MAIB: Normalising of unsafe practice – fatal man overboard incident
- Safety Flash
- Published on 5 November 2026
- Generated on 5 November 2026
- IMCA SF 19/26
- 3 minute read
The UK Marine Accident Investigation Branch (MAIB) have published Accident Investigation Report 16/2026 into a fatal man overboard incident on board a bulk carrier offshore Sweden.
What happened?
The bosun on Isle of Man registered bulk carrier World Prize died when he fell overboard from the main deck while the crew were preparing the pilot ladder following the vessel’s departure from Rönnskär, Sweden. A pilot boat was a short distance away, waiting to collect two pilots from World Prize. The pilot boat’s crew saw the bosun fall to the water and tried to recover him, but he sank beneath the surface during their attempt. His body was recovered from the seabed the following day.
What went wrong?
- Unsafe procedure (used when rigging the pilot ladder) had become normalised practice, placing the crew at serious risk of injury.
- Crew members working near the unguarded deck edge were not equipped with the appropriate personal protective equipment to prevent them from falling, arrest any fall, or support them in the water.
- Nobody in the vicinity of the pilot ladder acted to interrupt the work- no-one stopped the job.
- The vessel was not equipped with sufficient handheld radios for use by the crew.
- Permits to Work were largely completed as a compliance exercise to satisfy oversight requirements, rather than being used as a practical mechanism to manage risk and ensure safe operations.
- The deckhand on the pilot boat had not been trained on the new man overboard recovery system on board the boat, reducing the capability of the crew to recover an unconscious person from the water.
Actions taken
- Crew training and modifications to provide suitable anchor points for safety harnesses when rigging the pilot embarkation equipment.
- The pilot ladder davits were reinstated and the deck near the pilot embarkation stations was marked to highlight the fall hazard.
- The vessel was provided with
- Personal flotation devices compatible with the safety harnesses carried on board
- Additional handheld radios for use by the crew.
- The operators of the pilot boat removed all the superseded equipment from its vessels and amended its digital training and maintenance management system to include all crew in man overboard drills.
Lessons to learn
- Be alert to the “normalising” of unsafe practice – could this be happening to you?
- Is there sufficient equipment on board to do the job safely, every time, all the time, or are crew having to “make do” with less?
- Permits to Work, Toolbox talks, and Risk Assessments, are potential barriers that could save your life.
- If necessary – STOP THE JOB!
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