Marine safety investigations & reports

Fall from the pilot ladder on the bulk carrier Atlantic Princess, Whyalla, South Australia on 3 July 2013

Investigation number:
300-MO-2013-007
Status: Completed
Investigation completed

Summary

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What happened

On 3 July 2013, a company representative was boarding the bulk carrier Atlantic Princess via the ship’s pilot ladder when he fell and landed on the deck of the pilot launch below. At the time, the ship was at anchor off Whyalla, South Australia, loading iron ore from an offshore transhipment barge.

The injured man was provided with immediate first aid and transported to the local hospital. However, he died later that day as a result of his injuries.

What the ATSB found

The ATSB found that while Atlantic Princess’s pilot ladder had been rigged in accordance with the relevant international requirements, no further risk assessment was carried out for the personnel transfer. The investigation also found that the company’s safety management system provided no guidance relating to actions that should be taken when less experienced personnel were to use a pilot ladder to board or disembark the ship.

In addition, there were no facilities on board the transhipment barge that could be used to provide a safe means of access between the barge and the ship for personnel transfers with the barge operator’s procedures prohibiting such transfers.

The investigation also identified safety issues relating to the content and implementation of the pilot launch operator’s safety management system.

What's been done as a result

The ship’s managers have issued a fleet safety circular noting that helicopters should be used for transfers of persons other than pilots wherever possible. When this is not possible, they are required to use a safety harness while climbing a pilot ladder. These requirements are to be advised to the ship’s agent in advance.

The pilot launch operator’s safety management system has been audited and the company is working to improve the system and its implementation. The company’s personnel transfer procedures have also been updated.

Safety message

This accident highlights the fact that while pilots may be competent in the use of pilot ladders, it should not be assumed that other personnel are proficient in climbing or descending a pilot ladder, or fit to do so.

 

Download Final Report
[Download  PDF: 1.79MB]
 
 
Alternate: [Download  DOCX: 940KB]
 

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Safety Issues

Go to MO-2013-007-SI-01 - Go to MO-2013-007-SI-02 - Go to MO-2013-007-SI-03 - Go to MO-2013-007-SI-05 -

Risk assessment

Atlantic Princess’s safety management system provided no guidance relating to actions that should be taken when persons less experienced than a pilot used a pilot ladder to board or disembark the ship.

Safety issue details
Issue number: MO-2013-007-SI-01
Who it affects: All masters owners and operators of ships
Status: Adequately addressed

Safe means of access

There were no facilities on board the Floating Offshore Transfer Barge Spencer Gulf that could be used to provide a safe means of access for personnel transfers between the barge and the ship. Furthermore, the barge operator’s procedures prohibited such personnel transfers.

Safety issue details
Issue number: MO-2013-007-SI-02
Who it affects: Owners and operators of ports and offshore loading facilities
Status: Not addressed

Safety management system compliance

The examples of non-compliance with the requirements of Whyalla Launch Services’ safety management system indicate that the system was not fully and effectively implemented on board Switcher.

Safety issue details
Issue number: MO-2013-007-SI-03
Who it affects: All masters, owners and operators of ships and small vessels
Status: Adequately addressed

Safety management system guidance

Whyalla Launch Services’ safety management system did not provide effective guidance in relation to assessing a passenger’s ability to climb a pilot ladder or positioning of pilot launches while passengers were climbing and descending ladders. The system also referenced superseded SOLAS regulations and IMO resolutions relating to pilot ladders.

Safety issue details
Issue number: MO-2013-007-SI-05
Who it affects: All masters owners and operators of ships and small vessels
Status: Adequately addressed
General details
Date: 03 July 2013   Investigation status: Completed  
Time: 1050 (UTC+9½)   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Whyalla    
State: South Australia    
Release date: 09 May 2014    
Report status: Final   Occurrence category: Accident  
  Highest injury level: Fatal  

Vessel details

Vessel details
Vessel Atlantic Princess  
Flag Panama  
IMO 9296200  
Type of operation at anchor, personnel transfer  
Damage to vessel Minor  
Departure point Jingtang, China  
Destination Whyalla, SA  
Last update 14 November 2018