RMI investigation: Fatal fall from ladder attributed to SMS non-compliance

The incident

On 10 June 2020, the RMI-registered bulk carrier SFERA was underway in the Philippine Sea on a ballast voyage to Newcastle, Commonwealth of Australia. Planned work for the day included cleaning the lower portions of the cargo holds under closed hatches.

During the afternoon, the Able Seafarer Deck (ASD) 1 fell approximately 3-3.5 meters while climbing down a portable ladder after cleaning a portion of the forward bulkhead in Cargo Hold No. 2 that had not been cleaned the previous day. At the time, he was working with the Bosun.  The ASD1 suffered serious head injuries and died later that day.

 

Probable causes

The marine safety investigation conducted by the RMI identified the following causal factors that contributed to this very serious marine casualty:

(a) the ASD1 slipped and fell approximately 3-3.5 m while climbing down a portable ladder without maintaining three points of contact;

(b) non-compliance with the procedures in the company’s SMS for:

1. safe use of portable ladders; and
2. use of required personal protective equipment (PPE) while climbing and working from a portable ladder;

(c) ineffective supervision of the ASD1.

Additional causal factors that may have contributed to this very serious marine casualty include:

1. an apparent acceptance of the risk associated with working from height while not wearing the required PPE; and
2. the decision to work from height without first obtaining a Working Aloft Permit, securing the ladder, and rigging a fall arrester before cleaning a dirty section on the forward bulkhead.

 

Actions taken

In response to this very serious marine casualty, the company has taken the following preventive actions:

1. Established a requirement for ships’ Masters and Chief Engineers to conduct daily, random inspections to ensure required PPE is being used.
2. The frequency of training regarding safe work practices and use of PPE on the Company’s ships was increased to once a week.
3. Established a requirement that records of Toolbox Talks and work permits be signed by all involved crewmembers.
4. Work must be stopped immediately if required PPE is not used.

 

Recommendations

Following the investigation, RMI recommended the company to:

1. ensure that shipboard requirements are consistent with Company procedures;
2. revise its procedures for pre-task risk assessments to ensure that potential hazards for the conditions that exist at the time that the task is going to be performed are identified and addressed when planning the work;
3. revise its generic risk assessment for hold cleaning to include all reasonably foreseeable hazards commonly associated with this task, including falls from height;
4. revise its procedures for issuing work permits to require that the actual scope of any planned work is described; and
5. revise its requirements for cargo operations to include guidance to check the relevant IMSBC Code cargo schedule and MSDS to determine cargo-specific PPE requirements.

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