The Incident

On July 20, 2018 the vessel 'MATAR N' was on anchorage off Gunsan, South Korea, in the out of port limits anchorage, waiting orders for its next employment.

Three crewmembers, the Bosun, AB1 and OS1 were ordered to perform spot painting in the side hull. The AB1 was alone on the painting stage doing the actual work. The Bosun was supervising and the OS1 was in attendance and assisting the AB1 from the main deck above the painting stage.

Prior to the afternoon break, the Bosun informed the AB1 to stop painting and prepare himself for climbing up. Before climbing up, AB1 had to wait for the rigging of a rope ladder by OS1.

When the Bosun pulled up the paint bucket, saw AB1’s safety harness still secured-hooked to the safety line. The AB1 was resting on the painting stage waiting for the rigging of the rope ladder. While OS1 was rigging the ladder, heard AB1 shouting and when he looked over the ship’s starboard side, saw the AB1 into the sea.

After that, man-over-board procedure was immediately implemented. A Life-Ring with line was thrown towards the AB1. The Bosun jumped into the sea to rescue him. When he approached, saw him beneath the sea surface, sinking quickly. The General Alarm was sounded, and “Man-Over-Board” was announced through the public address system. A digital selective call distress alert on VHF Ch. 70 was sent and by voice broadcast urgency message on VHF Ch. 16 PAN PAN “Man-Over-Board” X 3 times. MOB flag was raised by the Deck Cadet.

The vessel’s starboard life-boat was launched. The life-boat picked-up only the Bosun. Search and rescue operation was conducted in cooperation with Korean Coast Guard. Search and rescue operation started on 20/07/2018 at 15:05 hours and ceased on 23/07/2018 at 05:45 hours. Results of the Search and rescue operation negative. The body of the missing AB1 was never found.

Probable Cause

According to MAIC:

  1. The Immediate Cause of the accident: The missing guard (life-line);
  2. The Root Cause of the accident: Safety (Risky) attitude of the victim has been the root cause of the accident;
  3. The Contributing Causes of the accident: 
  • Attention Failure: Distraction and inattention possibly caused by boredom have been a contributory factor to the accident.
  • Ability to swim, shock of falling into the sea and impact with water, weight of sodden overalls and ingestion of sea water, have been contributing factors in the loss of the seaman, after he fell into the sea from the painting stage.
  • Although a permit to work over the side had been issued, a basic precaution in using a Life-Jacket, was not in place and the safety harness with lifeline was not continuously worn during the work. Therefore, inadequate safety precautions were a contributory factor to the accident.
  • Inadequate assertiveness of the supervisor has been contributory factor to the accident.
  • Inadequate implementation of the Risk Assessment’s additional control measure requirement for a Tool-Box-Meeting to be held prior to work, may have been contributory factor to the accident.
  • Improper ascending /descending arrangement for overside work, was a contributory factor in the loss of the seaman, after he fell into the sea.


  1. Wearing a flotation aid significantly improves the chances of a person's survival and recovery, and its design should be appropriate for the work being undertaken. It is also essential to have effective man-over-board recovery measures in place, including properly trained crew and maintained equipment such as rescue boats.
  2. Safely working over the side of a ship relies on an effective Risk Assessment and Permit To-Work, that ensures suitable precautions are in place, including appropriate stages, stages lashing and rope ladder, the wearing of an appropriate flotation aid and a proper use of fall prevention equipment. Work over the side must be properly supervised to ensure all measures identified in the permit to work are followed.
  3. The Management Company by way of a circular or other means, to educate its crews, on Risk Assessment and Work Permit System, with particular emphasis on crew responsibility for carrying out the work and taking safety measures as described on the Work Permit.

Concluding, Cyprus MAIC highlights that after the accident the vessel had her name changed from 'MATAR N' to 'ALLEGRO N'.

For more information on the accident report, you may click on the PDF herebelow