Fatal Fall Into Ballast Tank – Investigation Report

On 28 January 2009, the chief officer on board the UK registered container ship Ville de Mars fell almost 8 m when descending into a water ballast tank (the vessel’s forward ballast tank). The vessel was on passage in the Gulf of Oman. He was removed from the tank by the ship’s crew and died while being flown to a hospital ashore in Oman by a Royal Navy helicopter. The chief officer had been due to leave the vessel the following day in Jebel Ali, UAE. No postmortem was conducted.

The MAIB investigation identified that the chief officer was not wearing a fall arrestor as he entered the ballast tank, and it is almost certain he slipped and fell from an un-guarded stringer. The precautions taken in preparation for his entry into the tank did not comply with the requirements of company procedures or industry practice. No permits to enter into an enclosed space or to work at height were issued. Although non compliance with the permit to work system had previously been identified during a company internal audit, no effective remedial action had been taken.

This is one of an increasing number of accidents which have resulted from complacency. Preventing this kind of behaviour at sea, where ship owners and managers are frequently thousands of miles from their vessels, is a huge challenge. A recommendation has been made to CMA CGM Group aimed at identifying ways of combating complacency and instilling a positive safety culture on board its ships. It also aims to ensure that the methods identified are shared with the industry via the MCA’s Human Element Advisory Group. A further recommendation has been made to CMA CGM Group aimed at improving the effectiveness of its internal vessel audit regime.

Left – Forward bulkhead with stringers, ladders and guardrails
Right – General arrangement showing the location of WBT 1F

Furthermore, the MAIB investigation identified the following failures in the vessel’s Safety Management System:

  1. The precautions taken before the chief officer’s entry into the tank fell significantly short of the requirements of the vessel’s procedures, the expectations of the vessel’s managers and industry practice.
  2. The repeated failure to issue permits to work for enclosed spaces and the failure to take the precautions detailed on the permits on the occasions they were issued, clearly indicates that the permit to work system on board Ville de Mars was ineffective.
  3. The action taken following the identification of a failure to use the permit to work system paid lip-service to the audit process and allowed the underlying problem to remain unaddressed.
  4. Complacency at all levels led to important safety procedures being disregarded on board Ville de Mars. Work is required to find ways in which a positive safety culture can be successfully instilled in ships’ crews.

Source: MAIB

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