202037 Fall from ladder

Fatal fall from ladder As edited from official Transport Safety Investigation Bureau (Singapore) MIB/MAI/CAS.008

A bulk carrier was underway. The vessel was in ballast and hold washing was scheduled in preparation for taking the next cargo. An officer, bosun and another deck crew conducted a risk assessment for cargo hold washing operations, as required by the shipping company’s SMS. The risk assessment was approved by the Master, and the officer conveyed the contents of the risk assessment to the other members of the washing team. The washing team completed the cleaning of holds one and two by the end of the first day without incident. The next day, washing of hold three was commenced.

A crew member standing on the first platform started climbing up the vertical ladder to reach the main deck. He slipped and fell to the bottom of the cargo hold, about 12 metres below. An emergency team was quickly mustered to help the victim, who was conscious but complained of severe abdominal pain and difficulty breathing.

The victim was evacuated from the cargo hold on a stretcher using the ship’s crane and transferred to the ship’s infirmary. He was placed under constant observation and his medical condition was monitored and recorded. About six hours later, all vital signs were absent and he was declared deceased. The investigation found that there was no securing arrangement to which to fasten a safety harness lifeline.

Because of this, it was common practice for the crew to climb up and down the ladder without securing the safety harness lifeline to any point and without any fall arresting device. A damp and wet cargo hold, wet gloves and a ladder slippery with seawater from the wash were probably contributing factors to the fall. The risk assessment carried out for cargo hold washing operations did not identify the risk of falling from height during climbing up or down the vertical ladder.

Lessons learned

• As is often the case, hazards remain in plain sight but go unseen by crew who have become desensitised to them. In this case it was accepted practice to climb up and down the hold ladder, which was not fitted with a cage, without fall arrest or safety lines.
• Another indicator of this particular fall hazard going unseen by crew: the hold washing risk assessment did not mention this risk.