Crew practices should match procedures

Lethal fall from height inside a hold: Mars 202212

As edited from the Republic of the Marshall Islands Maritime Administrator report of 22 April 2021

A bulk carrier in ballast was en route to the next loading port and deck crew were cleaning the cargo hold. The weather conditions made it necessary to keep the hatches closed while cleaning was taking place, meaning that fall arresters could not be rigged. Hence, only the lower portions of the holds were to be cleaned. A work permit had been issued, but it made no mention of working aloft.

The company’s generic risk assessment for cargo hold cleaning was apparently reviewed prior to the work, but it did not identify falls from height as a potential hazard either when entering or exiting a hold or while performing the task.

Cleaning progressed all morning and after lunch the work was resumed. Sometime after 14:00, it was noticed that a portion of the forward bulkhead about 3.5 metres above the tank top had not yet been cleaned. Since the crew were unable to clean this area from the tank top, the deckhand decided to use a portable ladder that had been left in the hold from the previous day to reach the area. The deckhand climbed the ladder, which was held steady by another crew member, and started cleaning, using both hands on the pressure washer wand.

Once the deckhand finished washing, he started to descend the ladder, with one hand on the washer wand and the other on the ladder. As he was descending, he slipped and fell to the tank top, 3.5 metres below. Although unconscious, the victim was breathing and had a pulse. The alarm was raised and within minutes first aid was being administered.

Among other injuries, the victim had a massive hematoma on the upper left side of his head and was bleeding from his left ear. About ninety minutes after the accident, the victim’s pupils stopped reacting to light. Meanwhile, the vessel had increased speed and diverted to a port for medical aid, but this was many hours away. A request for an immediate evacuation of the victim by helicopter was sent to the local Coast Guard. Some seven hours after the accident, the victim had no vital signs and was deemed deceased.

Investigation findings

The official report found, among other things, that a Working Aloft Permit is required by the company’s SMS (safety management system) when work is planned more than two metres above a base level. Procedures require the use of a safety harness with a lifeline secured above the work position. The SMS also requires someone to hold the ladder base and that the top be secured when possible (if this is not possible, the bottom must be secured). Additionally, the SMS states that both hands must be on the ladder rungs, and tools should never be carried when climbing portable ladders. None of these requirements were met prior to the accident.

Lessons learned

- In theory, SMS procedures are there to protect crew from known hazards. But this protection can only be useful if the actual practices employed by crew are in line with the procedures.

- Issuing work permits is a fruitless paper exercise if the requirements set out in the permit do not reflect the practices of the crew.Fatal fall into a hold: Mars 202213

As edited from the Liberia Maritime Authority report of 30 September 2021

A bulk carrier in ballast was underway. The deck crew were washing the cargo holds, as clean holds were necessary for the planned arrival for loading in two days. Two teams were working at different locations. The hatch covers of holds 1 and 2 were partially opened in order to remove the remaining corn cargo lying at the cross joint channels of the hatch covers. This resulted in a large gap at the middle cross joint. A crew member started washing the top of hatch cover panels No. 2-1 and 2-2, standing on top of the hatch covers to do so, while another crew member controlled the length of the hose used by the washing crew member.


After cleaning the forward panels, the washing crew member came down on to the hatch coaming to hose down the water to the middle cross joint area of the hatch cover. Then he went up again, this time to the aft panel No. 2-3 (indicated by an arrow)in the photograph), and started cleaning at the starboard side of panel No. 2-3. While moving toward the port side, out of sight of the crew member tending the hose, he slid down the incline, through the gap in the hatches, and fell at least 17 metres to the hold tank top. A cry was heard and the crew member tending the hose began searching, only to see his colleague lying on the tank top of the hold in the middle of the hatch area.

The alarm was raised and the victim was quickly attended to, but he had no vital signs. First aid was nonetheless administered including CPR, but without success.

Investigation findings

The official investigation found, among other things, that there was no responsible officer supervising or assessing the safety of the work. The bosun was supposed to supervise both teams of two crew, who were working at different places. Instead, the bosun went down to hold 1 with one of the teams. The chief officer was busy in the deck office preparing the loading plan for the next port, so there was no effective supervision of the team washing the hatch covers.

Additionally, crew did not use fall arrest equipment while working and climbing on top of the partially opened hatch covers.


Lessons learned

In an environment dominated by a weak safety culture, even such a dangerous situation as standing at the top of an open inclined hatch without fall protection does not dissuade people from “getting the job done”.





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