The third officer aboard the cargo ship Amazoneborg read the dockside draft marks over hand-held radio. He then passed another crewmember on deck while walking seaward to the port side to collect a similar reading.
Nobody saw or heard from the third officer again. Roughly 10 minutes later, the chief officer called for the missing mariner several times over radio but got no response. Crew searched the deck, where they found a lowered Jacob’s ladder and a draft measuring tape.
The chief officer alerted the captain at about 2240 on Sept. 29, 2017, roughly 15 minutes after the crewman failed to respond. The ship was tied starboard side to the dock on the St. Lawrence River at Trois-Rivieres, Quebec.
The third officer’s body was found eight days later in Champlain, Quebec, roughly 12 miles downriver. He was not wearing a personal flotation device (PFD), which crew found hanging in his locker.
Investigators with the Transportation Safety Board of Canada (TSB) determined that the third officer “likely fell into the water while using a Jacob’s ladder to read the vessel’s amidships seaward draft marks. There was no indication that the ladder malfunctioned.”
The report also noted that the lack of a PFD “diminished the third officer’s chances of survival in the water.”
Amazoneborg, a 469-foot ship registered in the Netherlands, docked at Section 19 of the Port of Trois-Rivieres on Sept. 28 to load nickel concentrate. Cargo operations began the next morning and were still underway when the third officer went overboard.
The chief officer registered the crewman missing at about 2225. After searching the vessel, Amazoneborg’s master ordered its rescue boat launched at 2301. Several good Samaritan vessels also looked for the missing crewman, including the tanker Chem Ranger, tugboat Ocean Bravo and pilot boat Jean H. The Canadian Coast Guard deployed two vessels to assist with the search, which authorities called off at 1648 on Sept. 30.
A Jacob’s ladder was hanging over the port side of the ship near the amidships draft marks after the incident.
Conditions at the time of the incident included overcast skies, light north winds, a 1.5-knot river current, 1- to 2-foot waves and a water temperature of about 68 degrees. The coroner cited drowning as the third officer’s likely cause of death. Minor injuries to his body could have occurred from the 27-foot drop from the deck railing to the river.
It was standard practice on Amazoneborg for the crewmember gathering draft marks to collect the dockside figures from the dock. Gathering the amidships seaward draft marks was typically done by looking over the railing or lowering a draft measuring tape. Amazoneborg’s shipboard manual did not specify how to record draft marks, and it did not prohibit using a Jacob’s ladder.
It’s not clear how often the crew used a Jacob’s ladder to accomplish this task. However, 16 hours before the third officer fell overboard, the second officer used a Jacob’s ladder to gather initial draft data for a surveyor who was prohibited by his employer from using one. These ladders are typically made from rope or chain with shallow wooden rungs.
The second officer wore a PFD, and presumably others knew when he climbed overboard on the ladder earlier that day. Neither was true for the third officer, who failed to let other crew know or ask for assistance or supervision. The third officer rigged the Jacob’s ladder to a guardrail, which required him to climb over the rail to access the ladder — a maneuver investigators considered unsafe.
“To transfer between the deck and the ladder, the user had to climb up the guardrail, straddle it briefly and then descend the guardrail,” the report said. “The permanent guardrail is intended to prevent personnel from falling overboard and is not intended to secure a ladder.”
The TSB stated in its report that Jacob’s ladders are not a suitable means of reading draft marks because they often lack sufficient handholds and footholds when flush against the hull. They also can be unstable or slippery.
Three days after the incident, vessel operator Wagenborg Shipping B.V. reiterated to its entire fleet that crews must obtain work permits when going overboard to collect amidships draft marks. Wagenborg also barred the use of Jacob’s ladders for this task and now requires pilot ladders or embarkation ladders. Other changes require crew to wear PFDs when working overboard, and assigning another crewmember to supervise the activity with a lifebuoy ready to deploy.