Safety and Communication Failures Led to Fatal Fall

September 29, 2024

The UK Marine Accident Investigation Branch (MAIB) has published its report into the death of a seafarer on the bulk carrier Equinox Seas whilst the vessel was undergoing scheduled maintenance in a yard.

On April 17, 2023, a crewman on board Equinox Seas was fatally injured when he fell 10m down an open ventilation trunk where a fan had been removed for maintenance by the shipyard. The fitter was recovered from the base of the ventilation trunk and moved to a local hospital, where he died from his injuries.

Source: MAIB
Source: MAIB

The investigation concluded he had passed a tape barrier placed across the entrance to the fan room access by the shipyard, possibly due to a reduction in alertness due to the time of day the accident occurred (about 1350).

The man was scheduled to work from 0800 to 1700, with an hour for lunch taken between 1200 and 1300. In the days leading up to 17 April 2023, the records of rest showed that his working hours exceeded those in the published schedule and that he had worked routinely from 0700 to 1800 with an hour for lunch and two short breaks in the morning and afternoon. This working pattern did not breach Maritime Labour Convention (MLC) rest requirements.

The MAIB concluded that the barrier controls in place in the fan room were insufficient to mitigate the risk of falling from height, and the specific risks associated with the fan removal had not been assessed or mitigated.

Safety on board Equinox Seas was not effectively managed during the entire stay at the shipyard, and ineffective communication and coordination between the shipyard and ship’s staff meant that deficiencies of safety management were not addressed.

Relevant industry guidance on the management of safety in a shipyard was not incorporated into the working practices of the shipyard. The Code of Safe Working Practices for Merchant Seafarers did not contain any guidance related to the risks created or amplified on ships in a shipyard environment.

Following the accident, the ship’s management company, Equinox Maritime, amended its safety management system to address risks arising in a shipyard environment.

MAIB has recommended that ONEX Syros Shipyards in Greece update its safety management system to ensure that risks created by the work carried out by its workers are effectively managed and coordinated with a ship’s crew and that the responsibility for safety is clearly understood between all parties.


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