Final report
Safety summary
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.
Inquest
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:
The Coroner's report can be obtained from the Coroner's Court of WA. Contact details are available at: www.coronerscourt.wa.gov.au. Queries regarding the Coroner's findings should be directed to the Coroner's Court of WA.
Occurrence summary
| Investigation number | 290-MO-2011-010 |
|---|---|
| Occurrence date | 17/11/2011 |
| Location | off Fremantle |
| State | Western Australia |
| Report release date | 05/02/2013 |
| Report status | Final |
| Investigation level | Systemic |
| Investigation type | Occurrence Investigation |
| Investigation status | Completed |
| Mode of transport | Marine |
| Marine occurrence category | Fatality |
| Occurrence class | Accident |
| Highest injury level | Fatal |
Ship details
| Name | MSC Siena |
|---|---|
| IMO number | 9252096 |
| Ship type | Container ship |
| Flag | Liberia |
| Departure point | Melbourne, Vic |
| Destination | Fremantle, WA |