Inquest into the Death of Samuel Eya LEOPOLODO
Deceased
Samuel Eya LEOPOLODO
Demographics
27y, male
Date of death
2011-11-17
Finding date
2015-05-26
Cause of death
Unascertained - either multiple injuries or immersion (drowning) or combination of both
AI-generated summary
Samuel Leopoldo, a 27-year-old Filipino seafarer, died after falling overboard from the container ship MSC Siena on 17 November 2011 while rigging a pilot ladder in rough seas near Rottnest Island, Western Australia. He was struck by large waves while hanging from a safety harness, sustaining multiple injuries, and subsequently lost his grip or slipped from the harness, entering the water in a severely injured or lifeless state. Key clinical and safety lessons: the work permit system for hazardous tasks was not completed despite being mandatory; weather conditions (2.5-4m waves, 28-33 knot winds) were not assessed before commencing work; safety harness buckles were not properly fastened; life jacket wear was uncertain; and the tethering rope was excessively long, leaving him hanging dangerously close to water. The employer, Allseas Marine, subsequently implemented comprehensive safety improvements including enhanced work permit procedures, crew training on personal protective equipment, and strengthened safety management culture across its fleet.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Work permit system not completed despite being mandatory for hazardous work
- Weather conditions (rough seas 2.5-4m waves, strong winds 28-33 knots) not assessed before commencing work
- Safety harness not properly fastened - chest buckle and right leg buckle were undone
- Life jacket not properly worn or checked
- Tethering rope excessively long, leaving worker hanging dangerously close to water
- No fall arrestor used in tethering equipment
- Risk assessment not undertaken for the task
- Communication between deck crew and bridge not clear and precise
- Crew fatigue - hours worked not properly monitored
- Complacency - task completed over 30 times in 2 months without incident
- Ship course not adjusted to take advantage of upcoming course alteration that would have reduced weather exposure
Coroner's recommendations
- Allseas Marine to continue implementation of enhanced work permit system for work over the side, with specific guidance and precautions for combination pilot ladder operations
- Continued crew training on personal protective equipment use and life-saving appliances
- Maintenance of improved safety management culture and systems across entire fleet
- Ongoing risk assessment procedures to be implemented before hazardous work tasks
- Weather condition assessment to be incorporated into work planning decisions
- Proper use and fitting of safety harnesses with all buckles fastened and checked
- Use of fall arrestor equipment in tethering systems
- Appropriate tethering rope lengths to be determined through risk assessment
- Ship course planning to incorporate weather exposure minimization
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