REPUBLIC OF THE MARSHALL ISLANDS

Maritime Administrator

ECO GALAXY MARINE SAFETY INVESTIGATION REPORT

Occupational Fatality

Port Klang Pilot Station, Malaysia | 30 August 2023

Official Number: 6293 IMO Number: 9715555

Published by: Republic of the Marshall Islands Maritime Administrator on 15 January 2025
 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 | [email protected]
TABLE OF CONTENTS

LIST OF ABBREVIATIONS AND ACRONYMS 6

DOCUMENTS CITED 7

PART 1: EXECUTIVE SUMMARY 8

PART 2: FACTUAL INFORMATION 9

PART 3: ANALYSIS 13

PART 4: CONCLUSIONS 17

PART 5: PREVENTIVE ACTIONS 18

PART 6: RECOMMENDATIONS 18
 LIST OF ABBREVIATIONS AND ACRONYMS

2/O. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Second Officer

6
3/O. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Officer

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

C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Degrees Celsius
°

E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . East

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

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

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

ISM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . International Safety Management

kn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Knots

LPG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Liquefied Petroleum Gas

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

mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Milligrams

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

MRSC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Maritime Rescue Sub-center

N. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . North

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

NMOHSC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . National Maritime Occupational Healty and Safety Committee

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

Republic of the Marshall Islands Maritime Administrator

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

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

SMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Safety Management System

UTC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Coordinated Universal Time

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

VTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vessel Traffic Services

 List of Abbreviations and Acronyms / Documents Cited

DOCUMENTS CITED

COSWP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Code of Safe Working Practices for Merchant Seafarers

7
MLC, 2006. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Maritime Labour Convention, 2006

MSC.1/Circ.1182/Rev.1. . . . . . . . . . . . . . . . . . . . . . . . . . IMO Maritime Safety Committee Guide to Recovery Techniques

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

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

Part 1: Executive Summary

PART 1: EXECUTIVE SUMMARY

On 30 August 2023, at 0005,1 ECO GALAXY picked up the Pilot at Port Klang pilot station, Malaysia. The ship
was proceeding with a speed over ground of 8 kn and there was squally weather, reducing the visibility. The 3/O and
ASD1 of ECO GALAXY welcomed the Pilot at the boarding area and, after completing the boarding procedures, the
3/O began to escort the Pilot to the Bridge. When leaving the boarding area, the 3/O and the Pilot heard a scream
and shouting for help. They then realized that the ASD1 had fallen overboard. The 3/O ran aft to throw a lifebuoy
to the ASD1 and meanwhile alerted the Master on the Bridge by means of his hand-held radio. The ASD1, who was not
wearing a life jacket, was not able to reach the lifebuoy.
Republic of the Marshall Islands Maritime Administrator

The pilot boat became aware of the situation and approached the ASD1 in the water. A crewmember on board the pilot
boat grabbed a lifebuoy with light and jumped into the water to rescue the ASD1. Without having succeeded in aiding
the ASD1, the crewmember was recovered by the pilot boat. After the pilot boat recovered their crewmember, sight of the
ASD1 was lost.

On 1 September 2023, during a SAR operation coordinated by MRSC Johor Bahru, the ASD1 was recovered deceased.

The Republic of the Marshall Islands Maritime Administrator’s (the “Administrator’s”) marine safety investigation
determined that the ASD1 most probably fell overboard while securing the rail chains of the pilot access point. The
investigation was not able to determine the cause of the ASD1’s death.

1 Unless stated otherwise, all times are ship’s local time (UTC +8).
 Part 1: Executive Summary / Part 2: Factual Information

The following lessons learned that were identified are that:

(a) the decision to enact a rescue attempt without proper
SHIP PARTICULARS
equipment or training carries a high degree of risk and
using rescue cradles or similar equipment can help to 9
successfully recover persons from the water;
Vessel Name
(b) the importance of proper oversight of crewmembers while ECO GALAXY
working on deck and during seamanship evolutions; and
Registered Owner
(c) suitable PPE should be worn when the risk of falling
Wolverines Inc.
overboard exists.
ISM Ship Management
Stealth Maritime Corporation S.A.
PART 2: FACTUAL
INFORMATION Flag State
Republic of the Marshall Islands
The following Factual Information is based on the information
obtained during the Administrator’s marine safety investigation.
IMO No. Official No. Call Sign
9715555 6293 V7LL5
ECO GALAXY Pilot Boarding Area
Year of Build Gross Tonnage
ECO GALAXY is a gas carrier built in 2015 in Shimonoseki 2015 5,320
City, Japan. The ship has a depth of 8.90 m and the designed draft
is 6.80 m. In laden summer draft condition, the Upper Deck is Net Tonnage Deadweight Tonnage
2.70 m above sea level. 1,995 5,878

Length x Breadth x Depth

110.11 x 18.2 x 8.9 m

Ship Type
Gas Carrier
Figure 1: ECO GALAXY General Arrangement plan. The location of the
starboard side pilot boarding area is shown in the red square.
Document of Compliance
Recognized Organization
Lloyd’s Register
There is a dedicated pilot boarding area on either side of the Upper
Deck, near the midship section on the ship’s port and starboard sides Safety Management Certificate
(see Figure 1), where the fixed railing is interrupted and replaced by Recognized Organization
Lloyd’s Register
two removable chains that are permanently secured to a stanchion on
one side and that can be opened by a hook on the opposite stanchion Classification Society
when the boarding area is in use. The pilot boarding area is painted Lloyd’s Register
with anti-skid paint. A lifebuoy with a light is located adjacent to
the boarding area (see Figure 2). Persons on Board
16
 Part 2: Factual Information

10

Figure 2: Starboard side pilot boarding area.

The starboard side pilot boarding area is illuminated with floodlights on deck and near the Navigation Bridge Deck. All
lights were working at the time of the incident.

Crew
ECO GALAXY had a complement of 16 crewmembers, two more than what was required by the Minimum Safe Manning
Certificate issued by the Administrator. All crewmembers were medically fit and in possession of valid certificates for
their assigned position.

The ASD1 was a 57 year old Filipino national who joined the Company in 2003 and had 13.7 years in rank. On 21 June
2023, he was declared medically fit for duty without restrictions and later joined ECO GALAXY on 15 July 2023. He
was diagnosed with an Atherosclerotic Aorta and Thoracic Spondylosis, but these conditions were not considered to
affect his ability to join a ship. The ASD1 was also diagnosed with Hypertension which needed to be controlled by
taking Amlodipine Besylate 10 mg (hereinafter “Amlodipine”) daily and lifestyle modification. Both the diagnosis and
the medication had been declared to the Company.
Republic of the Marshall Islands Maritime Administrator

Besides Amlodipine, Diclofenac (Philflam DR) 50 mg (hereinafter “Diclofenac”)2 and Paracetamol3 were also
encountered among the ASD1’s personal effects. The ASD1 had not declared to the Master or to the Company that he
was taking Diclofenac.

The ASD1 was working daily from 0800 to 1700 and was not assigned to a navigational watch. One of the ASD1’s
tasks was to install the pilot ladder and to welcome the Pilot on board regardless of the time of day. On 29 August 2023,

2 A non-steroidal anti-inflammatory drug, Diclofenac is a medicine that reduces swelling (inflammation) and pain. It is used to treat aches and pains, as well as problems
with joints, muscles, and bones (see https://www.nhs.uk/medicines/diclofenac/).
3 Paracetamol is a common painkiller used to treat aches and pain. It can also be used to reduce a high temperature (see https://www.nhs.uk/medicines/paracetamol-
for-adults).
 Part 2: Factual Information

the ASD1 worked the day shift from 0800 to 1700, installed the pilot ladder from 2030 to 2130, and started working
again at 2330 to welcome the Pilot.

The 3/O on board ECO GALAXY was a 51 year old Filipino national. He joined the ship on 2 April 2023 and had been
11
working with the company for 10 years, of which 4.5 years were in the rank of 3/O.

The Master on board ECO GALAXY was a 50 year old Filipino national. He joined the ship on 7 May 2023 and had
been working with the Company for 16.8 years, of which 8.1 years were in the capacity of Master.

The Administrator did not find any indication that any crewmembers involved with this marine casualty did not receive
the required amount of rest mandated by the IMO’s STCW Code, Section A-VIII/1, paragraphs 2 and 3 and the ILO’s
MLC, 2006, Regulation 2.3.

Narrative
On 29 August 2023, around 2000, ECO GALAXY was loaded with a butane / LPG mixture and the ship’s freeboard
was 2.70 m when the ship arrived near the pilot station at Port Klang, Malaysia. Around 2030, the ASD1 and ASD2
rigged the pilot ladder at the starboard side, about 1 m above sea level. Around the same time, ECO GALAXY was
informed that the Pilot would only embark around midnight, and subsequently the ship dropped anchor to wait for the
arrival of the Pilot.

At 2330, ECO GALAXY heaved up its anchor to meet the Pilot at the pilot station. Sunset was recorded at 1920, and
the weather was inclement with squally conditions and reduced visibility less than 5 NM. A Beaufort Force 5 westerly
wind was blowing. The sea was moderate with waves of approximately 1 m and a slight swell. Reportedly, the waves were
not significant for the size of the ship and the ship was not rolling. The outside temperature was 28°C. The seawater
temperature was 25°C. There was a westerly current, less than 1 kn.

Around midnight, the pilot boat approached ECO GALAXY. The Master had the con4 and he was assisted by the 2/O,
who had the 0000 to 0400 navigational watch. A Lookout and a Helmsman were also present and on watch on the
Bridge. ECO GALAXY’s speed was approximately 8 kn. The Master had switched on all the floodlights to have good
visibility on deck. The 3/O and the ASD1 proceeded to the starboard pilot boarding area to welcome the Pilot. They
were each wearing a raincoat, a safety helmet, safety shoes, a coverall, and gloves. Neither the 3/O nor the ASD1
were wearing a lifejacket. The 3/O was holding a hand-held radio to communicate with the Bridge.

On 30 August 2023 at 0005, the Pilot embarked ECO GALAXY. The 3/O reported to the Bridge that the Pilot had
safely boarded the ship. After completing the standard boarding procedures, the Pilot advised the 3/O and ASD1 to leave
the pilot ladder in the rigged position as he would use the same pilot ladder to disembark after berthing. The 3/O
then escorted the Pilot toward the Bridge and the pilot boat proceeded toward the port.

4 The person who has the con holds the authority to give helm orders and is responsible for the ship’s navigation and maneuvering.
 Part 2: Factual Information

When the 3/O and the Pilot were approximately 20 m away from the pilot boarding area, they heard a scream and
shouting for help in Tagalog.5 The 3/O and Pilot turned around and did not see the ASD1 on deck. When the 3/O
looked over the side, he saw a person floating in the water moving toward the starboard quarter of ECO GALAXY.

12
The 3/O assumed that it was the ASD1, based on the shouting he heard and as he could not locate the ASD1 on deck. The
3/O alerted the Bridge, by means of his hand-held radio, and ran toward the starboard quarter where he took a lifebuoy
with line and threw it to the ASD1. He was not able to observe if the ASD1 could reach the lifebuoy. Meanwhile on
the Bridge, the MOB position, 02°51.15'N, 101°15.22'E, was plotted on the ECDIS and the Master ordered all deck
and search lights switched to the on position (see Figure 3).

As the 3/O ran to the Poop Deck, the Pilot proceeded to the Bridge. The pilot boat that had just left when the MOB incident
occurred, proceeded toward the ASD1 in the water.

When the Pilot arrived on the Bridge, the Master immediately sought his advice to turn the ship around. Subsequently,
the Pilot contacted Port Klang VTS, but as the ship was sailing inside the navigation channel to Port Klang and the
depth outside of the channel was insufficient, the VTS advised to wait until passing Selat buoy.
Republic of the Marshall Islands Maritime Administrator

Figure 3: Track of ECO GALAXY from anchorage.

Meanwhile, a crewmember on board the pilot boat grabbed a lifebuoy with a light and jumped into the water to rescue
ASD1. Reportedly, the ASD1 was unable to grab the lifebuoy or to grab the hand of the crewmember and appeared
non-responsive. The crewmember from the pilot boat was recovered from the water, and by the time the crewmember
was on board the pilot boat, the ASD1 was out of sight.

5 Tagalog is a Philippine language. Although the working language on board was English, Tagalog was often used between crewmembers as their local language.
 Part 2: Factual Information / Part 3: Analysis

After the Pilot’s VHF call to VTS, the Pilot hailed the pilot boat in Malay by means of VHF. At 0012, the pilot boat
informed the Pilot on board ECO GALAXY that the pilot boat crewmember was recovered from the water. Based
on the information received from the pilot boat, the Pilot and the Master wrongly assumed that the ASD1 was rescued.
By 0018, it became clear that the ASD1 was still in the water and out of sight of the pilot boat. ECO GALAXY
13
had now reached the Selat buoy and the Master immediately ordered the Pilot to turn the ship around. At 0020, the
general alarm was sounded to muster all the crewmembers to assist in the search for the ASD1 in the water.
The Operator, agent, and local authorities were informed that an MOB incident had occurred. Port Klang Traffic
Control and West Port Control were contacted to request assistance to find the ASD1.

At 0124, ECO GALAXY anchored approximately 1 NM north of the MOB position to avoid hindering the traffic and
installed a sharp lookout. Shortly thereafter, the Pilot disembarked.

In the morning of 30 August 2023, the Malaysian Navy and Coast Guard initiated a SAR operation to locate the ASD1.
Later that morning, ECO GALAXY received permission to proceed to port.

MRSC Johor Bahru coordinated the SAR operation from 1230 onward. On 1 September 2023 at 1027, the ASD1 was
found deceased in the water.

PART 3: ANALYSIS
The following Analysis is based on the above Factual Information.

Cause of Fall Overboard

No crewmembers witnessed the fall of the ASD1 overboard. The 3/O and the Pilot were walking toward the
accommodation and had their backs toward the ASD1. The 3/O assumed that the ASD1 was following him together
with the Pilot. He was not aware of the ASD1’s activity at that moment. The pilot boat, having just turned away from
ECO GALAXY was no longer witnessing activities on board the ship.

As the Pilot had informed the 3/O and the ASD1 that the pilot ladder could be kept in place, no handling was required
other than closing the two removable chains (see Figure 2). Most probably, the ASD1 fell overboard while attempting
to close the chains between the two upright stanchions but the reason for falling overboard could not be determined
with certainty. It was possible that the ASD1 slipped on the wet deck despite the anti-skid paint or that he tripped
over a part of the pilot ladder that was lying on deck or over a securing point on deck. As the activity of the ASD1
before falling overboard was not witnessed, it could not be excluded that he was checking or repairing a part of the
pilot ladder over the ship’s side and lost his balance.

Medical Condition
The ASD1 was diagnosed with Hypertension and was in possession of Amlodipine on board ECO GALAXY. There
was no indication that he was not taking the medication as prescribed.
 Part 3: Analysis

The ASD1 was also in possession of Diclofenac, a prescribed medicine that reduces inflammation and pain. During the
investigation, it could not be determined if any medical advice was given to the ASD1 to take Diclofenac whilst suffering
from Hypertension and/or to combine Diclofenac with other medication. When taking Diclofenac tablets or capsules,
more than 1 in 100 people encounter side effects such as nausea, vertigo, headaches, stomachache, or mild rash.6 The
14
ASD1 had not complained about any of the described side effects since he joined ECO GALAXY.

Two weeks before joining ECO GALAXY, on 21 June 2023, the ASD1 was medically examined and did not declare the
use of Diclofenac during this examination, nor did he declare it to the Company or the Master.

A copy of the autopsy report was not available for the Administrator’s investigation and thus it was not possible to confirm
or exclude any relationship between the medications that were taken and the fall into the water and any relationship
between the medical condition of the ASD1 and the cause of death.

Safety Culture
The SMS on board ECO GALAXY contains a PPE Matrix7 which stated that a buoyancy aid or a personal flotation device
should be used when working with boats, near the ship’s side, and when working over the ship’s side. The crewmember
involved in the transfer of persons was to wear a personal flotation device when installing the pilot ladder and during
the transfer of persons.8 As part of the familiarization procedure completed upon joining ECO GALAXY,9 both the 3/O
and the ASD1 were familiar with the PPE Matrix. Neither the ASD1 nor the 3/O were wearing a life jacket when the
Pilot boarded the ship and consequently were not complying with the Company’s SMS. Interviews with the ship’s
crewmembers indicated that personal flotation devices were not always used during the transfer of persons.

The crew of ECO GALAXY is required to discuss the activities on board in daily work planning meetings and toolbox
meetings10 which includes the correct PPE to be worn. The Pilot’s boarding was not part of the daily work planning
meeting that was held on 29 August 2023. No indication was found during the investigation that a toolbox meeting was
carried out in relation to the boarding of the Pilot on 29 August 2023.

The Master and the OOW were present on the Bridge and observed the ASD1 and the 3/O proceeding to the pilot
boarding area. Neither the Master nor the OOW could recall after the incident whether the 3/O and the ASD1 were
wearing a lifejacket at that moment.
Republic of the Marshall Islands Maritime Administrator

The risk assessment11 for rigging the pilot ladder, as conducted on 29 August 2023, was signed by the ship’s four ASDs,
three Deck Officers, and the Master on 29 August 2023 and addressed the risks related to an improperly rigged pilot
ladder. The risk assessment further specified additional risk control measures for the Pilot climbing the ladder.

6 Detailed information on Diclofenac medicine consumed by individuals for the treatment of pain and reduction of swelling (see https://www.nhs.uk/medicines/
diclofenac/).
7 See Safety, Health and Hygiene Manual — Appendix I — PPE Matrix, as part of the ship’s SMS.
8 See Procedure M2.2.5.3 Pilot/transfer of personnel operation, as part of the ship’s SMS.
9 See Form OP 146 Crew Familiarization and Hand Over Report, as part of the ship’s SMS.
10 See Procedure M2.2.5.6: Daily Work Planning/Toolbox Meeting, as part of the ship’s SMS.
11 See Form SF 118: Risk Analysis-Risk Assessment, as part of the ship’s SMS.
 Part 3: Analysis

Wearing a lifejacket was a control measure in case the pilot ladder was swinging and the wearing of safety shoes, leather
gloves, and a helmet were identified as control measures against slipping and falling. The risk assessment did not address
any risks related to the safety of the crew in respect to the rigging of the pilot ladder or in the boarding of the Pilot.

15
The PPE Matrix also requires a safety harness to be worn when working over the ship’s side. Generally, a safety harness
was not worn when welcoming a Pilot on board as this activity did not include any work over the ship’s side. It could not
be determined if the ASD1 was carrying out unplanned work over the ship’s side at the moment that he fell overboard.

Familiarity with Pilot Boarding

Between 30 August 2022 and 30 August 2023, ECO GALAXY had called Port Klang 27 times at regular intervals. In the
same period, other ports in the South-East Asia region were frequently called as well (see Figure 4).

Figure 4: Voyages of ECO GALAXY between 30 August 2022 and 30 August 2023.

The ASD1 joined the ship on 15 July 2023. It was the seventh time on board ECO GALAXY that the ASD1 was engaged
in a Pilot transfer at Port Klang.

The crew of ECO GALAXY was familiar with the weather conditions in the area during that time of the year, including
squally weather as was observed at the time of the incident.

It can be concluded that Pilot transfers were frequently and regularly executed on board ECO GALAXY which could
have led to risk normalization. Dangerous conditions can be perceived as normal over time and accepted practice and
silent deviations from procedure may arise.12

12 Nejc Sedlar, Amy Irwin, Douglas Martin, Ruby Roberts, A qualitative systematic review on the application of the normalization of deviance phenomenon within high-
risk industries, Journal of Safety Research, Volume 84, 2023, Pages 290-305, ISSN 0022-4375, (see https://doi.org/10.1016/j.jsr.2022.11.005).
 Part 3: Analysis

Emergency Response
Emergency response procedures13 are available to guide the Bridge team on board ECO GALAXY when an MOB incident
occurs. The procedures include immediate actions to be considered on board such as the release of an MOB buoy from
16 the Bridge wing, marking the ship’s position in relation to the MOB position, maneuvering to turn the ship, sounding
of the general alarm, and the launch of the rescue boat and/or a life raft.

Four persons were present on the Bridge when the MOB occurred; the 3/O was on deck. The Pilot was proceeding to
the Bridge shortly after the ASD1 had fallen into the water. The pilot boat was still in the vicinity and approached the
ASD1 shortly after he had fallen into the water.

When the ASD1 fell overboard, the ship’s speed was approximately 8 kn and the ASD1 quickly reached the ship’s
starboard quarter. The 3/O first informed the Bridge and then threw a lifebuoy with line towards the ASD1. The MOB
buoy near the Bridge wing had not been launched.14

Since ECO GALAXY was entering the approach channel to Port Klang, to safely turn the ship back towards the
MOB position, it was necessary to first obtain advice from the VTS. When the Pilot arrived at the Bridge, the Master
immediately asked for advice to turn the ship. The Master was informed by the Pilot that this was not possible as the
available depth outside the channel was insufficient.

Launching a rescue boat was assessed by the Master, but due to the weather conditions and the limited visibility, it
was considered by the Master as unsafe to operate a rescue boat. The launch of a life raft had not been considered.15

As it was initially understood by the Pilot, that the ASD1 had been rescued by the crew of the pilot boat, the
general alarm was delayed, being sounded approximately 12 minutes after the ASD1 had fallen overboard. Although it
cannot be stated with certainty, this delay likely did not significantly affect the outcome of the emergency response,
as additional lookouts would likely not have been able to visually sight the ASD1 in the water due to the prevailing
weather conditions, darkness, and presence of deck lighting affecting night vision. Additionally, the ship was still
moving away from the MOB position, as it was not possible to immediately turn the ship.

Rescue Operation and Cause of Death

Republic of the Marshall Islands Maritime Administrator

The pilot boat arrived at the location of the ASD1 quickly after the ASD1 had fallen into the water. The pilot boat was
not equipped with a device such as a rescue basket or a cradle to lift a person in a horizontal position from the water.16

A crewmember of the pilot boat took a lifebuoy and jumped into the water. The crewmember was not wearing a personal
flotation device and was not attached to a safety line.

13 See Emergency Response Manual — Appendix 1 Contingency Plans — Man Overboard/Search and Rescue/Recovery persons from the water, as part of the ship’s SMS.
14 The standard response is to release one of the two lifebuoys that are capable of quick release from the Bridge. Each are provided with a self-igniting light and a self-
activating smoke signal. See SOLAS regulation III/1.3
15 See MSC.1/Circ.1182/Rev.1 paragraph 5.5, ECO GALAXY was making way through the water and could not immediately turn. Guiding the liferaft towards the person
in distress would not have been possible.
16 The preferred means of recovery is to lift a person from the water. Additionally, to reduce the risk of cardiac arrest the person should, when possible, be lifted in a
horizontal or near-horizontal position, See MSC.1/Circ.1182. Rev.1, paragraph 10.5.6.
 Part 3: Analysis / Part 4: Conclusions

There was no indication that the act of the crewmember was planned and his response placed him at risk of requiring
assistance as well.17

It was reported that the ASD1, who was conscious after falling into the water, was not able to reach the lifebuoy that
17
was thrown by the 3/O. The ASD1 was also not able to reach the hand of the crewmember who jumped in the water or
to grab the lifebuoy that the crewmember of the pilot boat had taken with him. Neither was the ASD1 able to swim to
the crewmember or to the pilot boat. The ASD1 could not be located after the crewmember of the pilot boat was back
on board.

The ASD1 was wearing a coverall, a raincoat, and safety shoes, but was not wearing a life jacket. There was a moderate
sea with waves of 1 m in height. These conditions may have complicated the ability of the ASD1 to stay above the
surface of the water.

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

1. Causal factors that contributed to this very serious marine casualty include:
(a) not wearing a lifejacket when the risk of falling overboard is present.

2. Additional causal factors that may have contributed to this very serious marine casualty include:
(a) deviations from safety procedures on board ECO GALAXY regarding Pilot transfers, potentially
resulting from risk normalization.

3. Additional issues that were identified but that did not contribute to this very serious marine casualty include the:
(a) crewmember of the pilot boat who had no training as a rescue swimmer, jumped into the water
without wearing a lifejacket or being connected to the ship by a lifeline, to assist the ASD1 after he
fell into the water; and
(b) absence of any rescue device on board the pilot boat to lift a person from the water.

17 See MSC.1/Circ.1182/Rev.1, paragraph 10.3.10. It is also noted that water safety organizations worldwide advise that persons who are not specially trained as rescue
swimmers or lifeguards should not enter the water to assist another person. See for example: The Royal National Lifeboat Institution, How to rescue someone from
drowning (see https://rnli.org/magazine/magazine-featured-list/2017/march/how-to-rescue-someone-from-drowning); Royal Life Saving Australia, How to Carry Out
a Rescue Safely (see https://www.royallifesaving.com.au/stay-safe-active/in-an-emergency/how-to-carry-out-a-rescue-safely); and American Red Cross, Water Safety:
Know What to do in an Emergency (see https://www.redcross.org/get-help/how-to-prepare-for-emergencies/types-of-emergencies/water-safety.html). MSC.1/Circ.1182/
Rev.1, paragraph 10.5.8 states that persons who are not able, without assistance, to get into a rescue basket or other device may be assisted by a crewmember from the
recovering ship provided that the crewmember is “wearing personal protective equipment and a safety line.” This guidance also states: “remember, however, that this
should be planned for.” Guidelines issued by the NMOHSC regarding procedures for responding to a man overboard state that crewmembers assisting with the recovery
of a person in the water “must be wear[ing] immersion suits and be securely attached to lifelines, which in turn are attached to a boat fall or to the ship.” See NMOHSC,
Guidelines to Shipping Companies on Procedures in Cases of Man Overboard, p. 4. These guidelines are referenced in the COSWP, sections 4.6 and 4.7.
 Part 5: Preventive Actions / Part 6: Recomendations

PART 5: PREVENTIVE ACTIONS

In response to this very serious marine casualty, the Company has taken the following Preventive Actions:
18
1. During visits to the vessels of the fleets and during audits, there will be a campaign to focus on safe working practices
and safe shipboard operations.

2. The lessons learned from this incident will be discussed during safety meetings on board, during the annual senior
officers’ conference and during web conferences with crewmembers.

3. A review of the PPE Matrix and the emergency response procedures has been executed.

4. Shorebased pre-embarkation training related to procedures to be followed during Pilot and personnel transfer
operations has been conducted for all Company’s crewmembers.

5. Stricter criteria for fitness for duty prior to embarkation have been adopted by the Company.

6. A Pilot and Personnel Transfer Campaign has been initiated to all ships in the Company-managed fleet using reflective
learning material.

7. Criteria for Pilot and personnel transfer operations have been developed within the Company.

8. Rank specific age limits for all seafarers have been adopted.

9. More frequent MOB drills have been implemented over the entire fleet.

10. An evaluation of the safety culture of the organization has been carried out by an external party.

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

1. The Company is recommended to ensure that:

Republic of the Marshall Islands Maritime Administrator

(a) risk assessments, safety meetings, and toolbox meetings are held as required by the Company’s SMS; and
(b) PPE is worn as required by the Company’s SMS.

2. The Malaysian Marine Department is recommended to consider:

(a) requiring Malaysian-registered launches used in Malaysian waters to transport seafarers and other persons
to embark or disembark a ship be fitted with rescue cradles or similar devices; and
(b) making operators of launches used in Malaysian waters to transport seafarers and other persons to embark
or disembark a ship aware of the need for crewmembers to receive regular training for recovering persons
from the water.

The Administrator’s marine safety investigation is closed. It will be reopened if additional information is received that
would warrant further review.