Abstract: On January 19, 1999, Employee #1 and two other employees were conducting maintenance on a turbocharger of a cargo ship. The ship was anchored 3 miles off shore. A water taxi boat was contracted to transport the employees to and from the ship. After completing the assigned work on the turbocharger for the day, the boat arrived to collect the employees. An accommodation ladder/gangway was lowered to the employees to provide them with a disembarkation platform. The ladder consisted of a 45 degree incline set of steps with handrails on each side and a platform on the bottom that opened to the port side. According to a witness, there was quite a surge,and the taxi would go two feet above the platform and the two feet below. When Employee #1 stepped for the boat, he completely missed the boat. He momentarily hung on to the gangway and then fell in. Due to the riptide, He was quickly carried to the aft of the ship. Due to the wind and the curvature of the boat near the aft end, it was difficult getting close to him. He disappeared underwater, and came up face down about 100 ft off the aft end of the ship. He drowned because he was not wearing a lifejacket. Further, the dangers of embarking and disembarking ships had not been discussed in safety meetings to him and the other employees.