1 . What the type of casualty?
Very Serious Marine Casualty : Fall from height in a ballast water tank resulting in a fatality
2 . What happened ?
An officer, safety officer and crew member were proceeding to exit a ballast water tank. They had just completed an air quality inspection of the tank prior to its undergoing maintenance. The crew member, who was to be the last person to exit the tank, was about one metre from the exit when he lost his grip and fell approximately 10 metres. Although the crew member was treated in the tank, he succumbed to his injuries two hours later. It took four hours to cut an escape hatch by which the crew member could be recovered from the tank.
3 . Why did it happen ?
· The design of the tank's access prevented the immediate removal of the injured crew member from the inside of the tank.
· Fall arrestors, lanyards and safety harnesses were not being used, nor were there any brackets or strong points for securing safety equipment.
· The crew member was carrying a gas detector (which he wore around his neck and which lay on his stomach) and a rope while climbing the ladder. As he tried to untangle the gas detector, he lost his grip and fell.
1 . 压载舱开口的设计妨碍了舱内受伤船员的转移；
2 . 人员进入压载舱时没有佩戴防坠落装置、吊绳和安全带，也没有用来固定安全设备的任何支架或支撑点；
3 . 这名船员在攀爬梯子时，携带一部气体探测器（他将气体探测器挂在脖子上，设备悬在他的腹部）和一根绳子。当他试图解开气体探测器时，他没有抓稳掉了下去。
4 . What can we learn ?
·Hazard and rescue assessments should be carried out prior to entering a confined space.
·Safety procedures should be established and followed for use of ladders. These should include keeping hands free at all times and using appropriate means for hoisting and lowering of tools and equipment.
·Tank entrance design should accommodate the possibility of evacuating an injured person.
·The importance of proper safety harness and its use.
1 . 在进入受限空间前，应开展风险和救援评估；
2 . 应建立并遵循梯子使用安全程序。程序应包括保持双手空闲（能一直腾出手），及使用适当方式升起或降下工具和设备；
3 . 压载舱的入口设计应考虑撤离受伤人员的可能性；
4 . 正确使用安全带的重要性。
5 . Who may benefit ?
Shipowners, operators and crews.