Gerome Baon Reyes · Prevention of Future Deaths report

On 25/05/2016 I commenced an investigation into the death of Gerome Baon Reyes, 26. The investigation concluded at the end of the inquest on 12 January 2017. The conclusion of the inquest was Accidental death. I determined that at about 11.20 (GMT + 2 hours) on 22 May 2016 whilst on board MV Moonray sailing across the North Sea approximately 25 miles northeast of North Foreland and in international waters, messman Gerome Reyes was alone in the galley unloading a goods lift when he activated the lift whilst its door was open and was dragged up as the lift ascended, as a result of which he sustained traumatic multiple injuries. No door limit switch was fitted to the lift so that it could be operated whilst the door was open. He died as a result of Head and Trunk Injuries

The death would not have occurred if the door limit switch had been fitted to the goods lift being operated by the deceased.

(1) The Deputy Commissioner of Maritime Affairs for the Republic of the Marshall Islands made recommendations for the relevant goods lift on MV Moonray not to be brought back into service until door limit switches were installed. There has been no confirmation that this recommendation has been acted upon.
(2) It appears to me possible that other ships of the same design may also have goods lifts installed without door limit switches being installed and so there is the potential risk of injury or death if they are operated in similar circumstances. There is no confirmation that Marine Safety Advisory No. 20-13 issued on 26 May 2016 has been implemented.