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Routine task ends in fatality

Man overboard from Hyundai Dangjin at Cape Lambert, WA, on 10 July 2015

A tragic man overboard fatality shows why it’s vital that mariners always plan properly for all tasks, no matter how seemingly straight forward or routine. 

The tragedy unfolded on 10 July 2015 when Hyundai Dangjin was in the final stages of loading its cargo of iron ore at Port Walcott, Western Australia. The ship was starboard side alongside the wharf and the chief mate and draught surveyor were on the wharf to check the ship’s draught. (The draught is the distance between the surface of the water and the lowest point of the ship).

They could see the forward and aft draught marks but not the midships marks.

At 0450, the chief mate asked the second mate, via UHF radio, to read the midships draught on the ship’s port (outboard) side. The ship’s crew had already rigged a rope ladder adjacent to the draught marks there.

In preparation to climb down the rope ladder, the second mate donned a life vest (non-inflatable flotation aid). The able seaman (AB) on duty offered to go down the ladder instead of the second mate, who was a large and heavy man. The second mate declined the AB’s offer (mates are trained to read draught marks).

Just after 0455, the chief mate and draught surveyor returned from the wharf to the ship’s office. The chief mate then called the second mate and asked for the midships draught. The second mate did not reply.

At that time, the second mate was near the bottom of the ladder, about 7 m below the ship’s deck. He called out to the AB for help and said he was having difficulty. When the AB checked, he saw the second mate struggling to hold on to the ladder. As the AB looked around for a rope to throw down, the second mate fell into the water. The AB threw a nearby lifebuoy to the second mate and it landed a few metres away.

The second mate tried to swim to the lifebuoy, but was not able to reach it. The sea was rough (1.4 m sea on a 0.4 m swell) and the water temperature was about 22 °C.

The ATSB found the rope ladder had been rigged upside down. With their wrong side up, the ladder steps (folded aluminium) did not provide a flat surface to stand on comfortably. Further, the steps were not good handholds.

The sole precaution taken by the second mate while reading the draught marks was his life vest. No fall prevention measures were put in place or used. The life vest’s specifications could not be determined but similar types provide around 7 to 10 kg of buoyancy.

Safety message

In many cases, little attention is paid to planning apparently straightforward tasks, such as using a rope ladder. This can lead to important factors and relevant considerations not being taken into account, including the experience and physical ability of persons undertaking the task.

The ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported by industry. Marine work practices is one of those safety concerns.

Read the full investigation report MO-2015-004

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Last update 28 January 2016