the ship’s side. It may be worth considering whether this particular task should be done by two people instead of one.
Source: The Nautical Institute / Mars Report
