RMI investigation: Fatal fall from inclined ladder onboard

by 30, Sep, 2020Innovation

The incident

On 14 May 2019, the RMI-registered oil tanker POLAR COD was underway in the Arabian Gulf on a loaded voyage from the Kingdom of Saudi Arabia to Singapore.

At 1300, the Third Engineer reported to the Engine Control Room (ECR). While in the ECR with the Chief Engineer and Second Engineer, a high-level alarm for a waste oil tank activated.

After acknowledging the alarm, the Third Engineer left the ECR to check the cause. He was seen climbing an inclined ladder leading from the engine room’s second deck to the upper deck.

Shortly thereafter, the Fourth Engineer saw him falling to the main engine cylinder head intermediate platform. The Fourth Engineer was working in the Engine Workshop at the time and did not witness the start of the fall.

The Messman, who was reported by the Company to also be a medical doctor, checked the crew member and determined he was not breathing and did not have a pulse.

CPR was immediately started by the crew; however, the engineer was determined to be deceased at 1415.

As the time elapsed between the fall and when he was seen climbing the ladder was under 10 seconds, it is presumed that he fell from the inclined ladder between the second deck and upper deck from a height of 6 to 11.3 meters (m).

Probable causes

Although the cause of the 3/E’s fall could not be determined since there were no witnesses, the marine safety investigation conducted by the RMI concluded the following:

Causal factors which may have contributed to this very serious marine casualty include:

  • the height of the handrails on the inclined ladder between the second deck and the upper deck of POLAR COD’s Engine Room were lower than the design specification;
  • possible physiological or psychological stresses resulting from the 3/E’s weight loss efforts; and
  • high ambient temperatures in the Engine Room while the ship was in the Arabian Gulf.

An additional factor identified, which did not contribute to this very serious marine casualty, was the 3/E’s failure to use the chin strap of his safety helmet at the time of his fall.

Actions taken

Following this very serious marine casualty, the company has taken the following preventive actions:

  1. The height of the handrail on the involved inclined ladder was immediately raised and an intermediate guard between the stringer and the handrail was fitted. The same modification was also implemented on a sister ship under the Company’s management.
  2. A circular was sent to all ships in the Company’s managed fleet which detailed the lessons learned from this incident.
  3. The inclined ladders on all ships in the Company’s managed fleet were inspected to ensure adequate fall protection was provided. As a result, inclined ladders on four ships were modified to provide greater protection to the crewmembers.
  4. Another circular was sent to all ships in the Company’s managed fleet, as well as all officer staff, which discussed the safe use of stairs.
  5. A fleetwide safety campaign was implemented regarding the use of chin straps when wearing safety helmets. This included the requisition of additional chin straps to ensure they were immediately available to crewmembers at all times.
  6. An article was published in the Company’s newsletter regarding the incident and the lessons learned. The dangers associated with excessive dieting were specifically discussed in this article.
  7. The lessons learned were discussed during a safety meeting held on all ships in the Company’s managed fleet.
  8. An additional, dedicated safety meeting was held on all ships in the Company’s managed fleet to review the lessons learned.
  9. The Company’s full investigation report was sent to all ships in the Company’s managed fleet to raise awareness.


After investigation, RMI issued the following recommendations:

  • It is recommended that IACS consider amending Recommendation No. 132 to address the design of inclined ladders (those having an angle of inclination greater than 45° but less than 80°), including recommendations relating to handrail height above tread, handrail diameter, and use of two-tier handrails on exposed sides.
  • It is recommended that the Administrator consider submitting a proposal to the IMO to develop and implement prescriptive requirements for the design of stairs, ladders, and inclined ladders, including the design of handrails and means of fall protection.

Find further details herebelow:

Polar Cod report

September 2020