Transport Malta Investigation: Fatal overboard fall of a crew member

Transport Malta has published an investigation report regarding an incident that took place on 26 September 2022, when the master of VS Salome had just signed off and was disembarking the vessel while at anchor, on to a service boat, using the port side pilot ladder.

The incident

He was carrying a backpack under his inflatable lifejacket. As he was descending the pilot ladder, he lost balance from the first step onto the next step and fell into the water. The life jacket inflated, but it took the vessel’s crew and the service boat about 15 minutes to recover him. Despite attempts to revive him, the master died of cardiorespiratory arrest associated with cold water immersion. Taking into consideration the safety actions taken by the
Company, no recommendations have been made. Recommendations were made to the service boat owners, addressing the maintenance of FFA, and the recovery of persons falling overboard.

The vessel

VS Salome was a Maltese-registered oil and chemical tanker of 5,039 GT. It was built in Türkiye in 2007, at the Adik Anadolou Shipyard in Tuzla. The vessel’s registered owners were Valloeby Salome Ltd., and since August 2022, it was managed by Hellespont Shipmanagement GmbH & Co. KG, based in Hamburg. Bureau Veritas (BV) acted as the classification society, while American Bureau of Shipping (ABS) acted as the recognised organisation, in terms of the International Safety Management (ISM) Code, for the vessel. The vessel had an overall length of 120.98 m, a breadth of 17.20 m, and a summer displacement of 7,915 tonnes, corresponding to a summer draft of 6.86 m. Propulsive power was provided by a MAK medium speed direct drive internal combustion diesel
engine, producing 3,840 kW at 600 rpm. This drove a single, controllable pitch propeller, enabling the vessel to reach a service speed of 14.0 knots.

Manning

The Minimum Safe Manning Certificate of VS Salome stipulated a crew of 13 persons. At the time of the occurrence, there were 18 persons on board; 15 crew members, the outgoing master, and two Indian technicians. The crew members were Filipino nationals and the working language on board was English.
The master The disembarking master was a 55-year-old Filipino national, holder of a valid STCW II/2 certificate of competence. He had started his seafaring career in 1990 and became a master in 2008. He had been working on small and medium sized oil and chemical tankers. The master had completed
a contract of almost eight months on board, having joined the vessel on 04 February 2022.

The master was certified as being medically fit and a medium built person with a height of 153 cm and a weight of 63 kg. At the time of the accident, he was wearing warm clothing and old working leather gloves, laced sports shoes, and an inflatable life jacket, which had a buoyancy of 150 N.

Analysis 

Aim

The purpose of a marine safety investigation is to determine the circumstances and safety factors of the accident as a basis for making recommendations, and to prevent further marine casualties or incidents from occurring in the future.

Cooperation

During this safety investigation, the MSIU received all the necessary assistance and cooperation from the UK’s Marine Accident Investigation Branch.

Cause of the accident

The loss of the master’s left shoe suggested that while descending the pilot ladder, his left foot did not make full contact with the depth
of the second ladder rung, possibly triggering the loss of balance. It also appeared that when he was descending on to the second rung, he lost his shoe and
balance when he was in the process of transferring his weight from the right leg on to the left leg.

The loss of balance was more than likely to have been caused by the heavy backpack that weighed just over 10 kg. This would have exacerbated his situation to recover his balance. Moreover, it also explained the eyewitness’ accounts that when the master let go of his right hand (that was holding on to the right stanchion), he pivoted to the left, and fell backwards.

The safety investigation also considered an alternative scenario where, while descending the ladder, the master may have inadvertently stepped on to the rubbing strake that had a round profile and protruded by about 8 cm from the hull. It was observed that although the pilot ladder steps rested firmly, the steps were held off the ship side because of the rubbing strakes, which may be also viewed as a trip hazard. However, a closer inspection of the pilot ladder led to the exclusion of this scenario. It appeared to be an unlikely one because the distance between the rubbing strake and the first rung was too narrow for the master to accidently insert his foot on the rubbing strake instead of the ladder rung. 

The crew members witnessing the accident recalled that it was the loss of the master’s left shoe which had led him becoming unbalanced and, unable to regain it back, he fell backwards.

Conclusions

1. The master lost his balance while descending and transferring his weight from the right leg on to the left leg. His left leg slipped on the second rung,
   lost his shoe and eventually his balance. The loss of balance was likely to have been exacerbated by the heavy backpack he was carrying.
2. The safety investigation determined and excluded the possibility that the accident had occurred due to either the condition of the ladder or that it had
   been incorrectly rigged.
3. The inflatable lifejacket would not have supported the master fully as the crotch strap had not been secured.
4. The heavy, wet backpack worn under the lifejacket would have exacerbating the flushing process.
5. The backpack also hindered the master’s recovery from the water.
6. Although the life jacket inflated as designed and that this was not contributory to the accident, the safety investigation determined that it had not
   been serviced since June 2016.

Safety actions taken during the course of the safety investigation 

During the safety investigation, the Company has taken the following safety actions:

• The pilot boarding position of the vessel has been reviewed and modified
• Company procedures for the use of pilot ladder by the crew and other visitors have been reviewed and amended to address:
  • PPE;
  • general clothing;
  • weather limits and parameters to conduct personal transfer at anchorage;
  • transferred luggage and backpacks; and
  • general responsibilities.
• A risk standardised template for a risk assessment has been developed and included in the Company’s risk assessment library for use by all ships
  prior to any personnel transfer;
• Information on the accident was distributed to all Company managed vessels as a Safety Bulletin