Investigation number
Occurrence date
Port Hedland anchorage
Western Australia
Report release date
Report status
Investigation level
Investigation type
Occurrence Investigation
Investigation status
Occurrence category
Highest injury level

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.


Vessel Details
Departure point
Luojing, China
Port Hedland, WA
Vessel name
Cape Splendor
Marine vehicle sector
Marine occurrence type
Marine Operation Type
Vessel Operator
U-Ming Marine Transport, Singapore