BSafe Case Study 2 — A Job That Grew Past Its Own Permit

A Small, Authorised Job

Preparing for a US Coast Guard inspection, the crew found a corroded, seized lashing turnbuckle on the free-fall lifeboat. The chief officer authorised only rust removal and painting, at about a metre above deck, inside the railings — no work permit was needed for a job that small and that low. He also carried out a verbal risk assessment with both bosuns and, given the ship's moderate rolling, explicitly ruled out any working aloft that day.

Then the AB Noticed Something Else

While doing the authorised job, the AB spotted that the lifeboat davit's forward hook needed lubrication — a separate task, at height, never assessed or authorised. He asked the bosun to steady a ladder positioned on deck below the hook, roughly 4.8 metres up. The ladder's rubber feet were worn and not both in firm contact with the deck. It wasn't secured by any other means.

The AB climbed, without PPE. The bosun tried to stop him — and then, when that didn't work, held the ladder for him anyway. Partway up, the ladder slipped. The bosun couldn't hold it. The AB fell and was found unconscious on deck. Medevac by helicopter was assessed as several hours away. Two and a half hours after the fall, he stopped breathing; resuscitation failed.

What AIBN's Investigation Found

• No risk assessment or work permit existed for the actual task performed — required by the SMS for any work aloft, and the chief officer had explicitly ruled out working aloft that day for an entirely different job.
• The ladder was unsuitable for the task: worn feet, not both contacting the deck, and never secured — conditions that on their own should have stopped the climb.
• The AB wore no PPE; had he done so, it likely would have reduced the severity of his injuries, not necessarily prevented the fall.
• The accident would have been prevented if the bosun had stopped the job rather than assisting — his intervention attempt existed, but stopped short of actually stopping the work.

Recommended Actions

Drawn from AIBN's own findings:

1. A task discovered mid-job — however minor it looks — is a new task requiring its own assessment and authorisation, not an informal add-on to whatever's already been approved.
2. An explicit instruction ruling out a category of work (here, working aloft) needs to actually stop that work if it's attempted anyway, not just be a briefing note that gets overridden in practice.
3. Ladder condition is a pass/fail check, not a judgement call — worn feet not fully contacting the deck, unsecured, is a stop condition on its own.
4. Trying to stop a colleague and then assisting them anyway when they don't listen isn't a safer middle ground — it's participating in the same unassessed risk.

Human Element Analysis

Test Your Knowledge

Think you've got this covered? Put it to the test in Crew Connect's free Knowledge Checker — try a quick safety round and see how you score.

Related Reading

• BSafe Case Study 32 – another job that started small and grew past its own risk assessment