The latest tragic lesson to come from the Coast Guard is a man overboard case where everything went wrong — and nothing had to.

A marine safety alert making the rounds this week tells the story of a 29-year-old crewman who fell from the Chinese-flagged 738’ bulk carrier CF Crystal in December 2014, while it was anchored 10 miles off Sabine Pass, Texas.

He was over the rail in a bosun’s chair, to paint the mid-ship draft marks and load lines. The crewman did not know how to swim, and inexplicably was not wearing a personal flotation device (PFD).

When his crewmates began to haul him up, the line to the bosun’s chair parted, and he plunged into the sea. The man tried to reach a life ring tossed by his crewmates, but they saw him submerge, while others frantically tried to deploy a rescue boat that would not function.

The man overboard call went out and within half an hour, a 45’ medium response boat from the Coast Guard’s Sabine Pass station was on scene, and joined by an MH-65 Dolphin helicopter from the Houston air station. A Liberian-flagged tanker, the 600’ Corrido, lowered a lifeboat to join the search, but those mariners found only the missing man’s hardhat.

Coast Guard investigators learned the Crystal’s captain and chief mate had met and agreed on a suitable work plan for the painting job. It included inspecting the bosun’s chair and its manila rope rigging, requiring the crewman going over to wear a PFD and lifeline with a safety harness.

Yet none of that was done.

“Crewmembers failed to adequately check the strength of the bosun’s chair line, instead simply pulling on it,” according to the narrative from the Coast Guard’s Inspections and Compliance Directorate. What’s more, the lifeline was not belayed.

“Also, the deceased crewmember was not wearing a PFD, and, even though he wore a safety harness along with a lifeline, the lifeline went untended and was not tied off to the vessel. The vessel’s bosun was not present, and it remains unknown as to who was supervising the operation.”

Months before the accident, the chief mate had put in a requisition for new PFDs that worked with safety harnesses, and new manila line. The request was never fulfilled, the report notes.

The lesson to operators and crews: plan, and keep the attitude that anything, and everything, can go wrong. The recommended checklist:

  • Properly use safety equipment.
  • Ensure adequate supervision of work teams.
  • Develop workplace mindsets that properly develop and execute plans, including those for worst case scenarios.
  • Implement barriers to prevent such scenarios.
  • Fully implement and adhere to Safety Management System requirements.

Contributing Editor Kirk Moore was a reporter for the Asbury Park Press for over 30 years before joining WorkBoat in 2015. He wrote several award-winning stories on marine, environmental, coastal and military issues that helped drive federal and state government policy changes. He has also been an editor for WorkBoat’s sister publication, National Fisherman, for over 25 years. Moore was awarded the Online News Association 2011 Knight Award for Public Service for the “Barnegat Bay Under Stress,” 2010 series that led to the New Jersey state government’s restoration plan. He lives in West Creek, N.J.