B SAFE Loss Prevention BSAFE INCIDENT CASE STUDY 02: FATAL FALL FROM A LADDER Published: 23 December 2020 An AB on board a product tanker suffered severe injuries after falling from a portable ladder (Figure 1) while conducting maintenance work on the launching system for the ship’s free-fall lifeboat and later tragically died from his injuries. Figure 1 The ladder as positioned by the AB to reach the forward hook. Source: AIBN; USCG. WHAT HAPPENED? A product tanker was on route from South Korea to Los Angeles. While at sea, as the crew was preparing for an announced USCG inspection to take place while alongside in Los Angeles, it was found that a lashing turnbuckle for the ship’s free-fall lifeboat was defect due to corrosion, as the securing pin was seized. The chief officer informed both the bosun and the AB about the work and instructed that it should only involve the removal of the remaining rust and painting of the turnbuckle. The bosun was also told that the AB was to assist the rest of the deck crew in cleaning activities once the task was completed. No work permit was issued as the work was planned to take place at a height of about one metre above deck and in an area fitted with railings ( Figure 2 ). THE CHIEF OFFICER CARRIED OUT A VERBAL RISK ASSESSMENT OF THE MAINTENANCE JOB TOGETHER WITH THE TWO BOSUNS ON BOARD, AND ADVISED THAT DUE TO THE SHIP ROLLING MODERATELY NO WORKING ALOFT WOULD BE ALLOWED. Figure 2 The working area for the originally agreed maintenance task (turnbuckle marked with a yellow circle). Source: AIBN; Thome Ship Management Pte. Ltd While performing the job, the AB observed that the forward hook on the davit of the free-fall lifeboat needed lubrication. Having finished the work on the turnbuckle, he approached the bosun and asked him to assist him with lubricating the forward hook by steadying a ladder he had positioned on deck below the lifeboat forward hook ( Figure 1 ). The height from the deck to the hook was about 4.8 metres. The