Fatal MOB on World Prize – 1 Fatality

When Pilot Ladder Shortcuts Become Normal

Briefing on MAIB report 16/2026 into the World Prize man overboard. The MAIB carried out this investigation on behalf of the Red Ensign Group. A crew member, the bosun, fell from the main deck of the bulk carrier World Prize while the crew rigged the pilot ladder. He died.

What Happened:

On 14 October 2025, World Prize left her berth at Rönnskär, Sweden, at 0751 LT (UTC+2) with two pilots on board. The wind was light and the sea temperature was 6°C. The freeboard at the pilot station was about 13 m. So SOLAS regulation V/23 called for a combination ladder. That means using the pilot ladder in combination with the accommodation ladder.

The chief officer took over the job and held a toolbox talk. Two able-bodied seafarers (ABs) signed a permit to work that had been filled in beforehand. The safety chains were removed from the opening at the forward pilot station. The pilot ladder davit was out of service, so the team lowered the ladder by hand. When a spreader bar snagged, the bosun and two others lifted the ladder to free it. The ABs on the accommodation ladder had no radios. So the bosun and the chief officer leaned over the side to shout to them.

At 0840 LT, about 3.5 NM east-south-east of Rönnskär, the bosun fell head first through the unguarded opening. He struck an AB and the lower platform of the accommodation ladder, then went into the sea.

He wore a helmet, but no personal flotation device (PFD) (working duty lifejacket) or safety harness.

At about 0842 LT, the deckhand of the pilot boat Pilot 753 SE caught him with a boathook. The boat’s two crew could not lift him on board. They tied a rope to his arm, but he slipped free and sank.

Police divers recovered his body the next day.

Immediate Operational Checks:

Officers and crew who rig pilot ladders should check the following today:

• Fall prevention first: Rig fall protection before anyone opens a rail or removes a chain at the ship’s side. Clip a harness and fall arrest device to a tested anchor point. The Code of Safe Working Practices for Merchant Seafarers (COSWP), Chapter 17, says never to use a portable rail or stanchion as the anchor.
• Lifejackets: Wear a working lifejacket or PFD that fits over the harness. Keep a lifebuoy with a light and line ready at the boarding point. This should be mandatory whenever guard rails are down, or side shell doors are open. Consider thermal protection where water temperature is below 12°C (53°F).
• Pilot ladder gear: Test the davit or winch that handles the pilot ladder before each use. COSWP Chapter 22 says to report defects and repair them before the gear is used again. If you must handle the ladder any other way, carry out a new risk assessment first.
• Radios for all: Give everyone on the job a handheld radio, including the crew on the accommodation ladder. Nobody should have to lean over an open edge to be heard. Hands free kits should be considered for critical operators.
• Permit at the worksite: Check each control on the permit at the worksite before work starts. Review the permit again whenever the plan or the team changes.

Lessons Learned:

• The workaround became normal: With the davit in disrepair, the crew handled the pilot ladder by hand at an open edge. Nobody assessed the new risk. Each job without harm made the method look safe. Treat broken pilot transfer gear as a reason to stop and reassess. Fix it rather than work around it.
• Fall protection that could not work: The safety management system (SMS) required a harness, a fall arrest device and a PFD. But there were no suitable anchor points near the pilot stations.
• Lifejackets:The PFDs did not fit the harnesses and could not turn an unconscious person face up. Injured and without a PFD, the bosun likely could not keep his airway clear. Make sure this kit works together. Then make wearing it a condition of opening the rail. Buoyancy aids may feel comfortable, but they are not suitable for unconscious casualties.
• Paperwork over protection: The crew signed a permit but did not put its key controls in place. Nobody used fall protection. The MAIB found a safety climate that valued records of compliance over managing risk. A permit protects people only when someone checks the real conditions. Walk the worksite and confirm each control before you sign.
• Nobody stopped the job: The chief officer became both supervisor and worker, so nobody stood back to watch for danger. The plan changed, but nobody reviewed the permit. Nobody used the ship’s stop work policy. Rank may have kept junior crew quiet, and people watching the work did not step in. COSWP Chapter 22 puts a responsible officer in charge of rigging the pilot ladder, in contact with the bridge. That officer needs free hands and a clear view, not a hand on the ladder. Tell every team that anyone can call a stop, and back them when they do. Be aware of the human element, and cultural norms. People need to practice saying ‘no’, for when it matters.
• Recovery from a small boat: The pilot boat crew reached the bosun quickly but had to improvise. The deckhand had not been trained on the boat’s ARHoop recovery system, so he used a boathook. The MAIB said the ARHoop might have improved the chance of recovery. Train every small craft crew member, including temporary crew, on the recovery gear on board. See also our briefing on a workboat crew member who went overboard when the gangway dropped during departure. Workboat members should consider the increased importance of emergency drills and training for new employees. Their small crew sizes put greater demands on personnel in emergencies.

Tags: Fatal Accident, Man Overboard, Bulk Carrier, Permit to Work, Stop-Work Authority

Official Report

Read the full safety report here: Man overboard from the bulk carrier World Prize with the loss of 1 life (MAIB report 16/2026)