201931 Crew member dies while taking draughts

28 Apr 2019 MARS 2019

Edited from official TSB (Canada) report M17C0232

A small general cargo vessel docked starboard side to in a river port was preparing to load nickel concentrate. Before loading began, port state authorities inspected the vessel as per regulations for loading concentrates. An independent draught surveyor also boarded to conduct an initial draught survey before loading began. Under his supervision, some crew descended the rope ‘Jacob’s ladder’ to take the draughts amidships. (A Jacob’s ladder or monkey ladder is a flexible hanging ladder composed of vertical rope or chain and horizontal wooden or metal rungs of lightweight construction. In this case, the crew descended the ladder to take the draught because the draught surveyor was not permitted by his employer to use such a ladder.)

Soon after the survey the loading of the concentrate began. After about 14 hours of loading, and now in darkness, the duty deck
officer was tasked with taking the draughts. He disembarked on the dock and took the three inboard draughts, reporting these via VHF radio to the vessel’s cargo officer. He then proceeded to take the outboard midship draughts, descending the same Jacob’s ladder, which was still rigged amidships on the port side from the morning’s draught survey. The vessel’s cargo officer tried to contact the deck officer several times via VHF radio but received no response.


Upon investigation, the duty officer’s PFD was found in his locker, but the officer was nowhere to be seen. It was now assumed he had fallen into the water and a man-overboard alarm was raised. Although the vessel’s crew searched with their rescue boat and other vessels were tasked as search and rescue (SAR) resources, searching the waters proved fruitless. The crew member’s lifeless body was found downriver about seven days later. An autopsy showed death by drowning.

Some of the official investigation’s findings were:

  • The Jacob’s ladder was rigged to the guardrail in such a way that there was no safe means of access; to reach the ladder from the deck it was necessary to straddle and step over the guardrail
  • The Jacob’s ladder was unsuitable for the task of reading the midship seaward draught marks. The ladder was unsuitable for a number of reasons, not least the very small tread area available for a foothold.

Lessons learned

  • The ILO’s Code of Practice ‘Accident prevention on board ship at sea and in port’ states that persons working overboard should observe the following safety precautions:
  • Fall protection system and PFD to be worn
  • Another crew member should supervise and assist as needed
  • Lifebuoy with a safety line readily available
  • Risk assessment conducted and work permit issued
  • Although it is common practice to read the outboard draught marks from a rope ladder, a launch or small boat is more stable and brings the observer to a safer position closer to the water line
  • Even when taking the inboard (dockside) draughts, always wear a PFD, as dock edges can be slippery.

Editor’s note: For another unfortunate draught reading accident, see MARS 201822.