BSafe Case Study 16 — A Repair Party Nobody on the Bridge Knew Was There

A Restriction That Applied to One Person, Not Four

In Beaufort Force 7 with rough seas, the master judged the weather was easing enough that main deck access didn't need restricting. Separately, the third officer had already told an AB doing lifebuoy work not to go onto the forecastle. When the second engineer spotted daylight coming through the forecastle store's access hatch — meaning it had been torn off in the weather and water was getting in — the chief officer decided to investigate personally, then assembled a repair party of three: the bosun and two ABs.

Forward, Unseen, Unheard

The chief officer never told the bridge, or anyone else, where they were going or what they planned to do. None of the four carried a radio. Container stacks blocked the bridge watchkeeper's view of them on deck. Nobody on the bridge knew what the earlier phone call between the chief officer and second engineer had even been about.

The party found the access hatch cover torn off and lying on the windlass, ropes scattered across the deck. They secured the ropes, tried and failed to refit the distorted hatch lid, and the chief officer sent the bosun for plywood after canvas alone proved impractical against the updraught from the store. With two ABs positioned either side of the damaged lid, ready to lift it, and the chief officer standing forward of them facing aft, one AB felt the bow lift and saw a large wave coming. He shouted a warning and grabbed a forestay — the wave tore his grip loose anyway, washing him over the windlass. The second AB was washed against the windlass, injuring his leg. The chief officer was washed under the windlass.

Stunned, the first AB found no response from his colleagues and initially believed they'd gone overboard. He raised the alarm through the bosun; the bridge sounded the man overboard alarm and began a Williamson turn. The second AB, recovering, found the chief officer under the windlass. He was evacuated to the ship's hospital with a broken leg and severe chest and head injuries, and died later that day.

What This Illustrates

• An access restriction existed for one specific person and task (the AB doing lifebuoy work), while a much larger, more exposed repair party went to the same area with no restriction applied to them at all.
• The chief officer's decision to investigate, then organise a repair party, was never communicated to the bridge — the one place positioned to track weather risk to a forward working party in real time.
• None of the four carried a radio, cutting off any possibility of a timely warning or rapid alarm once the emergency began.
• The working party was not visible to the bridge watchkeeper due to deck cargo — meaning even passive observation of their exposure wasn't possible.

Recommended Actions

Grounded directly in what this incident shows:

1. Any decision to send a working party into an exposed forward area in marginal or deteriorating weather needs to be communicated to the bridge before the party leaves, not discovered afterward.
2. A working party in an exposed area during heavy weather should always carry a radio — the single fastest route to raising an alarm or receiving a weather warning from the one place with the clearest picture of sea conditions.
3. An access restriction that applies to one task or person should prompt the question of whether it should apply more broadly, not be treated as narrowly scoped to the original reason it was set.
4. Where deck cargo blocks the bridge's direct view of a working area, an active reporting requirement (not passive visual monitoring) needs to fill that gap.

Human Element Analysis

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Related Reading

• BSafe Case Study 7 – another fatality where a lack of communication between crew left nobody with the full picture