Compliance Without Conviction: The Safety Culture That Cost the Seatruck Pace Assistant Bosun His Life

A Rope Barrier, Crossed

On the morning of 17 December 2018, the assistant bosun aboard the ro-ro freight ferry Seatruck Pace did not attend the scheduled bosun's briefing and began preparing to paint the forward edge of a hatch cover instead. He crossed a temporary rope barrier into a narrow section of deck between the ship's side and an open ramp hatch — a 4.5-metre drop below. He had no fall protection equipment. At around 0820, crew in the cargo office heard a loud crash on the ramp. He was found lying there, with a heavy metal trestle across his leg. He died three days later.

Compliance Without Conviction

MAIB's investigation found the risk of falling in that area was known and accepted on Seatruck Pace — other crew members had taken the same risk during hatch cover maintenance two days earlier, without consequence or intervention. The safety culture aboard was characterised by procedural compliance treated as routine formality rather than genuine conviction. A rope strung across a gap looks like a barrier. It functions as one only if the people who see it believe the hazard behind it is real.

What the Days Before Showed

The assistant bosun was working alone, with no permit to work and no supervised task allocation, having missed the morning briefing where work would normally have been assigned and checked. Unsafe practices during hatch cover maintenance two days earlier had already shown the same pattern — a warning sign that, had it been challenged at the time, might have changed what happened on the 17th.

Recommended Actions

MAIB made no formal recommendations in this case — Seatruck Ferries Ltd had already taken corrective action following the accident. The investigation's value lies in what it documented about how a procedural safety culture fails at exactly the moment it's most needed.

Human Element Analysis