Summary

On 17 March 2018, the master of the bulk carrier Sage Amazon experienced a cardiac event while standing on an access ladder of No. 3 cargo hold. He fell from the ladder onto the main deck, receiving serious head injuries. At the time, the vessel was anchored 3 nautical miles off Port-Daniel–Gascons, Quebec. Medical aid, including CPR, was provided on the vessel, but was unsuccessful in reviving the master. He was later evacuated to the hospital in Chandler, Quebec, where a death certificate was issued. 

 

The incident

The Sage Amazon was anchored approximately 3 nautical miles off Port-Daniel–Gascons, Quebec.

At 0730 on 17 March, the master and chief officer proceeded on the main deck to cargo hold No. 3 to verify the status of the work being carried out in the hold.

To look into the hold, they climbed up the access ladders located on the forward coaming. The master used the starboard ladder, and the chief officer used the port ladder. Both climbed as far as the second rung from the top of the ladder, a height of 1.5 m, from which they could look over the coaming and down into the hold.

At 0735, a muffled sound was heard and the master was seen lying unconscious on the main deck.

The back of the master's head was resting on the save-all, and his hard hat was lying on the main deck beside him.

The chief officer immediately called for help using his portable radio.

The crew mustered at the accident site at 0740 and established that the master's condition warranted performing first aid. The chief engineer and the chief officer immediately began CPR.

At 0848, the MRSC Quebec contacted the fire department in Chandler, Quebec, which is listed as a local marine rescue unit, to transport an AED to the Sage Amazon using its rigid-hull inflatable boat (RHIB).

However, the fire department's RHIB had been out of service for almost 9 months. At 0923, the fire department located and initiated the deployment of an RHIB owned by a private citizen.

At 1118, two search-and-rescue (SAR) technicians were lowered down to the vessel. At 1120, the physician providing remote medical counselling recommended stopping CPR, based on the lack of response to CPR and the absence of any vital signs, and pronounced the master dead.

 

Probable causes

  • The master experienced an acute myocardial infarction while standing on an access ladder for the No. 3 cargo hold and fell onto the main deck, receiving serious head injuries. First aid initially focused on his head injuries.
  • When the possibility of a cardiac event was raised, with no automated external defibrillator (AED) onboard the vessel, it was not possible to confirm the master's cardiac condition.
  • Various search-and-rescue resources were dispatched, but it took approximately 3 hours for first responders to reach the vessel, at which point it was too late for medical assistance.

The master was pronounced dead about 4 hours after the cardiac event and subsequent fall.

 

Conclusions

  • If medical practitioners do not have access to full medical information and records, fitness for duty may not be assessed accurately, increasing the risk of seafarers endangering themselves, the vessel, the crew, and the environment in a medical emergency.
  • If crew do not have access to medical equipment such as an AED, that could assist in a medical emergency such as a cardiac event, there is a risk that shipboard personnel will not receive adequate medical treatment.
  • The medical certification process for fitness for duty does not allow the examining medical practitioner to access or to request the seafarer's personal medical records, which are normally maintained by the seafarer's personal health care provider(s).
  • Although the Chandler Fire Department was identified as a local marine rescue unit by the Canadian Coast Guard Maritime Rescue Sub-Centre, the Maritime Rescue Sub-Centre was unaware that the department's rigid hull inflatable boat had been out of service for approximately 9 months when it tasked the department during the occurrence.

An AED was eventually transported to the vessel and used, but, because more than 3 hours had elapsed since the master's fall, it was no longer of use.

 

Actions taken

Following the occurrence, the Republic of Liberia, the flag state for the Sage Amazon, conducted an investigation into this marine casualty incident and recorded the incident in its internal files for future reference and analysis.

Because the Republic of Liberia determined that the master's death was due to natural causes, a formal report of investigation was not produced under the IMO's Casualty Investigation Code.

 

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