An investigation report into the fatal fall of a bosun from a bulk carrier’s main deck during pilot ladder preparations.
The incident
On 14 October 2025, a bosun died after falling from the main deck of a bulk carrier while the crew were preparing the pilot ladder following the vessel’s departure from Sweden. A nearby pilot boat attempted to recover him from the water but was unsuccessful. His body was recovered from the seabed the following day.
Survivability
It is almost certain that the bosun’s injuries to his head and torso resulted from him striking the lower platform of the accommodation ladder as he fell to the water. These injuries were not life-threatening in themselves, although may have rendered him unconscious, and it was almost certain that he was alive when he entered the water.
The postmortem report recorded no indication of any cardiac arrest. It is therefore unlikely that either the bosun’s medication or the underlying conditions they were treating influenced the outcome of the accident. Without wearing a PFD to support him in the water, the injured bosun’s prospect of survival was significantly diminished.
The bosun’s injuries likely rendered him unable to help himself once he had entered the water. Without a PFD to support him in the water, and likely experiencing a cold-water response, the bosun was unable to maintain his airway clear of the water and therefore drowned.
Procedures for working on or near the ship’s side
The work to rig the combination ladder required the removal of the safety chains that spanned the gap in the solid guardrails running along the side of the main deck when a pilot embarkation station was in use.
The pilot ladder davit located on the vessel’s deck was not fit for use. Crew members had therefore likely become normalised to lowering and recovering the pilot ladder manually, handling its suspended weight. This created a tendency for the ladder to pull them towards the deck edge, exposing them to an increased risk of falling. The additional risk arising from the removal of the pilot ladder davit from service had not been identified.
The SMS identified that working near an unguarded deck edge constituted a hazard that required both the completion of a permit to work and the use of specific PPE to mitigate the risk presented. It specifically required anyone working on the accommodation ladder and in the vicinity of the open shipside railing to wear both a safety harness secured to a safe anchor point, and a PFD.
The area designated in the SMS as being a hazardous area was not wholly marked to highlight to the crew that they were at risk. None of the crew working near the fall hazard presented by the open gaps in the guardrails were using the PPE required by the SMS.
The investigation showed that the risk mitigations set out in the SMS were not applied when rigging the accommodation ladder during the vessel’s arrival or when rigging the combination ladder at the time of the accident.
The unsafe methods used while rigging the combination ladder and when conducting work in a hazardous area had likely become normalised practice, placing the crew at serious risk of injury.
Communication
The procedure for rigging the combination ladder required a crew member working shipside at the accommodation ladder to carry a handheld radio for communication.
A shortage of handheld radios was raised at the onboard safety committee meetings in July 2025 and August 2025. The lack of communication equipment for the work team meant that it was only possible to talk directly to the crew on the accommodation ladder by leaning over the side of the vessel. Doing so from the top of the pilot ladder, where the safety chains had been removed, placed crew members at risk of falling.
A lack of sufficient handheld radios for use by the crew contributed to them working close to an unguarded deck edge, increasing the risk of falling.
Fall arrest and fall prevention
The SMS procedure for working over the side of the vessel required personnel to use a safety harness and a fall arrest device. The procedure provided guidance on the selection of a suitable anchor point to which a fall arrest device could be secured.
However, the two demonstrated methods for the connection of the fall arrest devices at the pilot boarding stations did not meet the guidance contained in the SMS procedure, nor did they allow the free movement of personnel working on the accommodation ladder.
With no attachment points above the accommodation ladders that met the guidance criteria in the vessel’s SMS, it is unlikely that fall arrest devices were used when rigging the combination ladders.
The evidence that crew working on the accommodation ladder did not use fall arrest devices during the vessel’s arrival or at the time of the accident supports the likelihood that this equipment was not routinely used when rigging the combination ladder.
Similarly, it is likely that crew working on deck near the fall hazard created by the removal of the safety chains at the deck edge did not routinely use the required fall prevention equipment.
Crew members working near an area of unguarded deck edge were not equipped with the appropriate PPE to prevent them falling or arrest their fall should they do so.
Personal flotation devices
The vessel was equipped with PFDs for the crew to use when working in areas where there was a risk of falling into the water.
The waistcoat-type PFDs provided were incompatible with the dorsal connection point of the safety harnesses used onboard. This meant that their configuration would be unlikely to meet the certified performance standard if worn together.
The PFD’s buoyant solid foam was intended to provide additional buoyancy to help a conscious wearer remain afloat while awaiting recovery. They were not designed to rotate an unconscious person face up in the water.
The use of such PFDs did not account for the possibility that a crew member may not be able to assist themselves should they enter the water, making them almost entirely dependent on rapid recovery for survival.
The PFDs provided to crew members were incompatible with the safety harnesses used onboard and could not support them to keep their face out of the water should they enter the water when unconscious, placing them at significant risk when working on the ship’s side.
Permit to work
The COSWP stated that a permit to work provided an organized and predefined safety procedure, noting that each permit to work should be relevant and as accurate as possible for the task being undertaken.
The rigging of the combination ladder on 14 October 2025 was a planned activity that met the SMS requirements for the use of a permit to work. A review of the completed permit to work would indicate that the work to rig the combination ladder had been completed in full compliance with all of the SMS requirements intended to reduce the risks to the crew. However, many of the required safeguards were not implemented at the work site. The lack of safeguards replicated the observed activity to rig the accommodation ladder during the ship’s arrival.
The scant regard for the permit to work requirements continued after the accident, with the amendment to the completed permit to work to incorporate the rigging of the port combination ladder after the port side ladders had already been rigged and used. This reinforces the likely existence of an on-board culture in which the administration of safety was divorced from its effective management.
The risk mitigations in the permit to work were not strictly adhered to, and the form’s completion and subsequent amendment were possibly undertaken to demonstrate compliance, placing the crew at risk.
Stop work
A clear stop work policy was in place on board. It was displayed on posters throughout the ship and formed a standing agenda item in the vessel’s monthly safety committee meetings.
None of the crew invoked the stop work policy on the day of the accident, despite the activity to rig the combination ladder exhibiting numerous departures from the safe working practices set out in the SMS procedures for working at height. Locally, it is possible that the difference in seniority between the C/O and bosun and the more junior crew engaged in the work reduced the likelihood that any concerns would be raised. It is therefore possible that this contributed to the lack of challenge to the actions of the C/O and bosun.
Immediately before the accident the two pilots were near the pilot embarkation station on deck, waiting for the crew’s invitation to disembark. It was the crew’s responsibility to prepare the combination ladder for use and the pilots were not directly engaged in the activity, limiting their opportunity to identify unsafe practices and intervene.
The investigation report on the two fatalities on board another vessel underlined the need for crew members to have the confidence to exercise their authority to stop work when they observe an unsafe condition.
The presence of personnel observing the activity at the unguarded deck opening did not result in an intervention to stop the unsafe work, exposing the crew to a risk of falling.
Safety climate
The evidence of the inappropriate documenting of safety critical activities identified in the investigation places doubt over the records of other activities maintained on board. It is possible that the records maintained, and presented during routine audits, also contained erroneous entries.
Inappropriate recording of safety critical activities was evident over a period encompassing different crews on board, suggesting that it was a behaviour embedded in the working practices and not solely with those on board at the time of the accident.
A safety climate is shaped by the way safety policies are applied in practice, how leaders balance safety against operational demands, and the extent to which personnel feel able to challenge unsafe situations.
The evidence indicates that the safety climate on board resulted in an emphasis on the documentation of compliance rather than the effective management of risk.
The man overboard recovery attempt
The pilot boat was a short distance off the beam of the vessel when the bosun fell. The boat’s two crew were alert to the activity on board and saw the fall, immediately closing to attempt to recover the bosun from the water. The bosun was not wearing a PFD so the crew had little time to plan how the recovery should be carried out.
Faced with an urgent situation and minimal time for deliberation, the actions of the crew were almost certainly driven solely by procedures embedded through training. The deckhand had not been trained in the recovery procedure using the ARHoop system and did not consider using it. The deckhand was familiar with using a boathook to retrieve objects from the water, and it was this equipment they took to the bow of the vessel to attempt to recover the bosun.
The absence of a system to monitor and manage the training of temporary crew members had not been identified despite the ongoing development of training activities and safety drills focusing on MOB situations.
The suitability and lack of familiarity with equipment and training in MOB procedures reduced the capability of the crew to recover an unconscious person from the water.
Regulation
The ISM Code required that applicable codes and guidelines be taken into account in the development of an SMS. From a health and safety perspective, the Isle of Man Merchant Shipping (Code of Safe Working Practices) Regulations 1989 made reference to the UK COSWP to promote safe working practices on Isle of Man vessels.
Although the crew had access to the most recent version of the publication, the governing Isle of Man legislation explicitly required the carriage of the 1991 edition. This was both outdated and no longer available.
The Isle of Man legislation set a carriage requirement for an edition of COSWP that was no longer available, potentially placing seafarers at risk from hazards that more recent versions were intended to manage.
Safety issues directly contributing to the accident
- The bosun fell from the deck while working near an unguarded opening.
- The bosun’s injuries left him unable to help himself after entering the water. Without a personal flotation device (PFD), he was unable to keep his airway clear and drowned.
- Unsafe methods used when rigging the combination ladder had become normal practice, placing the crew at serious risk of injury.
- A shortage of handheld radios contributed to crew members working close to an unguarded deck edge, increasing the risk of falling.
- Crew members working near an unguarded deck edge were not equipped with appropriate personal protective equipment (PPE) to prevent or arrest a fall.
- Permit-to-work controls were not properly followed, and documentation was amended to demonstrate compliance rather than ensure safety.
- Supervision of the pilot ladder rigging operation was ineffective, placing the crew at significant risk.
- Personnel observing the unsafe work did not intervene to stop it, exposing the crew to the risk of falling.
- The vessel’s safety culture emphasized documenting compliance rather than effectively managing risk.
Safety issues not directly contributing to the accident
- Crew members were not provided with PFDs compatible with their safety harnesses or capable of supporting an unconscious person in the water.
- Limited familiarity with man overboard (MOB) recovery equipment and procedures reduced the crew’s ability to recover an unconscious casualty.
- Regulations required carriage of an outdated edition of the Code of Safe Working Practices, potentially leaving seafarers without current safety guidance.
Action taken
Actions taken by the operator
- Delivered additional crew training and counselling.
- Distributed a fleet safety alert and training video on the accident and its lessons.
- Reinforced stop-work authority and expanded behavioural and scenario-based safety training.
- Installed tested anchor points for fall restraint and fall arrest systems when rigging combination ladders.
- Returned the pilot ladder davits to service after maintenance.
- Reviewed PPE provision across the fleet.
- Replaced PFDs with units compatible with onboard safety harnesses.
- Supplied additional handheld radios.
- Re-marked hazardous areas adjacent to pilot embarkation stations.
Actions taken by the maritime administration
- Reviewed and updated man overboard (MOB) recovery equipment.
- Expanded the digital training system to include permanent and temporary crew in MOB drills and recovery training.
- Published a training video on MOB recovery procedures.
Actions taken by the ship registry
- Issued a shipping notice updating the Merchant Shipping (Code of Safe Working Practices) Regulations 1989 so they refer to the latest edition of the UK Code of Safe Working Practices
https://safety4sea.com/wp-content/uploads/2026/07/UK-MAIB-World-Prize-Fall-Overboard-2026_07.pdf