While lashing loaded containers on a vessel of 10 000 GT, a seaman fell down from the top of a container stack and was fatally injured.

Narrative
On a snowy winter day, a 140 m long container vessel, berthed in a Finnish port, commenced discharging operations. The temperature was about -7° C and the surface of the sea was covered with a 10-15 cm thick layer of broken pack ice. A short time later, loading commenced and the deck crew, under supervision of the bosun, secured the arriving containers. One AB was working with the bosun. The AB started the vertical lashing of containers in the 2nd tier on the aft part of hatch no.2 without wearing a safety belt. As the working area had not been cleared of snow and ice, the seaman slipped and fell overboard onto the ice covered water. The AB was rescued by a container bridge with a lashing basket on a spreader. Although he was immediately brought to hospital, he died from his injuries.

Findings
Although the company had set up and implemented a SMS, it was not effective as it was not sufficiently monitored in adherence to the ISM objective.

Recommendation
The company shall revise its SMS to foster effectiveness.

Lesson to Learn
The responsibility for an effective working SMS is with the company and should not be the responsibility of a single person on board. During cargo operations under unusual circumstances (ice on deck and containers) a risk assessment is to be made taking the extraordinary situation into consideration.