A seafarer fell down the Jacob’s ladder while trying to change a paint bucket which was on the bosun’s stage at the stern of a 100 m long vessel.

Narrative
A general cargo ship with a gross tonnage of 4000 t was waiting at anchor for the pilot to embark. In order to use the time effectively, paint works at the stern were in progress. Therefore, the chief mate did a risk assessment and issued a permit to work for working overboard. He ordered his crew to work in two-man teams – while one was working at the bosun’s stage, the other OS should secure the scene. The team was instructed to use a safety belt and always keep contact. Additionally, the deck crew was equipped with a hand held radio in order to communicate with the duty mate on the bridge, the chief mate and the bosun. The work passed uneventfully and in the afternoon, the bosun called for coffee break.
The break was not over yet when one OS who was assigned to the over board work, left the mess room to do some other job. His overboard work colleague went to the bosun’s stage on which he noticed an empty paint bucket and decided spontaneously to change it before the work continued. He climbed down the Jacob’s ladder to catch the paint bucket when he slipped and fell down into the water (strong river current). His workmate hurried to the scene having heard the screams of the OS in the water. The attempts to help him get out of the water remained without success and the body was never retrieved.

Findings
This very serious marine accident is a typical human factor occurrence and must have been the consequence of fundamental weakness in individual safety awareness. The seafarer ignored all safety instructions and failed to communicate with his colleagues. Although the company’s SMS has been implemented in a solid and professional way, a gap between the designed safety and the adherence to related orders and instructions in daily routine became obvious.

Recommendations
It is recommended that the company stabilizes its safety culture and security awareness through regular training on board and ashore.

Lesson to Learn
Special shipboard work projects have not only to be planned carefully but also to be monitored and supervised permanently.
An effective and permanent communication is essential.
It is necessary to concentrate on only one project.
Regular training and control are necessary for safety building and the development of the company’s safety culture.