Agatha Christie would have been proud of it: On the morning of 23 July 2015 the chemical-Product tanker Selandia Swan was on passage from Scheveningen, Netherlands to Ust-Luga, Russia through the North Sea with the Third Officer on watch without a lookout. During the 1000 crew break for coffee and tea and AB went to the bridge to make an internet phone call to speak to his family.
On the bridge the AB went to the port side of the centre console to use the cordless telephone. He did note the third officer. There was no answer when the AB called out that he was using the phone but assumed the officer was at the chart table or in the toilet. As he spoke he walked around the bridge and realised the third officer was not there.
Going out to the starboard bridge wing the AB saw just a single slipper on the grating by the lifebuoy. Quickly he searched the bridge then called the duty AB on the radio. Finally the two men reached the master, who went to the bridge, ordered search of the ship and, assuming the third officer had gone overboard, ordered a Williamson turn to bring the ship around and onto the track along which it had comes.
The crew failed to find the third officer - he was found later by a Danish rescue helicopter, dead.
There were a few clues to watch had happened: the light cap on the starboard lifebuoy had been partially unscrewed and one of the light caps and two O-rings of the port side lifebuoy was on the chart table. The third officer had logged the ship's position at 1000. The bridge navigational watch alarm, set at 15 minutes intervals had not sounded. On the VDR his last movement was head at 1004.50 and the AB was heard coming on the bridge at 1005.22. The third officer went overboard vanished, at latest during the five minute period before the AB found the slipper at 1010.
Investigators from the Danish Maritime Accident Investigation Board, DMAIB, pieced together the most likely scenario: The third officer had been conducting an inspection of the lifebuoys, a task that was to take place at monthly intervals and was six days overdue at the time of the interval. Since the onboard maintenance system did not say what the inspection should look for the third mate decided to look at the light caps on the lifebuoy.
A pamphlet from the manufacturer, Comet, indicates that the life buoys did not need preventative maintenance, just replacement after their expiry date.
The light and smoke signal apparatus was linked on each lifebuoy by a cord and on a mounting. Removing it from the mounting involved the risk of dropping it and accidentally setting it off. The Third Mate could not have reached it by standing on deck and leaning over the guard rail. He could only reach it by standing on a lower rail and probably lost his footing, and his slipper, while doing so.
Says DMAIB: "In the absence of instruction or guidance, he made a detailed inspection of the only item he could – namely the light. Neither the workplace nor the lifebuoy was designed for maintenance work. In order to carry out that inspection he had to climb the guard rail, thereby exposing himself to the risk of falling overboard. Presumably, he did not don a harness and fall arrester, because the risk of falling was not apparent to the 3rd officer as he was still behind the guard rail."
All too often it isn't the big stuff that gets you, it's the little stuff that seems like a good idea at the time.