Published on Australian Maritime Safety Authority (

Case study 1

A seafarer fell in the cargo hold while undertaking repairs from the number 3 cargo hold access ladder and sustained fatal injuries.1 The Australian Maritime Safety Authority (AMSA) conducted a port State control inspection and investigation following this incident. The vessel was detained with significant deficiencies related to the vessel’s safety management system. 

The investigation findings identified systemic failure in the vessel’s safety management system to ensure safe shipboard operations and maintenance of the vessel. The safety equipment, such as helmet and safety harness were in very poor condition and defective. The operator did not adequately maintain the safety equipment and did not provide safety harnesses required for working at heights. There was a lack of safety culture and leadership onboard the vessel. 

Shortcomings included: 

Image of a black harness","title":"Substandard, significantly worn waist harness. Source: AMSA Substandard, significantly worn waist harness. Source: AMSA.


1 AMSA (2021) Pacific Rawan Detention Report.