202513 Unsafe gangway + impaired faculties = fatalities
Providing learning through confidential reports – an international co-operative scheme for improving safety
As edited from MAIB (UK) report 10/2024
A large wooden sail training vessel was moored at a shipyard ahead of a planned dry-docking. ‘Holding off’ lines were rigged and adjusted to keep the ship from touching the sides of the dock and the gangway was aligned with a gap in shoreside safety barriers.
A relief cook had joined the vessel while the permanent cook was away on leave. The relief cook received a handover from the permanent cook and an induction brief from the chief mate before starting his duties the next morning. On the following nights, the relief cook went ashore to a local bar where some of the other crew noted that he was drinking alcohol at levels that could be considered more than ‘normal’.
One night, the relief cook joined his shipmates at the bar where, over the next two and three-quarter hours, he was observed to drink at least nine double whiskies and ice. The relief cook was the last customer in the bar when he left near 23:00. Walking back to the vessel alone, he arrived about 10 minutes later.
CCTV footage shows the relief cook slowly ascended the gangway, pausing for a few seconds to step down towards the deck via the bulwark ladder. Then he fell from the left-hand (aft) side of the top of the gangway, landing with a splash into the water. Another crew member heard the noise and ran up from their cabin to the well deck, arriving within seven seconds of hearing the splash. He looked to starboard, towards the gangway, then went to check the port side of the well deck; as he did so there was further movement in the water directly underneath the gangway. The crew member stepped up onto the gangway and looked around for the source of the noise but saw nothing.
The crew member then walked ashore and searched the area forward of the gangway. After a few minutes of searching and not seeing anything of concern he retired to his cabin. At breakfast the next morning the crew noticed the relief cook was absent and started searching for him.
After a review of the port’s CCTV the police were called to search for the victim. Some hours later, his body was recovered to the jetty. The investigation found, among other things, that:
- The vessel’s gangway did not provide a safe means of access to/from the vessel. Specifically, inadequate fencing and an inappropriately rigged safety net exposed all gangway users to serious hazard as they traversed the gangway.
- There was a lack of guidance and training for those crew rigging and those inspecting the gangway before use.
- The victim was well above the legal limit of blood-alcohol content for duty on a vessel when he fell from the gangway. It is likely that he experienced cold shock on entering the water and that his state of intoxication hindered his ability to raise the alarm or attempt to self-rescue.
- There were early indications of a problem with the relief cook’s alcohol consumption, but this did not result in an effective intervention by his shipmates.
Lessons learned
- Safe access/egress to and from your vessel is literally where a strong safety culture starts. Make sure yours is safe.
- One for all and all for one. Look after yourself but also look out for your shipmates.
- Alcohol abuse is usually easy to spot amongst shipmates. Help them get professional help and do not indulge their impaired behaviour.