OPTIMISM Training Platform

Reference Number	GDMR5
Description	Falling from height of less than 2.5/3.0 meters. Under the chief mate’s supervision, the crew were in the process of moving a tweendeck; the ship’s crane was used to hoist the tweendeck pontoon out of the hold so that it could be turned. The chief mate, who was standing on a fixed ladder near the hatch fell overboard and found dead.
Key Root Causes	ISM non-conformity (Inappropriate policy manual, inappropriate procedures.  The crew did not hold a safety meeting and the working practice on board did not coincide with the procedures of the Safety Management System (SMS). The available instructions were considered ‘unworkable’ by the crew).  Management fault (The crew did not hold a safety meeting).
Casualties	1 fatality (Chief Mate)
Action-Recommendation	To revise instructions and learn from similar accidents. The vessel’s sister ship used a safer method and the company was aware of this but failed to minimize risk.
Would it happen again	Maybe not, if a safety meeting was held and the CM had a harness he would not have died.

Title: An Investigation into Root Causes of Accident – Falling from Height

Accident Investigation Review 15 - Falling from Height

1. Introduction 

In this accident investigation was carried out by a qualified accident investigator employed by a leading Accident Investigation Agency. 

The investigation aimed to demonstrate the difficulties to establish the root causes of accidents. 

2. Background

The International Safety Management (ISM) Code, adopted by the International Maritime Organization (IMO), establishes a framework for safe operation and management of ships and the prevention of pollution. Shipping companies are required to implement and maintain effective safety management systems that comply with the ISM Code. The accident investigators were responsible for proposing remedies to ensure the accident does not happen again and in the process identify any other contributing root causes.

3. Methodology

The investigation by the accident Investigators involved a comprehensive review of accidents using any documents forwarded to them to carry out the investigation according to the Agency rules and practice. The Investigators employed a systematic approach to evaluate the accident and its root causes against the requirements set forth by the Agency.  C4FF reviewed the information available primarily from accident investigation report with a view to finding out if ISM can be more effectively implemented or its effectiveness improved.

4. Investigation

Falling from height of less than 2.5/3.0 meters. Under the chief mate’s supervision, the crew were in the process of moving a tweendeck; the ship’s crane was used to hoist the tween deck pontoon out of the hold so that it could be turned. The chief mate, who was standing on a fixed ladder near the hatch fell overboard and found dead.  

Findings

4.1 Investigation Practice

The Investigation took place in accordance with the Accident Investigation Agency procedures and practice. The Investigators examined various aspect of the accident and SMS Manual containing policies, procedures, and records/documents as well as non-Quality Assurance and Control deficiencies to ensure their findings would stop this accident from happening again. 

4.2 Accident investigator’s Report

Instructions must be continually revised. Safety meetings should be regularly held. Appropriate PPE such as harness must be utilized in this type of task. Learn from similar accidents and methods used by other ships to mitigate the risk.  

5. Observations 

The investigators' report reveals a significant error originating from an inappropriate policy manual and inappropriate procedures. The crew's failure to conduct a safety meeting and the inconsistency between onboard working practices and the SMS procedures were key issues. The crew's perception of the available instructions as 'unworkable' made the situation worse.

6. Comments

The accident investigation report highlights a tragic incident involving a fall from a relatively low height during a tween deck movement operation. The report underscores the need for regular instruction revisions, safety meetings, and proper PPE usage, such as harnesses. Learning from past accidents and adopting effective risk mitigation methods is crucial. The findings point to inadequate policies, procedures, and crew training. The report emphasizes the importance of aligning onboard practices with SMS procedures, conducting safety meetings. Despite the crew's incompetency in not adhering to SMS procedures and available instructions, the management could have implemented strict policies to ensure that procedures and instructions are followed as they should be.