Serious safety issues existed on a bulk carrier in West Australian waters when a seaman was knocked off a ladder and killed in 2011, an investigation has concluded.
In November 2011, the 27-year-old Filipino man was attempting to rig a combination pilot ladder to the side of the Greek-owned MSC Siena when a massive wave knocked him into the sea just off Rottnest Island.
The ordinary seaman (OS) had joined the ship's crew only six months before the accident.
Witnesses told the Australian Transport Safety Bureau (ATSB) inquiry that the wave forced the crewman off the ladder, and as he was suspended and trying to hold on, his legs were submerged in rough seas which pounded his body against the ship's side.
"The seaman on deck watched in shock as the OS, who appeared injured, went limp as he hung suspended by the harness rope, swinging fore and aft and side to side," the report said.
A massive air and sea search was launched but failed to find the seaman.
The ATSB investigation found several fatal errors on the ship's part, including the lack of a risk assessment for the rigging task and a lack of precautions for poor weather conditions.
"The weather conditions, safety harness tethering, wearing of a lifejacket and communication were amongst the factors that were not properly considered before the crew started rigging the ladder," the ATSB said.
It said Allseas Marine, the MSC Siena's manager, had significantly upgraded its safety regimes since the tragedy.
The ATSB said it was satisfied on-board training had been improved, a fleet-wide safety campaign had been carried out and ships' masters now had overriding authority on safety matters.