The Republic of the Marshall Islands (RMI) Maritime Administrator has issued an investigation report into an incident where an Able Seaman was killed instantly when steel plates fell and struck him.
Analysis
Steel plates on board were vertically stored in a longitudinal direction at the entrance of the Forecastle Store. The steel plates were kept in position by means of a retaining bar that was held in place by two nuts that were turned onto two threaded studs. The location and the means to store and secure the steel plates had not been adapted to accommodate the additional amount and size of steel plates that were stored.
The way the steel plates were stored on board made them vulnerable to fall as soon as the retaining bar was released as:
- steel plates that are stored in longitudinal direction are more susceptible to falling due to rolling motions. Depending on the initial inclination angle of the steel plates, even a minor force, such as a slight rolling movement of the ship, could be sufficient to cause the steel plates to fall;
- the retaining bar pushed the steel plates against the bulkhead below the centre of gravity of the larger plates. This force potentially brought straight vertically positioned steel plates out of balance resulting in the steel plates moving beyond the vertical plane; and
- no stopper was in place on the floor or bulkhead to prevent the steel plates from falling after the retaining bar was removed.
It was reported that the retaining bar, which was made of flat iron and susceptible to bending, suddenly pushed the nut closest to the Forecastle Store entrance off the threaded stud, before it was completely removed by the ASD2.
The way the steel plates were stored required that pressure be applied at both ends of the retaining bar to push the retaining bar onto the threaded studs. This pressure caused the retaining bar to bend around the area where the stack of steel plates was deepest (see Figure 3) and placed the retaining bar in tension when the nuts were screwed onto the studs to hold the steel plates in place.
As the ASD2 loosened the nut, this pressure most probably caused the retaining bar to suddenly spring off the stud. Wood or wedges filling the gaps between the steel plates and the retaining bar could have equally spread the tension of the retaining bar against the steel plates and could have prevented the retaining bar to bend around the plates, provided that the studs were long enough.
It was observed that no lifting appliances were in place to safely transport heavy steel plates into the entrance of the Forecastle Store.
Safe working
Two crewmembers were assigned to select a suitable steel plate. They had done this task before and were familiar with the storage location of the steel plates.
It was reportedly the first time, after adding additional steel plates in dry dock, that the retaining bar had to be loosened. During the investigation, it could not be determined whether or not the ASD1 and ASD2 were involved in securing the retaining bar after storing the additional steel plates on 4 May 2024.
The ISM Form S27 only verified if the listed safety precautions were applicable during a certain period or not and did not further assess if additional potential risks were present for certain activities. The list can be considered as a tool to check the presence of certain risks but does not invite consideration of all the risks related to the planned activities.
The experience and general safety awareness of the crewmembers was the only precautionary measure in place for detecting any job-related risk for activities that were not identified as activities with high risks. General safety awareness was trained by familiarisation with safe working procedures and by regular attendance of drills, work permit meetings, toolbox talk meetings for risky activities, and daily safety briefings.
The potential risk of steel plates falling over had not been assessed either when the steel plates were stowed on or around 4 May 2024 or before the crewmembers started to remove the retaining bar on 5 June 2024.
The situational awareness of crewmembers involved in the stowage of the steel plates and in the selection of a suitable plate was insufficient to identify the potential risk of falling steel plates when storing and retrieving them. No RA was in place to compensate for the lack of situational awareness and no pre-task RA was in place to guide crewmembers to identify unsafe situations or potential risks before commencing any activity.
PPE
A safety helmet was required when working on deck on board. Wearing a helmet was one of the safety precautions that was listed in ISM Form S27.
The ASD1’s safety helmet was found lying on the deck next to him, after he was struck by the falling steel plates. The safety helmet did not show any marks of a heavy impact by steel plates. Most probably his helmet was not properly secured and fell off either before or just as his head contacted the steel plates that were stowed on the opposite longitudinal bulkhead.
Conclusions
The following Conclusions are based on the above Factual Information and Analysis and shall in no way create a presumption of blame or apportion liability.
- Causal factors
Causal factors that contributed to this very serious marine casualty include the:
- steel plates falling suddenly onto the ASD1. As the nut holding the retaining bar was released, the force from the steel plates pushed the nut off knocking the ASD1 back against the opposite longitudinal bulkhead which resulted in fatal head trauma;
- design of the storage rack which:
- did not provide a mechanical means of preventing the steel plates from falling when the nut holding the retaining bar was released;
- required that the retaining bar be placed under tension when the nuts were tightened to secure the steel plates;
- inadequate situational awareness to detect the potential risk of falling steel plates when storing and retrieving them in combination with the absence of a system to identify the potential risks.
Additional causal factors that may have contributed to this very serious marine casualty include the:
- sea state and the consequent rolling motion of the ship possibly contributing to the falling of the plates, as the storage location was in a longitudinal direction;
- likelihood that the ASD1’s safety helmet was not properly fastened.
- Additional issues identified
Additional issues that were identified but did not contribute to this very serious marine casualty include that the:
- access hatch located in the bulkhead between Cargo Hold No. 1 and the Forecastle Store may create a potential hazard in case hazardous or oxygen depleting cargo is loaded within Cargo Hold No.1;
- storage location required the steel plates to be handled manually;
- six seafarers on board did not possess valid Republic of the Marshall Islands seafarer documentation.
Preventive actions
- Company actions
In response to this very serious marine casualty, the Company has taken the following Preventive Actions:
- Relocated the storage rack for steel plates to a safer position on board their entire fleet and secured them to prevent any risk of the plates falling (see Figure 5).
- When needed, steel plates will be divided into smaller, more manageable pieces for safer handling.
- New safety helmets were distributed to the crewmembers across the entire fleet together with instructions on how to properly secure them.
- Additional training sessions on heavy lifting and safety awareness were provided to crewmembers.
- A comprehensive review and enhancement of the ship’s SMS was carried out, resulting in:
- the introduction of new forms, and the revision of existing forms, related to safe working practices, including Form S28 – Heavy Load Lifting Control Checklist, and a revision of ISM Forms S27 and S18 – Entering Enclosed Spaces and Rescue Checklist (Revised);
- thirty new procedures being added to the SMS to enhance safety and reduce operational risks, including procedures for a Company-Specific additional training policy and High-risk Tasks and Safety Procedures Onboard Ships, and a complete update of the Enclosed Space Entry Procedures.
In response to the issue of expired or missing documents identified during the investigation, the Company has implemented a:
- centralized digital platform (NOZZLE) for real-time monitoring of all crew certificates and documentation;
- dual-stage verification process with an initial review at the office and final confirmation on board upon joining a Company-managed ship;
- required monthly compliance status report, submitted by the Master and C/O which is reviewed by the Personnel Manager and Assistant Personnel Manager.
- Administrator actions
The Administrator has taken the following Preventive Actions:
- Issued MSA 06-24 highlighting the urgent need for vessel managers and seafarers to ensure steel plates are properly secured and handled.
Lessons learned
- The location and design of storage racks for steel plates should eliminate the potential for steel plates to fall while being handled.
- Unsecured or partially unsecured objects have the potential to fall or move. Seafarers should maintain a safe position relative to the unsecured object.
- Safety helmets need to be properly sastened to prevent falling off during a fall or an abrupt movement.
Full advisory at the following link.
https://safety4sea.com/wp-content/uploads/2026/03/ATSB-MO-2025-013-PRELIMINARY-2026_03-1.pdf