KWK Legacy: The Sheave That Seized and Nobody Noticed

What Happened

KWK Legacy was transiting the East China Sea at 10 knots in good visibility and light to moderate winds (Beaufort 4–5). At a toolbox meeting on the bridge around 0730, the Chief Officer briefed the deck team on the morning's work, which included pre-arrival testing of deck machinery, among it the port and starboard accommodation ladders and gangways. The task for the bosun, an able seafarer, an ordinary seaman and a deck cadet was simple: lower each gangway to deck level and hoist it back. Nobody was expected to go over the side, and no maintenance was assigned.

The starboard side was completed without problems. At about 0930 the team moved to the port gangway. It was swung out and lowered to main deck level with no abnormal sounds. Then the bosun, who was 51, had 25 years with the company and was described by colleagues as hardworking and conscientious, decided to grease the movable parts. He stepped onto the gangway turntable and walked out along it, below main deck level, and clipped his safety harness to the gangway handrail. The fall arrestor was not in use. He leaned toward the lower outer sheave to apply grease.

Two colleagues heard a noise and saw the gangway jerk. There were a few more jerks, then the wire rope supporting the gangway parted. The bosun was briefly held in mid-air by his harness, because the gangway's upper turntable was still hinged to the deck. Then the gangway separated and fell into the sea with him.

The Response

A lifebuoy went in at once, but nobody could see him in the water. The Chief Officer raced to the scene and started preparing the rescue boat; the Master ordered hard to port and began a Williamson turn; the MOB marker was released from the bridge wing. A Mayday went out on VHF 16 at about 0950. Taizhou MRCC coordinated 24 fishing vessels, and helicopters joined the search. KWK Legacy, with her deep laden draft, was released from the search on 11 December because she could not safely make the sharp alterations an expanding square search needed. The search was called off on 13 December, with survival chances judged low after prolonged exposure. Sea temperature was about 16°C. TSIB found that the Master and crew acted in line with the muster list, and that deck crew volunteered extra hours to keep lookout.

What the Investigation Found

The failure. After the accident the company removed the upper outer sheave of the port gangway and found its bearing seized. It sat in a relatively inaccessible position and the seizure had not been detected. Every time the gangway was raised or lowered the wire slid across a stationary surface instead of over a turning sheave. The abrasion built up use after use. Forensic testing found the parted wire had a breaking strength of 85.6 kN against a required minimum of 97.1 kN, about 12% below the minimum.

Why the checks didn't catch it. The paperwork looked sound. The wire had been installed in July 2023 when the gangways went to a yard for refit. A crew load test followed. The Chief Officer carried out monthly inspections (most recently on 13 October and 13 November 2025), and the gangways were tested before arrival at two ports in the weeks before. All recorded the gangways as in good condition. The Chief Officer told investigators that the section of wire passing the sheave was difficult to inspect when the gangway was stowed, so damage there was unlikely to show up in regular checks.

Why the bosun was on the gangway at all. Under the company's rules, greasing gangway wires and sheaves was classed as high-risk work that needed a permit to work, with a work vest, a safety line and a lifebuoy ready. None of that applied to a plain pre-arrival test, and the bosun was not assigned the greasing. The company's PPE matrix also called for the lifeline to go to a point of adequate strength, such as a permanent fixture of the ship's structure. A gangway handrail is not that.

Stop Work. The company had a Stop Work Order policy. The other crew members saw the bosun go onto the gangway, saw him clip to the handrail, and knew he had no permit. Nobody used it. They told investigators that there was not enough time to intervene once he stepped on. TSIB noted it would have been desirable for them to do so, and reiterated ‘the need to watch over each other’.

TSIB's Recommendations and the Company's Actions

1. RM-2026-001 (to the company): ensure crew members exercise the Stop Work Order when they see unsafe operations, acts or conditions.
2. RM-2026-002 (to the company): ensure crew report the difficulties they face in maintaining and inspecting equipment.

TSIB's analysis went further, suggesting that an inaccessible sheave could be inspected alongside, with the gangway lowered and resting on the quay, or that the interval for turning the wire end-for-end (30 months) could be shortened. After the accident the company issued a fleet circular that requires wire renewal every two years, limits installed wires to within three years of manufacture and onboard storage to three years, and requires a water-bag operational load test after every wire renewal. The port gangway was replaced, the starboard one serviced, all gangway wires renewed in January 2026, and mental health support and an option to sign off early were offered to the crew involved.

Practical Actions

These are Crew Connect's takeaways, drawn from the findings above, rather than a restatement of TSIB's formal recommendations.

1. Ask where your equipment is hard to inspect. If a sheave, bearing or wire section can't be seen or reached when stowed, say so. Arrange to inspect it another way, such as alongside with the gangway on the quay.
2. Treat a clean checklist as a record, not proof. Every monthly check on KWK Legacy said ‘good’. Include moving parts (turn the sheaves) and the wire where it passes over them.
3. A test is not a licence to do maintenance. If the job grows from ‘lower and hoist’ to ‘go over the side and grease’, it needs a permit, the right PPE and the right anchor, whoever suggests it.
4. Anchor to the ship, not the equipment. Lifeline and fall arrestor go to a fixed, strong point on the ship's structure. A handrail on the thing you're standing on is the one place it must not go.
5. Use Stop Work in the first second. The time to speak is when someone is about to step onto the equipment, not after. An experienced, respected colleague is the hardest person to stop and the one you most need to.
6. Read across to the US Coast Guard alert on gangway inspection and maintenance, covered in our Week 39 roundup.