Marine safety investigations & reports

Man overboard fatality from Cape Splendor Port Hedland, WA on 6 October 2014

Investigation number:
Status: Completed
Investigation completed


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On 6 October 2014, Cape Splendor’s boatswain (bosun) descended to the lower platform of the ship’s accommodation ladder during his lunch break. He intended to fish from this location and asked a seaman to assist. At 1250, the bosun lost his balance and fell into the sea.

The seaman immediately returned to the ship’s deck and threw a lifebuoy toward the bosun, before raising the alarm. The ship’s crew deployed its rescue boat within 10 minutes, and an extensive air and sea search continued for 3 days. However, the bosun was not found.

What the ATSB found

The ATSB found that the bosun and the seaman were not wearing any flotation devices or fall prevention equipment. The bosun had seen fish below the accommodation ladder that was in the shade, and he probably saw it as a good opportunity to fish without considering the risks involved. The lack of a lifejacket, wet clothing, and possible entanglement with fishing gear, sea conditions, and the current would have adversely affected the bosun’s ability to stay afloat and swim.

The ATSB investigation also identified that the ship’s safety management system procedures for working over the ship’s side were not effectively implemented. Hence, the ship’s crew routinely did not take all the required safety precautions when working over the side. It was also found that the crew had differing attitudes to taking safety precautions during work and recreation times as the safety culture on board was not well developed.

What's been done as a result

Cape Splendor’s managers conducted a fleet-wide review of procedures and training to ensure ship crews comply with procedures and permits to work, with particular emphasis on working aloft and/or over the side. A number of fleet-wide memoranda describing the accident were issued to promulgate lessons learned, encourage compliance with policies and procedures, and reiterate the importance of taking safety precautions during both work and during leisure periods.

The ship’s managers have prohibited fishing from ships’ accommodation ladders and warning signs have been posted. Man overboard recovery procedures were reviewed and the accident was highlighted in training programmes.

The ATSB has issued a safety advisory notice (SAN) to shipmasters, owners, and operators to promote the importance of an effective safety culture on board ships. The SAN reinforces the importance of safety awareness at all times, during both work and recreational activities.

Safety message

Any task or activity that involves a person being on a ship’s accommodation ladder or other locations over the side of the ship can result in serious or fatal injury. Therefore, precautions to prevent a person from falling overboard, and to improve survivability in case one does fall into the water, are critical. It is important to ensure that these precautions are always taken, regardless of whether the person is engaged in work, recreational or other activities.


Download final report
[Download  PDF: 1.59MB]
Alternate: [Download  DOCX: 861KB]

Safety Issues

Go to MO-2014-011-SI-01 - Go to MO-2014-011-NSA-025 -

Implementation of SMS procedures

Cape Splendor’s safety management system (SMS) procedures for working over the side of the ship were not effectively implemented. As a result, the ship’s crew routinely did not take all the required safety precautions when working over the side. Further, they did not consider that any such precautions were necessary if going over the side when not working.

Safety issue details
Issue number: MO-2014-011-SI-01
Who it affects: All persons responsible for shipboard operations
Status: Adequately addressed

Safety culture

The safety culture on board Cape Splendor was not well developed and the ship’s managers had identified it as such. A consequence of this inadequacy was the ineffective implementation of working over the side procedures, including the general belief by its crew that safe work practices applied only when working, and not during recreational activities.

Safety issue details
Issue number: MO-2014-011-NSA-025
Who it affects: All persons responsible for shipboard operations
Status: Adequately addressed
General details
Date: 06 October 2014   Investigation status: Completed  
Time: 1250 LT (UTC +8)   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Port Hedland anchorage    
State: Western Australia    
Release date: 09 February 2016   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Vessel details

Vessel details
Operator U-Ming Marine Transport, Singapore  
Vessel Cape Splendor  
Flag Singapore  
IMO 9631333  
Sector Other  
Type of operation Anchored  
Damage to vessel Nil  
Departure point Luojing, China  
Destination Port Hedland, WA  
Last update 03 April 2020