What happened
On 1 February 2019, shortly after departing the port of Liepaja in Latvia, a deckhand on board the Dutch-registered general cargo vessel Lady Ami fell overboard. The incident occurred around 15:30 local time while the ship was underway toward Klaipeda, Lithuania. The crew had just finished unloading bales of waste, and the deckhand intended to enter the cargo hold to sweep out remaining debris before taking a rest break.
No one witnessed the fall. A motorman on the poop deck heard a scream and saw the deckhand in the water, along with a loose section of the hatch cover crane ladder hanging freely. The vessel was already moving at nearly full speed, causing the distance between the ship and the man overboard to increase rapidly. The captain immediately ordered a turn to port to bring the bow back toward the victim's last known position.
The search and rescue operation involved the Lady Ami, a pilot boat from Liepaja, and several local workboats. Despite these efforts, the deckhand was not located. His shoes were found floating in the water, confirming the search area was correct. As darkness fell around 17:05, the search was halted due to low visibility. The vessel returned to port by 18:05. Given the water temperature of 3 to 4 degrees Celsius, it is assumed the deckhand drowned.
The investigation
The Dutch Safety Board investigated the incident as a very serious marine casualty under IMO regulations. Investigators interviewed crew members and shipping company representatives, using the TRIPOD analysis method to identify failing barriers and organizational factors. Key areas of examination included the design and condition of the hatch cover crane ladder, the use of personal protective equipment, survival chances in cold water, and the effectiveness of man overboard procedures.
The vessel's Safe Working Manual required life jackets only in poor weather conditions. Since the weather was calm with good visibility at the time of the accident, wearing a life jacket was not mandatory for deck work. The investigation noted that the victim was not wearing one when he fell. Additionally, the man overboard drill had not been practiced with the vessel in motion; previous drills were conducted while stationary or as tabletop exercises only.
Findings
The precise cause of the fall could not be determined with certainty, but evidence suggests the deckhand may have fallen from the hatch cover crane ladder. The adjustable section of this ladder was found hanging loose, and no other plausible explanation for its position was identified. Crucially, the ladder lacked fall protection such as a handrail or cage, meaning there was no physical barrier to prevent a fall overboard.
The absence of a life jacket significantly reduced the deckhand's chances of survival in the cold water. Furthermore, the man overboard procedures were not followed completely due to sudden stress and a lack of routine practice for dynamic scenarios. Specifically, the man overboard button was not pressed, and the victim's position was not marked on the navigation system, which hindered the search operation.
Safety action
Following the incident, the shipping operator convened safety committees on all its vessels to review man overboard drills and recovery procedures. A significant change was implemented regarding personal protective equipment: the number of suitable life jackets available for deck work was increased from three per ship to one per crew member. These jackets are now mandatory for any deck activity, regardless of weather conditions, provided they do not hinder work. The company also consulted with the crane supplier regarding improved ladder safety solutions.