OPTIMISM Training Platform

Reference Number	C0013781
Description	When securing the drums stacks onto the poop deck in order to prepare for the severe weather conditions reported by the weather forecast an AB, OS A and OS B were facing one another to lift a toolbox; this is when OS B lost his balance and fell towards the chain railings, plunging about 18 meters onto the upper deck and later died.
Key Root Causes	ISM non-conformity (Inadequate risk -assessment - Inadequate system design - Inadequate competence/skills;  Management fault (Inadequate team operation; Incorrect perception; Inadequate leadership). Bad weather.
Casualties	1 Fatality
Action-Recommendation	Training on hazards of working on the deck specially when there is a bad weather.
Would it happen again	No if training is provided on risk assessment.

Title: An Investigation into Root Causes of Accident – Man Over Board

Accident Investigation Review 17 – MOB

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 accident 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 find out if ISM can be more effectively implemented or its effectiveness improved.

4. Investigation

When securing the drums stacks onto the poop deck in order to prepare for the severe weather conditions reported by the weather forecast an AB, OS A and OS B were facing one another to lift a toolbox; this is when OS B lost his balance and fell towards the chain railings, plunging about 18 meters onto the upper deck and later died.

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

Trainings on hazards including risk assessment focusing on bad weather should be provided to the personnel of the ship.

5. Observations 

The error arose from inadequate system design, compounded by insufficient competence, teamwork, and leadership. Incorrect perception and inadequate risk assessment further contributed, followed by challenging weather conditions. 

6. Comments

The accident investigation report highlights a tragic incident resulting from inadequate safety measures during severe weather preparations. The findings emphasize the need for hazard-specific training, particularly focused on risk assessment for adverse weather conditions. The incident underscores deficiencies in system design, competence, teamwork, and leadership. Addressing these factors through targeted training and improved safety protocols is essential to prevent similar accidents and ensure the well-being of crew members during challenging conditions.