Ever Wish: When the SMS Said It Was Safe and the Sea Disagreed

On 23 October 2025, a team of six crew members on the container vessel Ever Wish went on deck in the South China Sea to recover a fouled mooring rope. The operation failed. As the team prepared to abandon it, a large wave struck the deck. All six were injured. One crew member died.

The TSIBS (Transport Safety Investigation Bureau, Singapore) investigation found the proximate cause was not an unforeseeable weather event. The conditions that killed a crew member that morning were conditions the team went on deck into. And they went on deck because the company's SMS heavy weather threshold — based on forecast data — had not been met. So no heavy weather protocols applied. The Master was not informed. The required documentation was not prepared.

The sea did not read the SMS. The wave came anyway.

What the investigation found

The mooring ropes had not been secured for sea passage before departure. This was not negligence — the departure-time forecast did not trigger the SMS criteria requiring it. Heavy weather preparation, under the company's own procedures, was tied to a forecast threshold. Below that threshold, no additional controls were mandated.

When the mooring rope became fouled in open water, the decision to attempt recovery was made at watch officer level. The Master was not informed. The required permit or documentation was not completed. Six crew went on deck in conditions that, regardless of what the forecast said that morning, were producing large waves and significant vessel motion.

After the first recovery attempt failed, the team was in the process of withdrawing when the wave struck. The decision to stop came reactively — after the operation had already failed, in worsening conditions, without a pre-agreed abort trigger. The withdrawal itself was the moment of maximum exposure.

TSIBS recommended actions

1. SMS thresholds are floors, not ceilings. Conditions at or above the threshold require mandatory controls. Conditions below the threshold still require an independent risk assessment based on actual observed conditions — not just a check that the forecast number hasn't been met.
2. The Master must be informed before any non-routine deck operation in adverse conditions. This is an ISM requirement, not a suggestion. No command oversight was in place on Ever Wish — that is a systemic failure, not an individual lapse.
3. Required documentation must be completed before operations begin. A permit-to-work or equivalent is not retrospective paperwork. It is the control that forces the pre-operation risk assessment to happen.
4. Mooring ropes must be secured for sea passage based on route and conservative conditions assessment — not solely on departure-time forecast classification. The South China Sea in October presents real heavy weather risk independent of any single forecast.
5. Abort triggers must be set before operations begin. The time to decide when to stop is before you start. A pre-agreed trigger — a sea state, a time limit, a single failed attempt — takes the decision out of the hands of people under pressure at the worst possible moment.

Human element analysis

Procedure used as permission. The SMS threshold functioned as a green light rather than a minimum standard. Below the threshold, the crew felt implicitly authorised to proceed — removing the obligation to independently assess the conditions they were actually in. This is one of the most dangerous misreadings of a safety management system: treating the absence of a mandatory control as the presence of permission.

Command oversight absent from the decision loop. The Master was not informed. Six crew went on deck in rough weather on a non-routine operation, and the person with command authority and the broadest risk picture had no awareness it was happening. Authority existed. It was simply absent from the decision.

Reactive abort decision. The team decided to stop only after the operation had failed. By that point, conditions may have deteriorated further, the crew were already fatigued from the failed attempt, and the withdrawal itself — the transition from operating position to a position of relative safety — was the moment the wave struck. A pre-set abort trigger would have brought the team off deck earlier, under less pressure, in better conditions.

How this pattern repeats

The failure pattern on Ever Wish — a procedure used as authorisation to skip independent risk assessment, absent command oversight, and a reactive rather than pre-planned stop decision — appears across every high-stakes industry. Recognising it in other contexts sharpens the ability to catch it on deck.

Aviation — Air Ontario Flight 1363 (1989): The de-icing checklist was completed within the required time window. The crew assumed the aircraft was safe to take off without physically re-checking the wing surface, which had been re-contaminated. The procedure had been followed. The procedure said nothing about what to do when conditions changed after it was completed. 24 people died. The parallel with Ever Wish: the procedure was a one-time check at a fixed point in time. Actual conditions — which continued to change — were not independently reassessed.

Nuclear — Chernobyl (1986): The safety test that preceded the explosion was conducted by a night shift team, without the senior engineer who had been supervising it. He left before the test was complete. The night shift proceeded without him — without anyone with the full picture of what the test was attempting and what the warning signs would look like. Command oversight was physically absent from the operation. The parallel: the person with the broadest understanding of the risk was not present at the moment the decisions were made.

Offshore — Deepwater Horizon (2010): The negative pressure test result was anomalous. The pre-agreed interpretation — what a failing test should look like — was reinterpreted on the spot, under time pressure, by people who wanted to continue. The abort trigger existed. It was overridden by a reactive decision made at the worst possible moment. The parallel: Ever Wish's team had already decided to abandon the operation. The decision came too late.

Try the training scenarios

We've built the Ever Wish investigation findings into five knowledge-check questions on Crew Connect — covering SMS threshold interpretation, Master notification obligations, pre-departure securing decisions, and abort trigger design. They're free to try, built from the primary TSIBS source material.

Questions are available in the Knowledge Checks section. Filter by Safety module. No account needed for the first set.

If you want to go deeper, our Decision Simulator runs branching incident scenarios built from real investigation reports — where every decision you make changes the outcome. Try it at crew-connect.net/simulator-training.