MV WORLD PRIZE — A Broken Davit, an Unchallenged Shortcut, One Life Lost

An Ordinary Job, Done the Way It Was Always Done

World Prize had just finished discharging and was clearing Rönnskär, Sweden, with the pilot due to disembark. Rigging the pilot ladder for a pilot's departure is about as routine as shipboard tasks get — done, in some form, on every port call. On this ship, though, the ladder's davit — the mechanism meant to lower and recover the ladder without anyone manhandling its weight — was not fit for use. MAIB's investigation found the crew had, over time, become normalised to lowering and recovering the ladder manually instead: working its suspended weight by hand, at an unguarded deck edge, without the personal protective equipment that would arrest a fall.

That was the state of play when the bosun went to rig the starboard ladder. He lost his balance, fell from the main deck, struck the bottom platform of the accommodation ladder on the way down, and went into the water. The nearby pilot boat, Pilot 753 SE, attempted a recovery. MAIB found the pilot boat's crew lacked the equipment familiarity and recovery training the situation demanded, which reduced their ability to recover an unconscious person from the water. Without a PFD, and very likely experiencing a cold-water response, the bosun was unable to keep his airway clear. He drowned. His body was recovered from the seabed the next day.

What MAIB Actually Found

Nothing here was one dramatic failure. It was several ordinary-looking gaps, all present at once:

• Unsafe pilot ladder rigging had become normalised practice — not a one-off shortcut, but how the job was routinely done aboard this ship.
• Crew working at an unguarded deck edge had no PPE to prevent or arrest a fall.
• The risk mitigations written into the permit to work covering this job were not strictly adhered to.
• Local supervision of the rigging was, in MAIB's words, “ineffective in ensuring it was conducted in a safe manner, and no-one present intervened to stop the unsafe work.”
• The wider safety climate aboard “resulted in an emphasis on the documentation of compliance rather than the effective management of risk” — paperwork that said the job was safe, alongside a practice that wasn't.

Why MAIB Issued No New Recommendations

MAIB closed the investigation without recommending anything new, on the basis that the vessel's operator had already taken corrective action by the time the report was published. That's worth sitting with rather than reading as "nothing to see here": every safeguard that was missing on World Prize already existed on paper — a working davit, a permit to work with real teeth, PPE for edge work, supervision willing to stop the job. The failure wasn't a gap in the rules. It was a gap between the rules and what actually happened on deck.

Recommended Actions

Not new recommendations — the existing requirements that were already supposed to govern this job, and weren't followed:

1. Pilot ladders must be rigged, tested and used in accordance with SOLAS Regulation V/23 and the procedures set out in Merchant Shipping Notice MSN 1716 (M+F) — not an informal routine that's grown up around a broken davit.
2. MGN 432 (M+F), read with section 18.7.5 of the Code of Safety Working Practices for Merchant Seamen, requires a master-nominated officer to supervise the rigging, testing and use of pilot transfer arrangements, and to confirm crew involved have actually been instructed in the procedure — supervision present, not just assigned.
3. A defective davit is a permit-to-work stop condition, not a workaround to be absorbed into normal practice — report it, and rig only by a method the permit actually covers.
4. PPE suited to work at an unguarded deck edge (fall-arrest harness, PFD) is required whenever pilot transfer equipment is being manually handled, not just when using the ladder itself.
5. Anyone present who sees a permit's risk mitigations being skipped has standing authority — and an obligation — to stop the job, regardless of rank or how routine the shortcut has become.

Human Element Analysis

Cross-Industry Parallels

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Related Reading

• Kingfisher — another fatal MOB where a PFD would have changed the outcome
• Berge Mawson — another investigation where supervision existed on paper but not in practice
• New SOLAS pilot transfer arrangement requirements, entering force 2028