TSIB Singapore: Second Engineer falls overboard while carrying out maintenance work

The Transport Safety Investigation Bureau of Singapore (TSIB) has published its investigation report into an incident where a second Engineer fell overboard while carrying out maintenance work near the vessel’s side, but could not be recovered.

On 26 December 2025, a Second Engineer (2E) on board a Singapore-registered bulk carrier fell overboard while carrying out maintenance work near the ship’s side as the vessel was underway at sea.

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Following the occurrence, the bridge team initiated man-overboard (MOB) response procedures. At the time, winds were at Beaufort force 5, with sea and swell conditions of approximately 2 metres, creating challenging conditions for recovery operations and affecting the manoeuvrability of the rescue craft.

Despite repeated recovery attempts, the 2E could not be recovered from the water. The Transport Safety Investigation Bureau of Singapore classified the occurrence as a very serious marine casualty.

The investigation identified the following:

The work location, near the ship’s side, exposed the 2E to the risk of falling overboard while carrying out maintenance from an A-frame ladder while the vessel was underway.
The risk assessment for working at height required the use of fall-arrest equipment and identified a suitable anchor point. However, the investigation found no evidence that the fall-arrest equipment or its securing arrangements were in use at the time of the occurrence.
When the 2E was first sighted in the water by ASD-1 and subsequently by ASD-2, no lifebuoy or other buoyant flotation device was immediately deployed, although ASD-2 was positioned closest to the MOB location.
The MOB lifebuoy was subsequently released as part of the vessel’s response.
The prevailing sea conditions created operational difficulties for deploying the rescue boat. A decision was therefore made to launch the free-fall lifeboat. Although the free-fall lifeboat could be launched more readily under the prevailing conditions, its design characteristics and operating limitations reduced the effectiveness of the recovery operation.

Conclusions

On 26 December 2025, 2E fell overboard into the sea while carrying out maintenance work on the port side bunkering davit as CC was underway at sea. At the time of the occurrence, 2E was alone at the worksite near the ship’s side following the temporary separation of the work team. There were no eyewitnesses to the occurrence, and the manner in which 2E fell overboard could not be determined.

The RA for Working at Height/ Over the Side Permit identified general work-atheight hazards and control measures, including the availability of secure anchor points and the use of fall-arrest equipment. The investigation found no evidence that the fall-arrest equipment and its securing arrangements were in use at the time of the occurrence.

While the maintenance work on the bunkering davit did not require personnel to work overside, conducting the work from an A-frame ladder in close proximity to the ship’s side while underway exposed personnel to the risk of falling overboard.

When 2E was first sighted in the water, no lifebuoy or buoyant flotation device was immediately deployed towards 2E before the MOB lifebuoy was released as part of the ship’s MOB response.

The prevailing environmental conditions created challenging circumstances for MOB SAR operations. The Master assessed that deployment of the RB presented operational and safety risks and decided to deploy the free-fall LB. Although the LB could be launched more readily, its design characteristics reduced the effectiveness of the recovery operation.

Safety actions

The Company conducted fleetwide safety awareness and training sessions relating to work-at-height activities, use of personal protective equipment (PPE), Stop Work Authority, and MOB prevention measures. Additional safety familiarisation and training programmes were also carried out with shipboard personnel and manning agents.
The Company revised its PPE matrix to include additional fall-arrest equipment, including the use of inertia reels or equivalent fall-protection systems for relevant over-side and at-height work activities.
The Company enhanced its PTW, RA, toolbox meeting, and safety verification arrangements through additional reviews, audits, remote monitoring, and feedback processes conducted across the fleet. Additional procedural controls were also introduced to prohibit lone working during high-risk activities, particularly work-at-height operations.
The Company incorporated additional guidance relating to portable ladder inspection and usage into its safety management procedures and initiated engineering control measures, including the establishment of designated red-zone areas and installation of certified fall-arrest anchor points onboard selected vessels within the fleet.
The Company revised its MOB procedures to provide clearer guidance on rescue craft selection and deployment during MOB recovery operations. The revised arrangements reinforced that the RB remained the primary recovery craft for MOB situations, while alternative recovery craft were only to be considered where the RB was not operational or could not be safely and practicably deployed. The Company also introduced additional guidance and structured decision-making arrangements to assist Masters in assessing operational, environmental, safety, and recovery considerations during rescue craft selection and deployment.
The Company enhanced fleetwide MOB drill arrangements to include scenario-based exercises covering varying sea states, ship motions, visibility conditions, and rescue craft selection challenges. Additional guidance was also issued to reinforce crew understanding of the operational capabilities, limitations, risks, and readiness expectations relating to rescue boats and lifeboats during MOB recovery operations.
The occurrence was circulated fleetwide as a safety lesson learned to enhance awareness of the risks associated with work-at-height activities, MOB prevention, and emergency response arrangements.
Following the occurrence, the Company issued a fleetwide instruction on the “Immediate Deployment of Lifebuoys or Buoyant Flotation Devices upon Initial Sighting of a Person in the Water”. The instruction required crew members, upon the initial sighting of a person in the water, to immediately deploy available lifebuoys or other buoyant flotation devices towards the casualty, where safe and practicable to do so. This requirement was implemented across the Company’s fleet. All vessels acknowledged receipt, conducted onboard safety briefings and crew training, incorporated the requirement into familiarisation programmes and future MOB drills, and submitted training records and supporting documentation to the Company as evidence of compliance.