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Twenty Minutes Before Anyone Knew: Working the Fore Deck at Anchor in a Gale

🕑 5 min read words Safety • Incident • Deck-operations

Vessel: Hong Kong-registered chemical tanker (name not published in the notice)
Location: At anchor in the open sea east of Ningbo, awaiting a berth
Conditions: Gale force winds, rough seas and heavy swells
Outcome: Pumpman died of injuries; bosun seriously injured
Human Factors: Risk Underestimation · Ineffective Risk Assessment · Delayed Escalation
Source: Hong Kong Marine Department, Merchant Shipping Information Note 13/2026, 24 September 2026

6 decision points · 7 outcome paths · 8 min read

What Happened

A Hong Kong-registered chemical tanker was at anchor in the open sea east of Ningbo, waiting for a berth, when it met gale force winds with rough seas and heavy swells. On the morning of the accident the bosun and the pumpman went to the main deck to cover deck equipment with tarpaulin to keep seawater out.

They then found that the foam hose box and a mooring rope on the forward mooring deck had been damaged and displaced by the surging seas. They collected the foam hose and nozzle, which had been scattered from the box. While they were trying to tidy the mooring rope, a huge wave struck the bow. Seawater surged over the bulwark, struck them violently and swept them across the mooring deck.

About twenty minutes later the crew were alerted and organised a rescue. At around noon, with the injured crew members' condition continuing to deteriorate, the tanker was instructed to proceed to meet a rescue helicopter, and both were transferred to a shore hospital. The pumpman was declared dead there.

What The Investigation Found

Beyond the heavy weather itself, the notice identifies four contributory factors:

The crew did not follow the shipboard SMS procedures for working on deck in heavy weather.
The risk assessment and toolbox meeting held on board for deck work in heavy weather lacked relevance and effectiveness.
The hazardous effects of the heavy weather were neglected. In particular, the Chief Officer, the bosun and the pumpman lacked sufficient awareness of the potentially fatal risks of working on deck in heavy weather and underestimated them.
Medical evacuation for the injured crew members was not arranged in a timely and efficient manner.

The tidying job itself was a sensible, practical instinct: loose gear and a displaced mooring rope on a pitching forward deck look like exactly what a good seaman would want to fix. The notice's point is that the procedure existed precisely to stop that instinct taking people forward in those conditions.

Lessons Learnt (from the notice)

Strictly follow the shipboard SMS requirements for working on deck in heavy weather.
Make sure relevant and effective risk assessments and toolbox meetings are carried out as required.
Provide effective safety training to build the crew's awareness of heavy-weather deck work, and hold to the requirement of not proceeding to the deck area unless safety is ensured.
Arrange prompt medical evacuation for injured crew members when necessary.
For companies: carry out internal audits from time to time to confirm crews follow the heavy-weather procedures and that risk assessments and toolbox meetings are effective.

Where The Routine Job Broke — Stage By Stage

Every one of these jobs was routine, and each had a chain of checkpoints that could have caught it. Here is where each stage failed in this case, and what a preventive action looks like.

Stage	How it went wrong here	Preventive action
1. Plan the scope	The notice does not describe the plan. It found the SMS procedure for working on deck in heavy weather was not followed.	Plan the minimum. Cover the sheltered main deck only, make exposed areas out of bounds, list what can wait.
2. Test the risk assessment	The risk assessment and toolbox meeting lacked relevance and effectiveness, and the hazardous effects of the heavy weather were neglected.	Assess the real sea state: green water over the bow, exposed areas, and how little warning a sea gives.
3. Authorise the work	The notice found those involved lacked sufficient awareness of the fatal risks and underestimated them. The requirement of not proceeding to deck unless safety is ensured was not met.	Authorise in writing, name the people and the area, and exclude the forward deck while the sea state is unchanged.
4. Brief and watch the site	A toolbox meeting was held, but it did not address the actual risk.	Name the real hazard, agree radio checks, post a lookout on the sea, and have medical advice and evacuation details ready.
5. Decide and escalate	Two crew went forward to tidy a rope and gear damaged by the sea. About twenty minutes passed before the crew were alerted, and medical evacuation was not arranged in a timely and efficient manner.	Let a non-urgent job wait. If someone is hurt, call the rescue coordination centre and medical advice early.

Module 2: The Second Hazard

The Hong Kong notice stops at the evacuation. But the same wave that injured two crew members also damaged the foam hose box and displaced a mooring rope on the forward mooring deck, and the ship was still at anchor in a gale. Those facts create a second problem the notice does not describe: a damaged deck, degraded fire-fighting arrangements on a tanker, and pressure to go back out and fix it.

Our Module 2 scenario is a hypothetical extension, clearly marked as such. It asks you, as Master, to treat the recovery as a job in its own right, with the same five checkpoints. The traps it tests are well known across industries:

Secondary casualties. Rescuers and repair parties are sent into the same hazard that hurt the first people.
Divided attention. Everyone is looking at the casualties and nobody is watching the anchor or the ship.
The reused assessment. The old risk assessment is assumed to still cover a new situation.
The tidy-up reflex. A loose rope or scattered hose looks like a hazard that must be fixed now. Usually it can wait for the weather.

Human Element Analysis

Risk Underestimation

A ship at anchor feels like a ship that is safe. The motion is lower than at sea and the job is routine. The notice records that those involved underestimated the potentially fatal risk. A tidy-up on the forward deck in a gale is not a routine job, whatever it looks like.

Ineffective Risk Assessment

A toolbox meeting was held but lacked relevance and effectiveness. This is the familiar gap between doing the process and the process doing its job. A useful toolbox talk for this task asks one question: what is the worst the sea can do to the people on that deck in the next ten minutes?

Delayed Escalation

Twenty minutes passed before the crew were alerted, and the helicopter was requested around midday. In a serious casualty at sea, minutes matter. Early escalation to the coastal rescue coordination centre is cheap. Late escalation is not.

Industry	Incident	The Parallel
Space	Space Shuttle Challenger, 1986	Known environmental limits were set aside under pressure to proceed. Hazard information existed but was outweighed by the wish to continue — the same pattern as proceeding to the forward deck because the job needed doing.
Oil & Gas	Deepwater Horizon, 2010	Warning signs were explained away rather than treated as a reason to stop, and risk assessments did not match the real conditions.
Oil & Gas	Texas City refinery explosion, USA, 2005	A process existed but was not followed or effectively enforced, and the risk was underestimated by those on site. The audit that would have caught it did not happen.

Try the Decision Simulator

Take the job from start to finish as the Chief Officer: the plan, the risk assessment review, the authorisation to work on deck, the job site review, the decision on the forward deck, and if it goes wrong, how fast you call for help. Work through it in the free Decision Simulator — no login needed to preview.

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