RMI issued an investigation report on a bosun’s fatal fall overboard from the general cargo ship DELICATA, off Uruguay, in March 2020. The investigation identified poor compliance with the company’s SMS and safe working practices, as the crew member was not wearing a lifejacket or a safety harness when he descended to untie a pilot ladder.
The incident
On 17 March 2020, the RMI-registered general cargo ship DELICATA was outbound from Punta Pereira, Oriental Republic of Uruguay on the Rio de La Plata.
On the morning of 17 March 2020, in preparation for disembarking the Pilot, the Chief Officer (C/O) tasked the Bosun with adjusting the height of the pilot ladder.
Due to DELICATA‘s freeboard at the time, a combination arrangement of the accommodation and pilot ladders had already been prepared.
The Bosun assigned an Ordinary Seafarer (OS) to assist him with this task.
The two crewmembers attempted to pull up the pilot ladder but were unable to do so as it was tied to an attachment point on the ship’s hull.
The Bosun then descended the accommodation ladder, without wearing a lifejacket and safety harness, to untie the pilot ladder.
Shortly after, the OS heard the Bosun shout and looked over the side to see that he had fallen into the water.
The OS immediately notified the crew over VHF radio and then went aft to the Accommodation to call the Bridge.
DELICATA and other nearby ships conducted a search for the Bosun. He was spotted by another outbound ship and was recovered by the pilot boat. When recovered, it was determined that he was deceased.
Findings
Causal factors which contributed to the Bosun’s fall overboard and subsequent death:
- failure to wear a lifejacket, safety harness, and lifeline while working over the side as required by the Company’s SMS;
- failure to comply with the Company’s safe work practices by not issuing a Permit to Work Over the Side, not conducting a Toolbox Talk, not assigning an adequate number of crewmembers, and failing to make ready emergency equipment prior to working over the side while adjusting the pilot ladder;
- inadequate supervision of the assigned task; and
- inadequate onboard implementation of the Stop the Job authority.
Additional factors identified during the Administrator’s marine safety investigation include:
- the inappropriate initial response to the Bosun falling overboard by failing to immediately deploy a lifebuoy and failing to maintain sight of the Bosun;
- the personal protective equipment (PPE) matrix in the Company’s SMS did not indicate that a lifejacket was required while working over the side, contrary to the Company’s Permit to Work Over the Side; and
- inadequate communication between the Bridge and crewmembers working on deck.
Actions taken
In response to this very serious marine casualty, the Company has taken the following Preventive Actions:
- The crew of DELICATA was provided additional training on the Company’s safe work practices and the proper use of PPE.
- The requirement to wear lifejackets for certain tasks have been added to the Company’s PPE matrix so that it aligns with the safe work practices.
- The lessons learned from this incident have been shared with all ships in the Company’s managed fleet.
Recommendations
Following the above conclusions, RMI recommended that the Company review and update, as necessary, the training procedures relating to the actions to take in the event of a person falling overboard.
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