RMI Investigation: Fatal fall of bosun from scaffolding

The Republic of the Marshall Islands (RMI) Maritime Administrator has issued an investigation report regarding an incident where the bosun on board the bulk carrier PRISMA fell from scaffolding while painting a cargo hold, losing his life. 

The incident

On 29 January 2025, the Republic of the Marshall Islands-registered PRISMA, a geared five-hatch bulk carrier, managed by Maru LLC, was loitering in the Baltic Sea approximately 40–45 NM north of the Republic of Poland coast. Work being done on board included painting the cargo holds in preparation for loading cargo at the ship’s next load port. A few minutes before 2200, the Bosun, who was standing on scaffolding approximately 9.5 m above the tank top to paint the upper portions of frames located inside of CH No. 3, directed the ASD1 and ASD2 to move the scaffolding by 3 m.

The Bosun remained on the scaffolding when it was moved. The scaffolding, along with the Bosun, fell as the two ASDs were putting the stabilizer arms in place. The OS2, who was on deck, heard a loud noise from CH No. 3 and looked down into the cargo hold. He saw that the scaffolding had fallen and immediately reported by radio that the scaffolding being used in CH No. 3 had collapsed.

The ship’s C/O, who had just gone out on deck, heard the radio call from the OS2 and immediately entered the cargo hold. While climbing down the Australia ladder, he observed that the scaffolding had fallen and that ASD1 and ASD2 were assisting the Bosun, who was lying on the tank top. The Bosun was wearing a safety harness with a lifeline.

The clip on the lifeline was connected to the scaffolding. The C/O examined the Bosun and determined that he was unconscious, had labored breathing and a weak pulse, and that his eyes did not respond to light. The C/O informed the Master of the Bosun’s condition and requested medical equipment be brought to CH No. 3.

The C/O, with assistance from the 2/O and other crewmembers, began administering first aid to the Bosun. The Master informed the Company and requested medical advice from C.I.R.M. Rome. Based on advice from C.I.R.M. Rome, the Master directed the ship to proceed at full speed to the nearest port.

The Master also made a PAN-PAN broadcast on VHF Channel 16 requesting a MEDEVAC for the Bosun. MRCC Gdynia responded to the PAN-PAN broadcast and provided instructions for rendezvousing with a rescue helicopter and boat for MEDEVAC of the Bosun. At 2259, the C/O informed the Master that the Bosun was deceased.

The Master informed MRCC Gdynia, who then canceled the MEDEVAC. The marine safety investigation conducted by the Republic of the Marshall Islands Maritime Administrator ruled out either a material or structural failure of the scaffolding but was otherwise not able to determine why the scaffolding fell.

Conclusions

Causal factors that contributed to this very serious marine casualty included:

(a) that the Bosun remained on the scaffolding when it was moved;

(b) that the lifeline on the Bosun’s safety harness was connected to the scaffolding and not to the ship or to a fall arrestor;

(c) ineffective onboard implementation of stop-work authority; and

(d) ineffective oversight by the C/O of work being conducted in the cargo holds on 29 January 2025.

Additional causal factors that may have contributed to this very serious marine casualty included:

(a) ineffective onboard implementation of the Company’s permit to work procedures;

(b) that the Company’s procedures for working aloft did not address the safe use of scaffolding or other equipment, such as portable ladders, staging, bosun’s chairs, etc.;

(c) that the Company’s risk assessment for working aloft using a bosun’s chair, staging, or scaffolding did not identify equipment failures to include mechanical or structural defects of scaffolding, portable ladders, staging, bosun’s chair, etc.; and

(d) the removal of two of the scaffold’s four stabilizer arms before it was used in CH No. 3 on 29 January 2025.

Additional issues that were identified but did not contribute to this very serious marine casualty included:

(a) improper onboard implementation of the work and rest hour requirements in the STCW Code and MLC, 2006 in that

• the Master’s, C/O’s, and other crewmembers’ work and rest hour records for 29–30 January 2025 indicated they were resting and not that they were actively engaged in providing assistance to the Bosun after the scaffolding fell; and
• the C/O’s and other crewmembers’ hours of rest were divided into more than two periods while the ship’s cargo holds were being prepared for loading between 26–29 January 2025; and

(b) a dedicated Lookout was likely not on duty during hours of darkness or when the existing conditions might not have been appropriate for the OOW to serve as PRISMA’s only Lookout while the ship was loitering off the coast of Poland between 26–29 January 2025.

Lessons learned:

• Safe-work procedures are administrative controls that must be implemented consistently by all crewmembers to be an effective means of reducing exposure to hazards.
• Scaffolding, bosun’s chairs, staging, portable ladders, etc. must be set-up and used in accordance with the manufacturer’s instructions.
• Lifelines connected to a safety harness must be secured to a strong point on the ship or a fall arrester connected to the ship and not scaffolding, staging, portable ladders, etc. to provide protection from falls.
• The use of stop-work authority can prevent marine casualties. For stop-work authority to be effective, crewmembers must not only be aware that they have this authority, but they must also have confidence that the authority is nonnegotiable and can be exercised without fear of repercussion. Crewmembers must also be as familiar with how to issue and respond to a stop-work action or instruction as they are with their other shipboard duties.
• Work plans must prioritize watchstanding requirements (e.g., maintaining a proper lookout) and the rest-hour requirements in the STCW Code and MLC, 2006 over the course of the completion of routine ship-board tasks, such as preparing cargo holds for loading.
• source : safety4sea