What happened

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.

What the ATSB found

The ATSB’s investigation found that a risk assessment for the task of rigging the pilot ladder was not undertaken and a number of precautions, including taking into account the poor weather conditions, were not taken. With regard to this task, the ship’s safety management system was not effectively implemented and documented procedures, including issuing a work permit, were not followed.

What's been done as a result

Senior representatives from Allseas Marine, Greece, MSC Siena’s manager, attended the ship in Fremantle and conducted an internal company investigation. Since then, Allseas Marine has taken a number of steps to address the safety issues identified by its own and the ATSB’s investigation.

The company’s shipboard safety management system procedure for its work permit system has undergone major revision with regard to work over the side and a new, improved work permit form has been introduced. Importantly, the revised procedure specifically addresses the task of working on combination pilot ladders and task specific guidance and precautions have been provided.
Crew induction and familiarisation procedures, particularly for ships new to the company fleet, have been enhanced to support implementation of the revised work permit system procedure. On board training has been improved through safety videos and computer based training focusing on permit to work systems. A fleet wide safety campaign was carried out to promote the company’s work permit system. A requirement to report all work for which a permit is necessary to the company and submit the permit forms has been introduced.

Allseas Marine also obtained independent advice with regard to rigging pilot ladders. Based on that advice, the company considers that if pilotage services have not been suspended due to the weather conditions, rigging a pilot ladder may be permissible subject to the master’s overriding authority and judgment on safety matters.

The ATSB has assessed the action taken by Allseas Marine and is satisfied that it will adequately address the safety issues identified.

Safety message

Rigging a pilot ladder while working over the side of a ship can be a hazardous task and it is imperative that all the precautions necessary to prevent a person falling overboard are taken.