Two internal audits examined the working-at-height procedure. Both recorded it without comment.
Six months after the second one, a bosun fell through an unguarded opening and drowned.
Gulf of Bothnia. 14 October 2025. Sea temperature 6°C.
0813. The tugs are released. The master orders the starboard combination ladder rigged.
0824. Radio call to the deck. The pilots leave in fifteen minutes.
0832. Second call. Rig it early.
The safety chains across the opening come off. The accommodation ladder goes down.
Two able seamen work on it, about 7m below the deck edge.
There are not enough handheld radios. The only way to talk to them is to lean over the side.
0840. The bosun straightens up. He loses his balance. He goes headfirst through the opening.
He strikes the lower platform. Then the water.
0842. The pilot boat crew catch him with a boathook. He is unconscious, held up by air in his jacket.
They cannot lift him. He slips from the rope and sinks.
1100. The search ends. Divers recover his body next day.
Now the part nobody reads.
The shortage of radios was raised at the ship’s safety committee. In July 2025. Then again in August 2025.
Recorded twice. Nothing arrived.
The permit to work was pre-prepared. Two ABs signed it after the work started.
On paper it shows full compliance with every control the SMS asks for.
After the accident it was amended — to add a ladder that had already been rigged and used.
The SMS required a harness and a fall arrest device. The ship had no anchor point that met its own guidance.
➡️ The procedure demanded something the deck could not physically do.
Here is the sharp edge.
Internal audits in May 2024 and April 2025. Both looked at working at height. Both recorded it without comment.
The April 2025 audit recorded training in rigging the pilot ladder as complete.
Of the crew trained that day, one was still on board when the bosun died. The second engineer.
❌ The audit measured the ship. Competence leaves at crew change.
The May 2024 audit did find something. Safety officer inspection records were kept. The inspections were not.
By April 2025 that finding was gone. Nothing says whether it was fixed or simply no longer seen.
From the messroom.
“We have rigged it that way for years. Nobody ever fell.”
That is not recklessness. Repetition without injury reads as proof of safety.
The lesson.
The report’s ninth conclusion says it plainly: the safety climate produced documentation of compliance rather than effective management of risk.
Seven earlier investigations in the report describe the same shape. The oldest is 2014.
✅ Take one control out of your SMS this week. Find the record that proves it works.
Then go and watch the job.
A record proves that someone wrote something down. It does not prove that anything happened.
What did your last audit record without comment? Tell me below.
#MaritimeSafety #Auditing #SafetyManagement #OccupationalSafety #SafetyCulture
