The ATSB has found that a seaman may have been fatigued when he fell from a bulk carriers cargo hold ladder at the end the working day on 8 August 2007.
The Australian Transport Safety Bureau investigation also found that he may have been distracted by the equipment he was carrying and as a result of a mixture of perspiration and hydrochloric acid that would have caused irritation to his skin and eyes.
On 8 August 2007, Oceanic Angel was about three degrees south of the equator and en-route to Dampier, Australia.
After lunch, the crew were preparing the cargo holds for an upcoming salt cargo and, at about 1515, two seamen started work in number three hold. They began by spraying the dirty areas of the hold with hydrochloric acid, starting at the aft end and moving forward along the port side.
At about 1630, they stopped work for the day. One of the seamen made his way to the cargo holds aft ladder and started climbing out of the hold. The other seaman went to the forward ladder to do likewise. When the seaman on the aft ladder was almost at the ladders top platform, about 11.7 m above the tank top, he heard a loud 'thump'. He turned around and saw his colleague lying on the tank top.
The crew mounted an emergency response but the seaman had died as a result of the fall.
At 2300 on 17 August, Oceanic Angel berthed in Dampier. The local police attended the ship and the deceased seaman was taken ashore.
The ATSB investigation found that the ship's safety management system was not effective in ensuring that the crew carried out a risk analysis for the task of cleaning the cargo holds with hydrochloric acid. It also found that the crew were not aware of the safety information provided by material safety data sheets.
The ATSB has issued two safety advisory notices with the aim of preventing similar occurrences from occurring in the future.
Copies of the report can be downloaded from the ATSB website