ILHA DA MADEIRA - Very Serious Maritime Casualty
Vessel: ILHA DA MADEIRA
GAMA reference: 2021-208
Data da ocorrência acidental: 02-10-2021
Circulated on: 07-07-2022
Published on: 25-07-2022
Casualty Event: Missing
Summary
On 2 October 2021, during the final cargo securing operations at the Port of Leixões, a deck rating from ILHA DA MADEIRA was working alone near the port quarter on the seaward side of the vessel. The fall overboard was neither witnessed nor heard. The crew member's disappearance was only detected when he failed to respond to VHF calls. He was later located approximately 100 metres astern of the vessel, without a lifejacket, and recovered deceased. The investigation identified deficiencies in monitoring arrangements, collective protection measures and the use of personal flotation equipment.
Safety recommendations
SR01-2021/208,
to ISM Company of ILHA DA MADEIRA:
Assess equipping crew members securing cargo on the seaquay side with automatic-inflation lifejackets capable of keeping an unconscious person correctly afloat.
SR02-2021/208,
to ISM Company of ILHA DA MADEIRA:
Assess installing protective railings on sea-sidequay-side lashing platforms.
SR03-2021/208,
to ISM Company of ILHA DA MADEIRA:
Assess updating crews on cargo-securing hazards, physical fitnessfatigue, correct handling techniques, installed safety equipmentpersonal protective equipment.
SR04-2021/208,
to ISM Company of ILHA DA MADEIRA:
Assess ensuring that lashing platforms have high-contrast markings, non-slip surfacessufficient width for handlinginstalling lashing equipment.
Lessons learned
Lashing operations on the seaward side of a vessel should not be carried out in isolation or without effective monitoring. Platforms should be fitted with guardrails, non-slip surfaces, high-visibility markings and adequate width. Automatic-inflation lifejackets should be capable of maintaining an unconscious person in a safe position in the water. The allocation of personnel should preserve an effective capacity to monitor activities and respond to emergencies. Management should ensure that procedures reflect the way work is actually carried out in practice.