Crewman Death After Falling Overboard – Investigation Report

On 13 December 2010, an able seaman (AB) fell into the River Clyde from the St Vincent and the Grenadines registered cargo vessel Joanna, while the vessel was alongside in Glasgow, Scotland. He was recovered from the water about 25 minutes later, but could not be resuscitated. The investigation identified that the AB almost certainly fell while climbing up to the port side platform of the straddle lift used to move the vessel’s cargo hatch covers.

The crew usually accessed the platforms either by climbing up from the main deck or via the hatch covers. The figure to the left below shows the method usually adopted by the crew to reach the platform from the main deck. The crew climbed up the guardrails while facing the straddle lift and holding on to the hand/foot supports on the aft upright. When on the top guardrail, the crew would step across to the platform. To approach the platforms from the hatch covers, the crew either had to duck under the lift’s main beam or swing outboard of the aft upright using the hand/foot supports provided.

Left – Crew usuall access to the platforms either by climbing up from the main deck or via the hatch covers
Upper Right – Platforms were 1.65m above the deck and were 0.39m deep
Lower Right – Hatch covers were moved using a straddle lift

The accident happened soon after the cargo operations were completed. The chief officer instructed the bosun and the deceased seafarer to close the hatches. The two ratings left the bosun’s store and went to the ladder providing access to the main deck on the starboard side (please refer to the figure below). The bosun then went down the ladder and made his way along the starboard side of the main deck towards the straddle lift which was stowed amidships. It is assumed that the deceased also went down the ladder to make his way towards the port platform. Using the deck guardrail as a ladder, the bosun climbed onto the straddle lift platform and waited for the deceased seafarer to appear on the port side.

Access to the main deck on the starboard side

Soon afterwards, the bosun called out to the deceased seafarer because he could not be seen on the port platform as expected. There was no response. The bosun immediately climbed on to the hatch covers and walked across to the port side. He saw the deceased seafarer face-down in the water between 1 and 2 metres from the vessel’s hull. The bosun ran to the master’s cabin, shouting to raise the alarm along the way. The master immediately telephoned the ship’s agent, but there was no reply, so he rushed to the bridge and sounded the man overboard alarm.

On the poop deck, the chief engineer and cook heard the bosun’s shouts and looked over the port side of the vessel. They saw the deceased seafarer floating towards the stern and shouted out to him. Without delay, the chief engineer collected a lifebuoy and line. He and the cook then went on to the quayside where a ladder was sited astern of the vessel.

The commotion on board Joanna alerted the shore-side crane foreman and crane driver who went to the vessel to see what was happening. When they saw the two men in the water, the crane foreman immediately telephoned the port authority and requested that the emergency services attend. He also arranged for a personnel transfer basket to be made available.
Soon after, the cook and Stanislaw reached the ladder. The bosun lowered a line with a grappling hook, which the cook placed through the front of Stanislaw’s clothing. The bosun and chief officer then heaved on the line to keep Stanislaw’s face clear of the water. The cook then climbed out of the water because he was beginning to lose the feeling in his legs and hands.

Later on, the first of the emergency services had arrived on the quayside and the transfer basket was connected to the crane’s hook. The basket was lowered over the water. Inside the basket were a harbour pilot who had been attending an adjacent vessel, the crane foreman, and another port foreman. The deceased seafarer was pulled into the basket and was landed on the quay. He was then taken to hospital by ambulance but was declared deceased.

The MAIB investigation among others found that:

  1. the AB was working while under the influence of alcohol (analysis of postmortem blood revealed that the seafarer had a blood alcohol concentration of 193mg/100ml)
  2. the means of access to the straddle lift platforms used by the ship’s crew were unsafe
  3. the opening and closing of the cargo hatch covers had not been identified as a key element within the onboard procedures, and therefore the risks of accessing and operating the straddle lift had not been assessed
  4. important personal protective equipment (PPE) was either not available on board, or was not fit for purpose

As a result of the accident and the MAIB investigation the vessel’s manager:

  1. implemented a drug and alcohol policy
  2. renewed its shipboard  operations and risk assessments
  3. provided new procedures for the operation of the straddle lift
  4. provided replacement PPE on board Joanna

Source: MAIB


  1. As usual, there are questions with (seemingly) no answers.

    1. What led the AB to work under the influence of alcohol?

    2. Why did the crew consider it reasonable to access the straddle lift platforms in that way? It seems fair to suppose they did not think it was unsafe, or they would have done it otherwise.

    3. What was taken into consideration to decide which actions should be deemed key elements of the onboard procedures?

    4. What made the lack or inadequacy of PPE acceptable to the crew and to the management?

  2. Reblogged this on Safe Sease comentado:
    Death overboard M/V Joanna: report and questions…

  3. jose s. capuno jr. says:

    normally, a seaman should not work under the influence of alcohol. presumed that the seaman was ordered by the officer to work, without knowing the seaman is under the influence of alcohol; perhaps there is no other seaman to do the work, others are on shore leave too. officers on watch should be very careful in checking the crew after they came from shore leave.

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