Amadeus. The vessel held full-term certification.
The work still required a deckhand to lean over a 780mm bulwark.
Amadeus. German Bight. 13 December 2023.
At about 0009, a deckhand fell overboard while hauling crab pots in rough seas.
The wind was force 7, gusting force 8. Waves reached 2 to 2.5 metres.
He was not wearing a PFD.
Within 2 minutes and 30 seconds, he had lost consciousness and submerged.
The obvious explanation is familiar.
No PFD. Rough weather. A dangerous position near the vessel’s side.
But that explanation starts too late.
The hauling method required him to lean over the side in an unstable, forward-leaning posture.
A raised steel grating had reduced the effective bulwark height to 780mm.
No equivalent fall prevention arrangement protected that position.
Before the fall, he hauled 47 pots in about 12 minutes while the vessel rolled heavily.
He had worked for 97 consecutive days.
The investigation assessed that he had accumulated more than 46 hours of sleep debt during the previous four weeks.
This was not a brief lapse during an otherwise controlled task.
The task itself combined exposure, repetition, fatigue and vessel movement.
Now consider the documented control.
The vessel’s risk assessments required deckhands to wear a PFD. That requirement was not enforced.
Even if worn, the PFD would only help after someone entered the water. It could not stop the fall.
The inspection problem went deeper.
The May 2022 inspection took place in port. The pot hauling operation was not observed.
The reduced bulwark height and absence of equivalent protection were not identified because the risk assessment controls were not checked against the actual work.
Yet full-term certification was issued despite missing hours-of-work and rest records.
The paperwork described controls.
The certification described compliance.
The deck arrangement described the real risk.
Only one of those required the inspector to watch the job.
The Fishing Safety Management Code was voluntary. Uptake across the fleet varied.
On Amadeus, the risk assessments had not been substantively reviewed since February 2018. The report found they appeared to serve certification rather than active safety management.
That leaves a practical test for any DPA, surveyor or fleet manager.
Do not verify this control in the office.
Watch the hauling position under realistic conditions.
Measure the protective height from the surface where the crew member actually stands.
Observe posture, pace and vessel movement.
Then separate fall prevention from survival equipment.
A PFD may keep someone afloat.
It does not make an exposed working position safe.
Which controls in your system have been verified against the paperwork, but never against the job?
#MaritimeSafety #Auditing #MarineAccidentInvestigation #ManOverboard #FishingVessels
