Inquest into the Suspected Death of Pei Yao CHEN
Deceased
Pei Yao CHEN
Demographics
41y, male
Date of death
2014-10-06
Finding date
2022-02-09
Cause of death
Drowning in the Indian Ocean near B-7 Anchorage Point approximately 13 miles from Port Hedland, Western Australia
AI-generated summary
Pei Yao Chen, a 41-year-old Bosun, fell overboard from the cargo ship Cape Splendor while fishing from an accommodation ladder during a lunch break in October 2014. Despite wearing work clothes and no lifejacket (contrary to ship procedures), he lost balance and fell into strong currents near Port Hedland. Crew launched rescue efforts immediately, but he disappeared beneath the surface. The ATSB investigation identified that the ship's safety procedures for working over the side were not effectively implemented—crew did not appreciate the importance of fall prevention and did not consider safety precautions necessary during recreational activities. The coroner found the emergency response was appropriate but highlighted that safety culture failures and non-compliance with established protocols contributed to the incident. Recommendations focused on improving safety awareness and compliance across maritime operations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- Non-compliance with ship safety procedures requiring lifejacket wear when working over the side
- Inadequate implementation and enforcement of safety management system procedures
- Crew not appreciating importance of fall prevention when working over the side
- Crew not considering safety precautions necessary during recreational activities such as fishing
- Strong prevailing currents in the anchorage area
- Weight of sodden overalls affecting ability to stay afloat
- Exhaustion from swimming against strong current
Coroner's recommendations
- Implementation of more effective safety management systems and procedures for working over the side of ships
- Enhanced training and safety awareness programs emphasizing that safety precautions apply to both work and recreational activities
- Prohibition of fishing from accommodation ladders
- Posting of warning signs adjacent to accommodation ladders
- Improvements to man overboard rescue procedures
- Promotion of effective safety culture and safety awareness across maritime fleets
Full text
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