UK Maib report on shipboard fatality
The UK Marine Accident Investigation Branch (MAIB) issued the report of its investigation of the uncontrolled descent of an accommodation ladder from a container ship in San Francisco Bay on 10 September 2009 resulting in one fatality. The accommodation ladder fell because the gearbox of the hoist winch failed. The gearbox had recently undergone routine maintenance and had been incorrectly reassembled. The hoist winch was not considered to be lifting gear under national regulation; thus minimal standards were utilized in its maintenance and inspection. New international standards recently have come into force that improve those standards, but gaps still exist. Recommendations have been made for further improvement. Report 8/2010
Source:MAIB