Ever Wish: When the SMS Said It Was Safe and the Sea Disagreed

On 23 October 2025, a team of six crew members on the container vessel Ever Wish went on deck in the South China Sea to recover a fouled mooring rope. The operation failed. As the team prepared to abandon it, a large wave struck the deck. All six were injured. One crew member died.

The TSIBS (Transport Safety Investigation Bureau, Singapore) investigation found the proximate cause was not an unforeseeable weather event. The conditions that killed a crew member that morning were conditions the team went on deck into. And they went on deck because the company's SMS heavy weather threshold — based on forecast data — had not been met. So no heavy weather protocols applied. The Master was not informed. The required documentation was not prepared.

The sea did not read the SMS. The wave came anyway.

What the investigation found

The mooring ropes had not been secured for sea passage before departure. This was not negligence — the departure-time forecast did not trigger the SMS criteria requiring it. Heavy weather preparation, under the company's own procedures, was tied to a forecast threshold. Below that threshold, no additional controls were mandated.

When the mooring rope became fouled in open water, the decision to attempt recovery was made at watch officer level. The Master was not informed. The required permit or documentation was not completed. Six crew went on deck in conditions that, regardless of what the forecast said that morning, were producing large waves and significant vessel motion.

After the first recovery attempt failed, the team was in the process of withdrawing when the wave struck. The decision to stop came reactively — after the operation had already failed, in worsening conditions, without a pre-agreed abort trigger. The withdrawal itself was the moment of maximum exposure.

TSIBS recommended actions

1. SMS thresholds are floors, not ceilings. Conditions at or above the threshold require mandatory controls. Conditions below the threshold still require an independent risk assessment based on actual observed conditions — not just a check that the forecast number hasn't been met.
2. The Master must be informed before any non-routine deck operation in adverse conditions. This is an ISM requirement, not a suggestion. No command oversight was in place on Ever Wish — that is a systemic failure, not an individual lapse.
3. Required documentation must be completed before operations begin. A permit-to-work or equivalent is not retrospective paperwork. It is the control that forces the pre-operation risk assessment to happen.
4. Mooring ropes must be secured for sea passage based on route and conservative conditions assessment — not solely on departure-time forecast classification. The South China Sea in October presents real heavy weather risk independent of any single forecast.
5. Abort triggers must be set before operations begin. The time to decide when to stop is before you start. A pre-agreed trigger — a sea state, a time limit, a single failed attempt — takes the decision out of the hands of people under pressure at the worst possible moment.

Human element analysis

Procedure used as permission. The SMS threshold functioned as a green light rather than a minimum standard. Below the threshold, the crew felt implicitly authorised to proceed — removing the obligation to independently assess the conditions they were actually in. This is one of the most dangerous misreadings of a safety management system: treating the absence of a mandatory control as the presence of permission.