The Australian Transport Safety Bureau (ATSB) issued the attached report of its investigation of the man overboard fatality from the bulk carrier Hyundai Dangjin in Port Walcott on 10 July 2015.

The second mate descended a rope ladder to read the outboard midships draft mark while the vessel was loading cargo. He was wearing a work vest and an AB was standing by on deck. When the second mate fell into the water, the AB threw him a lifebuoy, but the second mate was unable to reach it before drowning.

Investigation revealed that the rope ladder had been rigged upside down and that the work vest had insufficient buoyancy for the second mate’s heavy build. With their wrong side up, the ladder steps (folded aluminium) did not provide a flat surface to stand on comfortably. Further, the steps were not good handholds.

A review of its shipboard safety management system (SMS) resulted in a ‘Safe Draft Check Instruction’ being included in the procedures related to cargo operations for bulk carriers. The instruction details the procedures (including permits to work) when checking the ship’s draught from a rope ladder.

Port terminal managers, reviewed the draught survey methods at its terminals. As a result of the review, the reading draught marks from rope ladders was prohibited. An alternate method, using a manometer, was put in place.

This report highlights the broad safety concerns. In many cases, little attention is paid to planning apparently straightforward tasks, such as using a rope ladder. This can lead to important factors and relevant considerations not being taken into account, including the experience and physical ability of persons undertaking the task.

Source: https://www.atsb.gov.au/publications/investigation_reports/2015/mair/321-mo-2015-004/