The Transport Safety Investigation Bureau of Singapore (TSIB) recently published its investigation report on its official website on 9 June 2026, regarding the fatal accident of a Chief Officer onboard a bulk carrier that occurred last year.

The TSIB concluded that the probable cause of the incident was that the Chief Officer, the designated Safety Officer, entered the cargo hold alone without informing anyone of his intention to inspect the cargo space, including the Officer of the Watch (OOW) on the bridge, and fell onto the tank top through an unguarded opening on the inspection walkway created by a metal grating left in the open position. Furthermore, the Safety Management System (SMS) procedures, such as completing the relevant checklists and obtaining the Permit to Work (PTW) required for cargo hold entry and working aloft, were not complied with, and Personal Protective Equipment (PPE) such as a safety harness was not worn.
(Source: TSIB Marine safety investigation report TIB/MAI/CAS.216)

While cargo hold cleaning and inspection are essential operations to maintain the quality of the next cargo, the inspection walkways inside the holds extend from the tank top to very high positions (with the fall in this incident being from a height of approximately 16 meters above the tank top), posing a constant and severe risk of falling. Leaving a grating open on an inspection walkway without implementing protective measures such as guardrails is extremely dangerous.

Preventive Measures
Strict Enforcement of Safe Work Procedures and Fostering a Safety Culture

　　　　
• Conducting Risk Assessments, Verification of Checklists, Toolbox Meetings, and Strict Implementation of Permits to Work (Prohibition of Deviation from Procedures):
  In accordance with each management company's SMS provisions, prior to commencing regulated operations such as working aloft (including elevated hold inspections as seen in this case), a proper risk assessment must be conducted to identify potential hazards (such as openings or wet ladders) and assess their associated risks. The identified hazards, assessed risks and corresponding controls must be shared with the team during Toolbox Meetings. It is required that operations commence only after conducting prior verifications via applicable checklists and strictly completing the Permit to Work (PTW) approval process. Furthermore, it is essential to strictly adhere to established SMS procedures and rules, maintaining a posture that under no circumstances tolerates deviation.

 

• Empowering Stop Work Authority (SWA):
  If a hazard such as an open grating is discovered, it is important to foster a culture where all crew members, regardless of rank, are empowered and obligated to exercise their "Stop Work Authority," halting operations and rectifying the situation until safety is secured.

 

• Wearing Proper Personal Protective Equipment (PPE) and Recognising "PPE as the Last Resort":
  When working aloft, it is a fundamental requirement to always wear and properly use appropriate PPE, such as a safety harness and lifeline. Although a safety harness itself was not worn in this incident, it must be simultaneously recognised that PPE is merely the "last resort" or the final line of defense in safety measures. The most effective approach to prevent falls is to eliminate the hazard at its source (such as ensuring openings are securely closed after work) or to install physical protective measures like guardrails. It is indispensable to combine the proper use of PPE with the elimination of such hazards and physical protection.

 

• Thorough Post-Work Inspection and Securing of Work Areas:
  Upon completion of work, it is necessary to conduct a thorough inspection of the work area. In particular, it is crucial to strictly enforce procedures to verify on-site that any openings temporarily uncovered or equipment moved for the work are properly closed, restored and securely fixed.

 

• Maintaining "Three-Point Contact" on Vertical Ladders:
  When climbing up / down cargo holds or accessing elevated areas using vertical ladders, seafarers must always maintain a strict "three-point contact" (two hands and one foot, or two feet and one hand) to firmly grasp the ladder, thereby preventing falls caused by slips or trips. Particular caution is required inside cargo holds immediately after cleaning operations, as ladders and walkways can be wet and extremely slippery.

For further practical guidance on risk assessment, you may find the following P&I Loss Prevention Bulletin helpful: Vol.51 Risk Assessment in Practice issued in June 2021.
In addition, please refer to our explanatory video on risk assessment.

We remain committed to providing the latest information and technical insights to support our Members in preventing accidents.