Make use of dynamic risk assessments when starting a new task or the same task but at a new location and scan for hazards. In a new Nautical Institute Mars Report, a hazard was missed by failing to do so, resulting in a fatal fall from height.

The Nautical Institute gathers reports of maritime accidents and near-misses. It then publishes these so-called Mars (Mariners’ Alerting and Reporting Scheme) Reports (anonymously) to prevent other accidents from happening. This is one of these reports.

A passenger vessel berthed and the crew was preparing to move the gangway from deck 2 to deck 1 to accommodate the tidal range, which was lower than at the last port. Extra deck crew were asked to assist with the move, although they were unfamiliar with this task. A work supervisor was responsible for the procedure and for overall safety. This person had several other areas of responsibility. Many tasks were lined up for the deck crew that day, and there was a sense of time pressure.

The crew first dismantled the railing and the gangway safety net so that wire rope cables could be connected. The crew involved in the work still had to use the gangway to get up and down from the quay area, despite the dismantling of the safety features.

On deck 2, three people were initially involved in the work on the gangway. Person 3, operating the winch, had not done so before and was given an introduction to which buttons to press by person 4, who had more experience with the winch and gangway. Person 1 observed the work from the forward part of the davit and Person 2 watched the cable of the forward davit.

The davit was hoisted back into its cradle so that it would not obstruct access to the gangway. The davit stuck in the vertical position, and when the cable was run out further, it became slack, while the davit remained vertical. Person 4 moved from the deck onto the gangway and pulled the cable in an attempt to loosen the davit. Person 3 was told to stop the winch and put the control down.

With the cable now slack, there was nothing to prevent the davit from pivoting back down to the horizontal position. As it pivoted down it struck person 4, who lost his balance and fell to the quay. First aid was administered and he was taken to a shore hospital by helicopter. He was later pronounced deceased as a result of the injuries sustained in the fall.

Also read: Fatal fall from crane grab

Investigation findings

The investigation found, among other things, that the crew did not consider gangway rigging tasks to be ‘work at height’. The crew had experience rigging the gangway from deck 1, which was lower, but not from deck 2.

The accident sequence revealed that the work method needed from deck 2 was different compared with that from deck 1; from deck 2 the davit had to be brought back to the cradle so as not to obstruct free passage of the gangway.

The crew did not habitually wear helmets or fall protection equipment for this job when it was performed from deck 1, nor did they do so when working from on deck 2 on the day of the accident.

Also read: Fatal fall overboard to quay

Advice from The Nautical Institute

  • A “dynamic risk assessment” process is a technique whereby workers constantly scan the workspace for hazards and make the necessary adjustments. In this case, the method of work for gangway manipulation from deck 1 was used, although the work was being carried out on deck 2. A dynamic risk assessment process should have identified that deck 2 presented a new hazard – work from height.
  • Working from height requires fall protection. Working on deck requires hard hat protection regardless of the task or location.
  • As mentioned in Mars Report 202443, time pressures are usually self-imposed. Even if time pressures are overtly expressed, the proper mindset should be “Safety First”.

Also read: LOTO lapse causes fatal ship repair accident

Mars Reports

This accident was covered in the Mars Reports, originally published as Mars 202446, that are part of Report Number 383. A selection of the Mars Reports are also published in the SWZ|Maritime magazine. The Nautical Institute compiles these reports to help prevent maritime accidents. That is why they are also published (in full) on SWZ|Maritime’s website.

More reports are needed to keep the scheme interesting and informative. All reports are read only by the Mars coordinator and are treated in the strictest confidence. To submit a report, please use the Mars report form.

Also read: Gangway falls from crane causing one fatality