Accident Investigation Report 8/2010
Read our marine accident investigation report, which includes what happened, actions taken and subsequent recommendations:
On 10 September 2009, an able seaman from the UK registered container ship Ever Elite drowned in San Francisco Bay after the lower section of the accommodation ladder he was standing on broke free and fell into the water. The vessel was approaching the container terminal in Oakland, California when the accident occurred and the seaman’s body was soon spotted by an accompanying tug and recovered onto a pilot launch.
The accommodation ladder was set free when the hoist winch gearbox failed; the gearbox had been incorrectly re-assembled by the ship’s crew following maintenance. Factors leading to this error included: the lack of technical information held; an ineffective management system of onboard maintenance; and the low-level maintenance and testing requirements adopted for the hoist winch because it had not been considered to be lifting gear as defined in national regulation. Rigging the ladder when underway was unnecessarily hazardous, and a safe system of work had not been developed. The seaman fell into the water and drowned because he was not wearing a fall arrest device and a lifejacket, which should have been required for working over the side. Other, unrelated, safety shortfalls were identified during the investigation.
A recommendation has been made to the British Standards Institution aimed at improving the international standard applicable to the hoist winches fitted to accommodation ladder systems by taking into account current technology, best practice, and the full scope of accommodation ladder operations. Recommendations have also been made to the Maritime and Coastguard Agency which are intended to highlight the weaknesses in the international standard and to make the guidelines on maintenance and testing of accommodation ladder systems more effective. A further recommendation aims to ensure that accommodation ladder hoist systems carried on board UK registered vessels are tested and maintained in accordance with national regulation. A recommendation made to Evergreen Marine UK is aimed at strengthening its safety culture and improving the maintenance management systems on board its vessels.
This report was published on 14 July 2010.
Published 23 January 2015