The UK Marine Accident Investigation Branch (MAIB) has published accident Investigation Report 9/19 into a fatal fall from height.  A crewman from the Cypriot registered ro-ro freight vessel Seatruck Pace died as a result of 4.5 metres fall through a vehicle ramp hatch.

The crewman was working alone and preparing to paint the leading edge of the open ramp hatch cover.  For reasons that could not be determined, the crewman crossed a temporary safety barrier guarding the edge of the open hatch and walked along a narrow deck edge between the ships side and the open hatch on which several trailer trestles were stowed.  The crewman’s fall was not witnessed but it is evident that he had fallen at or about the same time as one of the trestles.  He was treated at the scene before being taken to hospital.  He died three days later.

What went wrong?

• The crewman crossed a safety barrier protecting an open hatch;
• Risk seen as tolerable – the risk of falling was accepted, having probably taken similar risks in the past;
• Work practices indicated that adherence to the vessel’s safety procedures was based on routine rather than of understanding and conviction.

What actions were taken?

The following actions were taken by the owners:

• Reminded Masters of the dangers of bypassing safety control measures and prompted them to review the safety of deck openings;
• Provided safety chains, fittings and warning signs for use on the temporary barriers rigged on the main vehicle decks of its ferries;
• Reviewed its risk assessment and permit to work (PTW) concerning working at height;
• Introduced a procedure for recording the use of safety harnesses;
• Committed to ensuring that all Masters and safety officers complete a Maritime and Coastguard Agency safety officers’ training course;
• Completed a ‘safety culture survey’ among its senior management, and senior managers have attended the Health and Safety Executive’s (HSE) ‘Behaviour Change – Achieving Health & Safety Culture Excellence’;
• Engaged HSE consultants with the aim of forming a safety culture steering group and implementing the HSE’s ‘Safety Climate Tool’.