BSafe Case Study 17 — Experienced Enough Not to Need a Risk Assessment, Until He Wasn't

Separated by Policy, Not Just by Task

A shore-contracted riding team of 13 was hired to wash down cargo holds before the next load port. Under strict COVID-19 rules, the riding team and ship's crew had to maintain absolute separation with no physical interaction — even though the ship's crew still had to supply equipment and help pump out bilge water. The chief officer held a Toolbox Talk with the riding team leader alone; the leader, judging his team experienced, didn't think it necessary to brief them daily or complete a risk assessment, treating the job as routine. Risk assessments the chief officer had completed for hold cleaning, hatch cover operations, and high-pressure washing were never shared with the riding team leader — the chief officer believed they didn't apply to third-party contractors.

Last Seen on the Coaming Ladder

The riding team began cleaning hold No. 5 while the ship's own crew opened holds 1 and 2 for separate inspection and cleaning. A team member, last seen standing on the starboard coaming ladder at hold No. 5, fell from the top of the hatch coaming into the hold — roughly 17 metres. His water lance was found lying on deck where he'd last been observed. The team leader alerted the master, who raised the general alarm and set course for the nearest port. The crew member was later pronounced dead.

What Transport Malta's Investigation Found

• A language gap meant most riding team members, unlike their team leader, couldn't participate meaningfully in the safety Toolbox Talk conducted in English.
• Risk assessments completed under the ship's SMS should have been extended to external contractors, not treated as crew-only documentation.
• The team leader assumed a risk assessment was unnecessary because his team had prior experience — but prior experience doesn't reduce an unmitigated risk, it just makes the risk feel more familiar.
• No Permit to Work was completed, and no fall protection was provided or worn — the investigation concluded proper fall protection would likely have prevented the fatality.
• No safety lines were rigged across the open hatch, a standard barrier that would have physically blocked the fall.
• COVID-era manpower and separation pressures, combined with multiple simultaneous tasks, likely contributed to an absence of formal supervision of the riding team.

Recommended Actions

Direct from the investigation's findings:

1. Risk assessments completed under a vessel's SMS need to extend to any contractor working aboard, shared and acknowledged, not assumed inapplicable to third parties.
2. Prior experience with a task is not a substitute for a task-specific risk assessment — familiarity changes how a risk feels, not whether it's actually mitigated.
3. A Permit to Work system needs to specify and confirm the PPE required for the actual task — fall protection for work at an open hatch coaming, specifically, not general safety gear.
4. Physical barriers (safety lines across an open hatch) should be standard for any work at height near an unguarded edge, regardless of who's doing the work or how experienced they are.
5. Operational pressures that separate contractors and crew for legitimate reasons (like a pandemic protocol) still need a supervision plan that covers the contractors, not an implicit assumption that separation means self-sufficiency.

Human Element Analysis

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Related Reading

• BSafe Case Study 5 – another fatal cargo hold incident, a different hazard, the same gap between assumed and actual safety