REPUBLIC OF THE MARSHALL ISLANDS

Maritime Administrator

ELANDRA BALTIC CASUALTY INVESTIGATION REPORT

Man Overboard

Port Approaches Fos-sur-Mer, French Republic | 13 April 2020

Official Number: 4371 IMO Number: 9482562

Published by: Republic of the Marshall Islands Maritime Administrator on 12 November 2021
 DISCLAIMER
In accordance with national and international requirements, the Republic of the Marshall Islands
Maritime Administrator (the “Administrator”) conducts marine safety investigations of marine
casualties and incidents to promote the safety of life and property at sea and to promote the prevention
of pollution. Marine safety investigations conducted by the Administrator do not seek to apportion
blame or determine liability. While every effort has been made to ensure the accuracy of the information
contained in this Report, the Administrator and its representatives, agents, employees, or affiliates
accept no liability for any findings or determinations contained herein, or for any error or omission,
alleged to be contained herein.

Extracts may be published without specific permission providing that the source is duly acknowledged;
otherwise, please obtain permission from the Administrator prior to reproduction of the Report.

AUTHORITY
An investigation, under the authority of the Republic of the Marshall Islands laws and regulations,
including all international instruments to which the Republic of the Marshall Islands is a Party, was
conducted to determine the cause of the casualty.

Maritime Administrator

Please submit questions to: 11495 Commerce Park Drive, Reston, Virginia 20191-1506 USA | tel: +1 703 620 4880 | fax: +1 703 476 8522 | [email protected]
TABLE OF CONTENTS

LIST OF ABBREVIATIONS 7

PART 1: EXECUTIVE SUMMARY 8

PART 2: FINDINGS OF FACT 9

PART 3: ANALYSIS 18

PART 4: CONCLUSIONS 21

PART 5: PREVENTIVE ACTIONS 21

PART 6: RECOMMENDATIONS 22
 List of Abbreviations

LIST OF ABBREVIATIONS

7
4/O. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fourth Officer

ASD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Able Seafarer Deck

C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Celsius

ECDIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Electronic Chart Display and Information System

ILO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . International Labour Organization

IMO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . International Maritime Organization

ISM Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . International Management Code for the Safe

Operation of Ships and for Pollution Prevention

m. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Meters

MLC, 2006. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Maritime Labour Convention, 2006

MOB. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Man Overboard

MRCC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Maritime Rescue Coordination Center

NM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nautical Miles

OOW. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Officer of the Watch

PA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Public Address

PPE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Personal Protective Equipment

SAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Search and Rescue

SOLAS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . International Convention for the Safety of Life at Sea, 1974

STCW Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Seafarers Training, Certification and Watchkeeping Code

T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . True

UHF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ultra High Frequency

VHF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Very High Frequency

VTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vessel Traffic Service

Part 1: Executive Summary

PART 1: EXECUTIVE SUMMARY

On 13 April 2020, the Republic of the Marshall Islands-registered chemical/oil products tanker ELANDRA BALTIC,
managed by LSC SIA (the “Company”), was preparing for arrival at Fos-sur-Mer, French Republic (hereinafter, “France”)
to discharge a cargo of diesel.

At 0515,1 the Bosun and ASD2 commenced rigging the combination pilot ladder on the ship’s port side while preparing to
embark a pilot. After they lowered the accommodation ladder over the side, they noticed that the lower platform was not
parallel to the water and needed adjusting. The ASD2 went down the ladder without wearing the PPE required for working
over the side (outboard). He fell overboard while securing the lower platform. The subsequent SAR operation did not find
the ASD2.

The marine safety investigation conducted by the Republic of the Marshall Islands Maritime Administrator (the
“Administrator”) identified the following:

1. Causal factors that contributed to this very serious marine casualty include:
Republic of the Marshall Islands Maritime Administrator

(a) the lower platform for the port side accommodation ladder dropping as the ASD2 stood up after changing its
position without properly securing it;
(b) a reduction in the effectiveness of the Toolbox Talk due to its short duration as the attention of the Master
and 4/O was divided between navigating the ship and the review of the Company’s procedures for rigging
accommodation ladders, the required PPE, and the relevant risk assessments;
(c) not using the PPE required by the Company’s SMS while working outboard;
(d) ineffective supervision by the 4/O of the Bosun and the ASD2 while they rigged the combination pilot ladder;
(e) lack of communications between:

1 Unless otherwise stated, all times are ship’s local time (UTC +2).
 Part 1: Executive Summary / Part 2: Findings of Fact

(i) the Responsible Officer (4/O) and the two crewmembers who were rigging the combination pilot ladder
regarding the need to reposition the lower platform; and
(ii) the Bosun, Master, and 4/O to ensure they were aware that the ASD2 had gone down the accommodation
ladder; and 9
(f) crewmembers not identifying an unsafe condition and
subsequently not exercising their stop work authority to
SHIP
correct an unsafe condition as:
PARTICULARS
(i) neither the Master nor the 4/O directed the Bosun and the
ASD2 to stop work when they saw them start to rig the Ship Name
pilot ladder without using required PPE; and ELANDRA BALTIC
(ii) the Bosun did not direct the ASD2 to not go down the Registered Owner
accommodation ladder when he saw him step onto it Elandra Baltic Shipping Ltd.
without wearing the required PPE. ISM Ship Management
LSC SIA
2. Causal factors that may have contributed to this very serious marine
Flag State
casualty include:
Republic of the Marshall Islands
(a) inadequate preparedness for the MOB emergency as indicated
by the failure to deploy an MOB buoy and turning to starboard
IMO No. Official No. Call Sign
when beginning a single turn maneuver (Anderson turn) to 9482562 4371 V7WR2
recover the ASD2, who had fallen overboard on the ship’s
port side; and Year of Build Gross Tonnage
2011 29,736
(b) ineffective communications between the Master and OOW
(4/O) after the ASD2 was reported to have fallen overboard. Net Tonnage Deadweight Tonnage
14,113 51,406

Length x Breadth x Depth

PART 2: FINDINGS OF FACT 175.7 x 32.2 x 19.1 m

The following Findings of Fact are based on the information obtained

Ship Type
during the Administrator’s marine safety investigation. Due to travel Chemical/Oil Products Tanker
restrictions imposed in response to the COVID-19 pandemic, the
Document of Compliance
Administrator was not able to attend on board as part of its marine safety Recognized Organization
investigation of this very serious marine casualty. All related information Lloyd’s Register
available to the Administrator was obtained remotely.
Safety Management Certificate
Recognized Organization
1. Ship particulars: see chart to right. Lloyd’s Register
Classification Society
2. On the morning of 13 April 2020, ELANDRA BALTIC was Lloyd’s Register
preparing for arrival at Fos-sur-Mer, France to discharge a cargo of
Persons on Board
diesel. The freeboard was about 7 m. The Master had the conn. The
20
other bridge team members were the OOW (4/O) and a helmsman.
 Part 2: Findings of Fact

3. The weather was reported as good with winds of Beaufort Force 3 from the southeast, seas of 1 m, visibility greater
than 5 NM, and a cloudy sky. Civil twilight2 started at 0556 and sunrise was at 0701. The air temperature was
15°C and the sea water temperature was 16°C.

10 Rigging the Combination Pilot Ladder

4. At 0500, the ship received instruction from the Fos-sur-Mer Pilot Station to prepare the ship’s port side combination
pilot ladder. The OOW called the Bosun and ASD2 to rig the ladder.

5. The Master conducted an informal Toolbox Talk with the Responsible Officer (4/O), Bosun, and ASD2 on the
Bridge to review the work that needed to be completed. It was reported that the Company’s procedures and PPE
requirements for rigging the accommodation ladder and the ship’s risk assessments for rigging the ladder and for
working outboard were also reviewed.3

6. Preparations for rigging the combination pilot ladder included ensuring there was adequate lighting on deck, putting
a lifebuoy with a self-activating light at the pilot boarding station, and putting on lifejackets and safety harnesses
with safety lines.

7. At 0515, the Bosun and ASD2 started rigging the combination pilot ladder. This included securing the lower
platform of the port side accommodation ladder in position, raising and securing the railings, and then lowering the
ladder over the side. The OOW monitored the Bosun and ASD2 from the Bridge while they completed this work.

8. The Master and OOW reported seeing the Bosun and ASD2 take off their lifejackets and safety harnesses with
lines after lowering the accommodation ladder. The Bosun said they did this to make it easier to move as they
lowered the pilot ladder over the side and secured it in position.

9. The pilot ladder can be rigged in one of three positions (see Figure 1). The pilot ladder is located at either of the
two forward positions when a combination pilot ladder is rigged. On 13 April 2020, the pilot ladder was rigged
in the middle position. Access to this location was through an opening in the ship’s guardrail that could be closed
using chains. The guardrail had to be open when rigging or recovering both the accommodation and pilot ladders.
Republic of the Marshall Islands Maritime Administrator

Figure 1: A portion of the ship’s General Arrangement drawing showing the location of the pilot boarding area on the starboard side. The
arrangements on the port side are identical. The position where the pilot ladder was rigged on 13 April 2021 is circled in red.

2 Civil twilight is a period of incomplete darkness that starts in the morning when the center of the sun is 6° below the horizon.
3 Details of the Company’s procedures and these risk assessments are discussed later in the report.
 Part 2: Findings of Fact

10. The Bosun reported that they decided, after rigging the pilot ladder, that the lower platform of the accommodation
needed adjusting to be parallel with the water. The ASD2 then went down the accommodation ladder without
putting back on his lifejacket and safety harness.

11. The lower platform is held in position by a securing pin that passes through one of four sets of holes in the angle 11
bracket, which is bolted to the accommodation ladder, and a hole in the rectangular bar welded to the lower
platform (see Figure 2). The angle of the lower platform is determined by which set of holes on the angle bracket
that the securing pin is passed through.

Figure 2: On the left is a drawing of the lower platform of the accommodation ladder showing the angle bracket and plate (circled in red). On the
right is a picture of the angle bracket, plate, and securing pin. The lower platform was not secured in position when the picture was taken.

12. Changing the angle of the lower platform after the accommodation ladder was lowered required the ASD2 to
crouch down to reach and remove the securing pin with one hand while using his other hand to hold onto a rope
that was attached to the platform to keep it from dropping. He then used this rope to reposition and hold the
platform at the intended angle while he put the securing pin in the proper set of holes. Maintaining three points
of contact with the ladder while removing the securing pin and then putting it back in place required him to hold
onto the ladder with the same hand that he used to hold onto the rope that was attached to the platform.

Incident Description
13. At 0529, the ASD2 fell overboard. The Bosun immediately reported the MOB to the Bridge and then started
running aft. At the time, ELANDRA BALTIC was 3 NM south southwest of Cap Couronne. The ship’s speed was
6.4 knots.

14. The Bosun stated the ASD2 fell overboard when the lower platform dropped as he was standing up.

15. The ASD2 was wearing orange coveralls without any reflective material when he fell overboard.

16. The Bosun threw a lifebuoy toward the ASD2 as soon as he reached the ship’s stern. The Bosun stated he lost sight
of the ASD2 when he was about 100 m astern of the ship. The Bosun provided continuous updates using his
handheld radio to the Bridge regarding the ASD2’s position until he lost sight of him.

17. The Master and OOW began implementing the ship’s MOB response procedure immediately after receiving the
Bosun’s report that ASD2 had fallen overboard. About twenty seconds after the MOB was reported, the Master
ordered the rudder hard to starboard.
 Part 2: Findings of Fact

18. Other actions taken included activating the ECDIS’ MOB marker, sounding the General Alarm, announcing the
MOB on the ship’s public address system, broadcasting a MAYDAY, and reporting the MOB to Fos-sur-Mer port
control and the pilots by VHF radio.

12 19. An MOB buoy4 was not released. The Master reported that he thought it had been released after hearing the
Bosun’s report that a lifebuoy had been thrown overboard and had not directed the OOW to release the MOB buoy.

20. At 0531, additional lookouts were posted, and the crewmembers started preparing the ship’s rescue boat for
launching. Within minutes the rescue boat was ready to be launched.

SAR Operation
21. Between 0538–0554, MRCC La Garde directed a SAR boat and two pilot boats to get underway along with a civil
security helicopter to launch and search for the ASD2. The MRCC also suspended all vessel traffic in the approaches
to Fos-sur-Mer.

22. By 0541, ELANDRA BALTIC completed a single turn maneuver and reached the position where the ASD2
fell overboard.

23. By 0610, the pilot boats had arrived on scene and began searching.

24. At about 0645, the Pilot assigned to ELANDRA BALTIC decided to embark the ship to assist the Master and
coordinate with MRCC La Garde during the SAR operation. He reported that when the pilot boat approached
the ship, he saw the lower platform of the accommodation ladder hanging down. He also saw a line connected
to the platform leading up to the ship’s deck. He informed the Master by radio. He then saw a crewmember wearing a
harness and safety line go down the accommodation ladder and secure the platform.

25. When the lower platform was checked by a crewmember before being secured so the pilot could board, the securing
pin was found through one of the four sets of holes in the angle bracket. It did not pass through the hole in the bar
welded to the lower platform (see Figure 3).
Republic of the Marshall Islands Maritime Administrator

Figure 3: The lower platform of the accommodation shown as found after the ASD2 fell overboard. These pictures were taken while the ship was
at anchor after the SAR operation was suspended. The securing pin had not been passed through the hole on the bar welded to the platform when
it was put through the holes on the angle bracket.

4 This is a lifebuoy with a self-activating light and smoke signal that can be released from the Bridge. See SOLAS chapter III, regulation 7.1.3.
 Part 2: Findings of Fact

26. By 0700, the Pilot had safely embarked the ship and was on the Bridge assisting the Master.

27. At 0730, the ship’s lifebuoy was recovered by one of the pilot boats just over 1 NM to the north of ELANDRA
BALTIC’s position where the ASD2 fell overboard.
13
28. At 1005, MRCC La Garde suspended the SAR operation.

29. The estimated survival time in 16°C temperature water for an uninjured person in working clothes (coveralls) is about
1–3 hours.5

ELANDRA BALTIC Crew

30. ELANDRA BALTIC had 20 crewmembers on board, four more than required by the Minimum Safe Manning
Certificate issued by the Administrator. All held the appropriate Republic of the Marshall Islands-issued seafarer
documentation required for their position on board.

31. The experience of the involved crewmembers and those who were on the Bridge when the incident occurred:

RANK TIME ON BOARD TIME IN RANK TIME WITH TOTAL TIME

ELANDRA BALTIC COMPANY AT SEA
Master 2 months 5 years, 7 months 7 years, 1 month 25 years
4/O 2 months 1 year 3 years, 1 month 11 years, 10 months
Bosun 5 months 15 years 20 years 32 years
ASD1 5 months 5 months 1 year, 5 months 1 year, 5 months
ASD2 8 months 20 years 5 years 35 years, 10 months

32. Both the Bosun and ASD2 were very experienced seafarers. They were familiar with the PPE required when
working outboard and with rigging combination pilot ladders.

33. Both the Bosun and the ASD2 completed the required familiarization training after signing on ELANDRA BALTIC.
They had also participated in onboard work safety training, which included procedures for working outboard,
conducted on 1 April 2021.

34. The Administrator found no indications that any crewmembers involved with this incident had not received the
amount of rest mandated by the STCW Code, Section A-VIII/1, paragraphs 2 and 3 and MLC, 2006, regulation 2.3.

35. Alcohol testing conducted later in the morning on 13 April 2021 found 0.0% blood alcohol in the Master, other
members of the bridge team, and the Bosun.

Company SMS Procedures and Emergency Readiness

36. As required by the ISM Code, the Company’s SMS provides procedures and required PPE for shipboard operations
and maintenance. These include general procedures for safe work and specific procedures for rigging combination
pilot ladders.

5 See Transport Canada, Survival in Cold Waters: Staying Alive (Publication TB13822E), p. 16.
 Part 2: Findings of Fact

37. The Company’s general safe work procedures require that all shipboard work be performed under the general
supervision of a ship’s officer. The supervisor’s duties include:
(a) ensuring work is properly planned;
14 (b) ensuring that crewmembers who will perform the work understand their role and the tasks that need
to be completed;
(c) examining the workplace; and
(d) verifying PPE requirements.

38. These general safe work procedures require the assigned supervisor or other experienced crewmember conduct a
Toolbox Talk with the crewmembers assigned to perform the work. The Toolbox Talk must be documented and is
supposed to:
(a) review planned work, including the sequence of tasks to be performed;
(b) review the procedures to be followed, including required tools, PPE, and communications;
(c) review who is supervising the job, who is performing it, and the specific role and responsibilities of each
person; and
(d) determine if the procedures are correct, the assigned crewmembers are appropriately qualified, if there is
adequate supervision, and if the PPE is adequate.
39. Based on available information, there is no indication that the Toolbox Talk conducted by the Master was
documented as required by the Company’s procedures.

40. The Company’s general safe work procedures emphasize the importance of every crewmember taking responsibility
for their own safety, regardless of their position on board. To support this, the Company requires that all
crewmembers conduct an informal or individual risk assessment before starting any shipboard task, even when there
are time pressures to complete the work.

41. The informal risk assessment is similar to the hazard assessment conducted as part of a Toolbox Talk and is intended
to be conducted without a checklist. The requirement for crewmembers to complete an informal risk assessment
is included as part of the Company’s familiarization training that is completed when a seafarer signs on board a
Company managed ship.
Republic of the Marshall Islands Maritime Administrator

42. The Company’s general safe work procedures include a requirement for all crewmembers to routinely observe
and note any at-risk behavior so that it can be corrected immediately; this includes self-monitoring. Crewmembers
carry Stop Work Authority pocket cards and are authorized to stop any job if they feel it is not being conducted
safely. In accordance with these procedures, the job is supposed to be resumed when the observed safety issues
are resolved to the satisfaction of the crewmember who exercised the stop work authority.

43. The Company’s specific procedures for working outboard or aloft require that a Work Outboard/Aloft Permit be
issued before starting any work in these locations. These procedures also include the following special precautions
when rigging or unrigging the accommodation ladder as part of a combination pilot ladder when the ship is underway:
(a) completing a risk assessment and Toolbox Talk;
(b) providing an adequate lee;
 Part 2: Findings of Fact

(c) that the work be conducted by at least two experienced and properly trained ship’s crewmembers working
under a deck officer’s general supervision;
(d) that all required PPE, including safety harness with safety line, lifejacket, and safety helmet secured with
a chin strap be worn by any crewmember working outboard; 15
(e) that adequate lighting be provided;
(f) that a lifebuoy with lifeline be immediately available; and
(g) that the crewmembers be actively monitored from the Bridge.

44. Based on the available information, there is no indication that a Work Outboard/Aloft Permit was issued before the
Bosun and the ASD2 started rigging the combination pilot ladder.

45. On 16 February 2020, the ship’s Master and deck officers completed a risk assessment for rigging an accommodation
ladder. This assessment was valid through 16 May 2020. The hazards and associated existing controls that were
identified by this risk assessment included: 6

HAZARD HAZARD DESCRIPTION EXISTING CONTROLS

Crewmembers do not
Unsafe operation due to insufficient • Work team instruction on
follow operational
qualifications/experience/training safe work procedures
procedures

• Work to be done under the control

of the OOW
• UHF radio communications with
the Bridge
Falling overboard during rigging of • Persons working outboard must
Falling overboard the accommodation ladder at sea, in wear a lifejacket, safety harness
port, or at anchor with safety line attached to a strong
structure, and a safety helmet
• If a crewmember falls overboard a
lifebuoy must be thrown and MOB
announced

• Working areas adequately lit and

cleared of incidental objects
• Use of appropriate PPE
Slip, trip, and fall hazards Unsafe movement on ship • Workplace assessment by
responsible officer
• Safety Officer’s monthly
inspections of access ladders/decks

6 The other identified hazards were movement of the ship due to weather and sea conditions and equipment failure.
 Part 2: Findings of Fact

46. Some of the hazards and associated existing controls identified by the risk assessment for working outboard that
were reviewed by the Master, 4/O, Bosun, and ASD2 included:7

16 HAZARD HAZARD DESCRIPTION EXISTING CONTROLS

• All essential information gathered

prior to commencement
• Assignment of standard duties for
Work not properly planned (without the crewmembers
Improper work planning taking into account all reasonably
foreseeable risks) • Risk assessment conducted and
approved by the Master
• Works directly supervised by
Responsible Officer

• Crewmember familiarization with

planned operation
Unsafe work outboard due to person’s • Daily work planning meeting
Crewmember unsafe acts insufficient qualifications, experience,
or training • Toolbox Talks
• Informal risk management
implemented

• Working areas adequately lit and

cleared of incidental objects
• Use of appropriate PPE
Slip, trip, and fall hazards Unsafe movement on ship • Workplace assessment by
responsible officer
• Safety Officer’s monthly
inspections of access ladders/decks

• Workplace familiarization
regarding safe work practices

Hazards associated with lack of • PPE requirements

Republic of the Marshall Islands Maritime Administrator

Personnel safety hazards proper PPE, defective equipment • Nomination of Responsible Officer
used when working outboard and assignment of crewmembers
involved in the task
• Inspection of equipment to be used

Lack of means of communication • Check UHF radios to ensure

Failure of communications between persons working outboard, batteries are charged and working
standby crew, and OOW properly

7 The other identified hazards were crewmember fatigue, adverse weather conditions, damaged equipment, inadequate pre-task inspection of equipment, fire/explosion,
and inexperienced or new crewmembers.
 Part 2: Findings of Fact / Part 3: Analysis

47. No additional controls were identified when the Master reviewed the risk assessment for rigging the accommodation
ladder nor for working outboard with the 4/O, Bosun, and ASD2.

48. The Company requires an MOB drill be conducted at least once a month. It also requires the drill be repeated
if the Master determines that the crewmember’s performance was assessed as unsatisfactory. The last two MOB drills 17
before this incident were conducted on 19 February 2020 and 17 March 2020. The Master’s evaluation of these
drills did not include any remarks.

PART 3: ANALYSIS
The following Analysis is based on the above Findings of Fact.

ASD2’s Fall Overboard

The Bosun stated that the ASD2 fell overboard when the lower platform of the accommodation ladder dropped as he
stood up after changing its position. After the incident, the platform was checked and it was determined that it had not
been properly secured (see Figure 3) when adjusted by the ASD2.

Changing the angle of the lower platform when the accommodation ladder was lowered over the ship’s side required
the ASD2 to crouch down to reach and remove the pin used to secure the platform in position. The position of the
platform was adjusted using a rope connected to it. To do this the ASD2 would have used one hand to hold the rope
to keep the platform in position while using his other hand to put the pin in the proper holes. This awkward position
and the limited lighting would have made it difficult for him to determine if the hole in the bar on the platform was
aligned with the intended set of holes in the angle bracket before putting the securing pin in position.

The platform would not have dropped if the securing pin had been passed through the set of holes in the angle bracket
on the accommodation ladder and the hole in the bar welded to the platform (see Figures 2 and 3).

The ASD2 was not wearing a lifejacket when he fell overboard. The incident occurred about 30 minutes before the start
of civil twilight and 90 minutes before sunrise. Darkness and the fact that he was wearing orange coveralls without
any reflective material would have made him hard to see from the helicopters and vessels that were searching for him.

In addition to not wearing a lifejacket, the ASD2 was also not wearing a safety harness with a safety line attached to
the ship when he fell. If he had, it could either have prevented him from falling off the accommodation ladder or have
made it possible for the ship’s crewmembers to bring him back on board.

Company Procedures
The Company has general safe work procedures in place to ensure that crewmembers could safely perform various
shipboard tasks. These included a requirement that all shipboard work be performed under the general supervision of a
Responsible Officer who is responsible for:
• ensuring that work is properly planned;
• ensuring crewmembers assigned to perform the work understand their role and the tasks that need to be completed;
 Part 3: Analysis

• examining the workplace; and

• verifying PPE requirements.

18 They also require that a Toolbox Talk be conducted and documented before starting any planned work.

The Company’s general safe work procedures stress the importance of all crewmembers taking responsibility for their
own safety and include a requirement for crewmembers to complete an informal risk assessment before starting any
shipboard task. The general safe work procedures also authorize all crewmembers to stop the job if they observe an
unsafe condition or behavior.

The Company’s specific procedures for working outboard or aloft require that a Work Outboard/Aloft Permit be issued
before starting any work in those locations. They also include special precautions when rigging or unrigging the
accommodation ladder as part of a combination pilot ladder when the ship is underway. These procedures and the ship’s
risk assessments for rigging the accommodation ladder and for working outboard addressed the primary hazards
associated with rigging a combination pilot ladder.

Both the general safe work procedures and the task-specific procedures must be consistently implemented to be effective.

Toolbox Talk
As required by the Company’s general safe work procedures, the Master conducted an informal Toolbox Talk on the
Bridge with the 4/O, Bosun, and ASD2 to rig the combination pilot ladder. This included a review of the Company’s
procedures for rigging accommodation ladders, the required PPE, and the relevant risk assessments before the Bosun
and ASD2 went out on deck to rig the combination pilot ladder. The Toolbox Talk was not documented as required
by the Company’s safe work procedures.

For a Toolbox Talk to be effective, the person conducting it and those who are participating should be focused on the
information discussed. The Toolbox Talk conducted in preparation for rigging the combination pilot ladder was held
on the Bridge as the ship approached the Fos-sur-Mer Pilot Station and involved the Master, who had the conn, and
the 4/O, who was the OOW. This would have required the Master and the 4/O to divide their attention between
navigating the ship and completing the Toolbox Talk.
Republic of the Marshall Islands Maritime Administrator

A Toolbox Talk should also be of sufficient length to address the planned work, review the relevant procedures, PPE
requirements, and risk assessments. Considering that the Bosun and ASD2 were called to the Bridge shortly after
0500 when the ship received instructions from the Fos-sur-Mer Pilot Station to prepare the port side combination
ladder and that they started rigging the ladder at 0515, this meeting was unlikely long enough to address these issues.

Rigging the Combination Pilot Ladder

The Company’s specific procedures for working outboard or aloft require that a Work Outboard/Aloft Permit be
issued since rigging the pilot ladder would have required the Bosun and the ASD2 to work outboard of the guardrail.
A work permit was not issued for this task.
 Part 3: Analysis

The Bosun and ASD2 went on deck after the Toolbox Talk was completed, put on the required PPE, and rigged the
port side accommodation ladder without incident. The angle of the lower platform was set before the accommodation
ladder was lowered over the side.

19
Both the Bosun and the ASD2 removed their lifejackets and safety harnesses with safety lines before they started
rigging the pilot ladder. The reason given for removing this PPE was to make it easier for them to move while lowering
the pilot ladder over the side and securing it in position.

Falling overboard is a hazard commonly associated with tasks requiring seafarers to work near or over the side, including
rigging a pilot ladder. The Company’s SMS included several requirements intended to reduce not only the potential
of a seafarer falling overboard, but of the potential severity of the consequences of such an incident. It was reported
that these were reviewed during the Toolbox Talk conducted before the Bosun and ASD2 rigged the combination
pilot ladder.

Both the Bosun and ASD2 each had over 30 years of experience. Based on this, they should have reasonably been
aware of the potential for falling overboard and the PPE needed (lifejacket, safety harness, and safety line) to manage this
hazard while rigging the pilot ladder.

Supervision
The Company’s procedure for rigging the accommodation ladder and the ship’s related risk assessments required that
the Responsible Officer supervise the work while it was completed. The Company’s procedures also required that the
work be monitored from the Bridge by the OOW. The 4/O was the OOW and had also been appointed as the Responsible
Officer for rigging the port side combination pilot ladder. Although the 4/O and the Master monitored the work from
the Bridge, the 4/O was not able to leave the Bridge to directly supervise the Bosun and ASD2 as they rigged the
combination pilot ladder.

The 4/O and the Master both indicated they were aware that the Bosun and the ASD2 had taken off their lifejackets
and safety harnesses with safety lines after they completed rigging the accommodation ladder. Based on the available
information, it is not clear if they became aware of this either before or after the Bosun and the ASD2 started rigging
the pilot ladder.

There is also no indication that either the Master or the 4/O informed them that an unsafe condition existed and directed
them to stop work until they had put the required PPE back on.

According to the Bosun, it was the ASD2 who determined the position of the lower platform needed to be changed after
they finished rigging the pilot ladder. There is no suggestion the Bosun agreed with this assessment. There is also no
indication that either the Bosun or the ASD2 informed the 4/O it was necessary to change the position of the platform
before the ASD2 started down the accommodation ladder.

Although the Bosun said he monitored the ASD2 while he was on the ladder, there is no indication that he identified
the ASD2’s actions as unsafe or that he attempted to exercise his stop work authority and require the ASD2 to come
back up on deck.
 Part 3: Analysis

Communications
There is no indication that either the Bosun or ASD2 made either the 4/O or Master aware that the lower platform
was not parallel to the water and needed adjusting. There is also no indication that the Bosun ensured that the Master
20 and 4/O were aware that the ASD2 had gone down the accommodation ladder to adjust the platform.

MOB Response
MOB drills were conducted on board ELANDRA BALTIC once a month. The most recent drill conducted before
this incident was held on 17 March 2020. The Master’s evaluation of the drill did not include any remarks. The Master,
4/O, Bosun, and ASD2 all participated in this drill.

The Bosun responded immediately after seeing the ASD2 fall overboard by informing the OOW of the MOB
emergency, keeping sight of the ASD2 for as long as possible, throwing him a lifebuoy, and providing continuous
updates to the OOW. These are all standard actions when responding to an MOB.

After receiving the Bosun’s initial report, the Master immediately ordered the rudder hard to starboard while the OOW
activated the General Alarm, announced the MOB emergency over the ship’s PA system, and marked the position
on the ship’s ECDIS. He also maintained communications with the Bosun. The MOB buoy was not released.

An MOB buoy should be deployed as soon as possible after a person is reported to have fallen overboard. The MOB
buoy is equipped with a self-activating lighting and a smoke signal. Deploying this buoy as quickly as possible marks
the MOB incident position and facilitates the search by indicating the direction and rate of drift. It also can provide
flotation for the person in the water.

Deploying an MOB buoy is an action that a qualified OOW is expected to take without prompting from the ship’s
Master. As previously stated, it was reported that the Master misunderstood the OOW when he reported that a lifebuoy
had been thrown to the ASD2. The fact that an MOB buoy was not deployed indicates the OOW was not adequately
prepared to respond to an emergency. It also indicates ineffective communications between the Master and OOW.

Unless there is not sufficient sea room, a ship should be turned in the direction that corresponds with the side a person
is reported to fall overboard when maneuvering to start an MOB recovery. This is so that the ship’s stern turns away
Republic of the Marshall Islands Maritime Administrator

from the person who fell overboard, reducing the potential that he or she is struck by the ship’s hull, propeller, or rudder.

The ASD2 had fallen overboard from the ship’s port side. However, the Master immediately ordered the rudder hard
to starboard when maneuvering to recover the ASD2. Based on the information that is available, there was sufficient
sea room for ELANDRA BALTIC to have been safely turned to port while maneuvering to recover the ASD2.
 Part 4: Conclusions / Part 5: Preventive Actions

PART 4: CONCLUSIONS
The following Conclusions are based on the above Findings of Fact and Analysis and shall in no way create a presumption
of blame or apportion liability. 21

1. Causal factors that contributed to this very serious marine casualty include:
(a) the lower platform for the port side accommodation ladder dropping as the ASD2 stood up after changing
its position without properly securing it;
(b) a reduction in effectiveness of the Toolbox Talk due to its short duration as the attention of the Master and
4/O was divided between navigating the ship and the review of the Company’s procedures for rigging
accommodation ladders, the required PPE, and the relevant risk assessments;
(c) not using the PPE required by the Company’s SMS while working outboard;
(d) ineffective supervision by the 4/O of the Bosun and the ASD2 while they rigged the combination pilot ladder;
(e) lack of communications between:
(i) the Responsible Officer (4/O) and the two crewmembers who were rigging the combination pilot ladder
regarding the need to reposition the lower platform; and
(ii) the Bosun, Master, and 4/O to ensure they were aware that the ASD2 had gone down the accommodation
ladder; and
(f) crewmembers not identifying an unsafe condition and then subsequently not exercising their stop work
authority to correct an unsafe condition as:
(i) neither Master nor the 4/O directed the Bosun and the ASD2 to stop work when they saw them start to rig
the pilot ladder without using required PPE: and
(ii) the Bosun did not direct the ASD2 to not go down the accommodation ladder when he saw him step onto it
without wearing the required PPE.

2. Causal factors that may have contributed to this very serious marine casualty include:
(a) inadequate preparedness for the MOB emergency as indicated by the failure to deploy an MOB buoy and
turning to starboard when beginning a single turn maneuver to recover the ASD2 who had fallen overboard
on the ship’s port side; and,
(b) ineffective communications between the Master and OOW (4/O) after the ASD2 was reported to have
fallen overboard.

PART 5: PREVENTIVE ACTIONS

In response to this very serious marine casualty, the Company has taken the following Preventive Actions.

1. Immediately transmitted a safety alert making all ships in their fleet aware of the MOB incident and then distributed
the Company’s investigation report to all ships in their fleet.
 Part 5: Preventive Actions / Part 6: Recommendations

2. Included the Company’s investigation report in the pre-appointment briefing program for on-signing officers.

3. Arranged for additional training for the Master in ship handling, risk assessment, and shipboard safe work practices,
and for both the 4/O and Bosun, training in risk assessment and shipboard work practices.
22
4. Conducted an internal navigational audit and safety cultural assessment on board ELANDRA BALTIC.

5. Conducted a review of the Company’s procedures for working outboard or aloft and for MOB emergency response
and training.

6. Conducted a Work Overboard or Aloft Safety Campaign in May 2020.

PART 6: RECOMMENDATIONS
The following Recommendations are based on the above Conclusions and in consideration of the Preventive Actions taken.

1. It is recommended that the Company review and, if necessary, revise:

(a) onboard training, taking into consideration the lessons learned from this incident for:
(i) conducting pre-task hazard assessments;
(ii) the identification of unsafe conditions; and
(iii) exercising stop work authority; and
(b) its procedures for monitoring and assessing the performance of ships’ crewmembers with respect to their
compliance with the Company’s safe work practices.

The Administrator’s marine safety investigation is closed. It will be reopened if additional information is received that
would warrant further review.
Republic of the Marshall Islands Maritime Administrator