Investigation Report
Uncontrolled descent of accommodation ladder from container vessel Ever Elite with loss of 1 life
Uncontrolled descent of accommodation ladder from container vessel Ever Elite with loss of 1 life
- MAIB
- Investigation Report
- Unknown
- Machinery and EquipmentMarine Operations
- DrowningMechanical failureRegulation and legislation
- Inspection and maintenanceMarine operationsWorking at height
- Fall protection equipmentLadderPersonal protective equipmentWinch
- Functional testingOperating and work proceduresPreventive maintenance
- Marine industry
- Marine watersVessel
Summary
An investigation synopsis describes a fatal accommodation-ladder accident aboard Ever Elite in San Francisco Bay. Incorrect gearbox reassembly after maintenance released the ladder. It identifies deficiencies in technical information, maintenance management, testing and working-over-side protection, and outlines recommendations concerning hoist standards, regulatory requirements and the operator’s safety culture.
Classifications: Drowning; man overboard; person overboard.
Classifications: Mechanical failure; equipment failure.
Classifications: Regulation and legislation; safety legislation; regulatory requirements.
Classifications: Inspection and maintenance; asset inspection; equipment maintenance.
Classifications: Marine operations; maritime operations.
Classifications: Working at height; work at height.
Classifications: Fall protection equipment; safety harness; fall arrest equipment.
Classifications: Ladder; ladders.
Classifications: Personal protective equipment; PPE; personal protection equipment.
Classifications: Winch; winches.
Classifications: Functional testing; function test.
Classifications: Operating and work procedures.
Classifications: Preventive maintenance; preventative maintenance; planned maintenance.
Classifications: Marine industry; shipping industry; maritime sector.
Classifications: Marine waters.
Classifications: Vessel; aboard ship; onboard vessel.
Summary
An accommodation ladder descended uncontrollably from a container vessel, causing one fatality.
Themes: machinery and equipment, marine operations.