ATSB response to the Coroner

The ATSB notes that Western Australian Coroner, Sharon Linton, recently delivered a record of investigation into a maritime fatality from a man overboard incident from MSC Siena that occurred on 17 November 2011. The ATSB gave evidence at the hearing of the matter. The accident was the subject of ATSB investigation 290-MO-2011-010. The Coroner’s findings were substantially in accordance with the findings of the ATSB investigation.

Circumstances of the accident

On 17 November 2011, a wave knocked a seaman off MSC Siena’s accommodation ladder while he was rigging a combination pilot ladder in preparation to embark a harbour pilot. The ship was near Rottnest Island off the port of Fremantle. An immediate search for the seaman was initiated by Australian search and rescue agencies but the search was unsuccessful.

ATSB Findings

The ATSB found identified the following contributing factors:

  • On 17 November 2011, a risk assessment for the task of rigging MSC Siena’s combination pilot ladder was not carried out. Consequently, the weather conditions, safety harness tethering, wearing of a lifejacket and communication were amongst the factors that were not properly considered before the crew started rigging the ladder.
  • MSC Siena’s safety management system procedure for working over the side required that a risk assessment be carried out, and necessary checks and precautions documented in a work permit. However, the procedure had not been effectively implemented on board the ship.
  • MSC Siena’s permit to work over the side and the associated procedure required that the ship not be underway when working over the side. However, this requirement could not be complied with when working over the side to rig a combination pilot ladder.

Safety action

The safety issues identified by the ATSB were addressed by the operator of MSC Siena, All Seas Marine. The ATSB was satisfied that All Seas Marine had taken proactive safety action and that had adequately addressed the issues raised. Details of the safety action can be found at Safety issues.

ATSB investigations and coronial investigations

Coronial investigations are separate to ATSB investigations. In this matter the respective authorities are largely in accord as to the factors that contributed to the development of the accident.

The ATSB's report can be downloaded by clicking on the link: Final Report

The Coroner's report can be obtained from the Coroner's Court of WA. Contact details are available at: Queries regarding the Coroner's findings should be directed to the Coroner's Court of WA.