Marine safety investigations & reports

Fall from the pilot ladder on board the chemical tanker Golden Concord, Goods Island, Torres Strait, Qld on 4 July 2013

Investigation number:
301-MO-2013-008
Status: Completed
Investigation completed

Summary

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What happened

On 4 July 2013, a coastal pilot was disembarking from the chemical tanker Golden Concord in the Torres Strait when the pilot ladder manrope he was holding appeared to give way. He was unable to establish a firm grip on the rope, lost his balance and fell to the deck of the pilot launch below.

The pilot did not sustain any serious injuries, as his fall was arrested by the deckhand on board the launch.

What the ATSB found

The ATSB identified that a number of risk controls designed to limit the likelihood of an error resulting in an accident had been compromised. These included: the use of a deck party on board the ship to assure the safety of the ladder and manropes, clear and standardised communication protocols between the pilot and the pilot launch crew and the provision of information to pilot launch crews to assist in recognising the correct pilot ladder arrangements for each pilot.

What's been done as a result

The ship’s management company has revised its pilot transfer procedures to ensure that all transfers are conducted with a deck party consisting of a supervising officer and at least one deck rating. The company has also revised its procedures to ensure that the rigging and securing of pilot ladders and manropes are in accordance with the most recent international requirements.

The pilotage company has revised its procedures to incorporate the provision of information about the use of manropes to pilot launch crews on their approach to the ship. The procedures now specify that pilots and launch deckhands shall conduct a visual and manual check of pilot ladders and manropes prior to disembarking. Additionally, the company will reinforce the importance of adhering to the standard communication protocols specified in their safety management system.

Safety message

Pilot transfers by way of pilot ladders are routine, yet inherently risky operations. In order to minimise the risk to pilots, ship operators and pilotage companies need to ensure that clear and standardised procedures and communication protocols are implemented and followed.

Download Final Report
[Download  PDF: 1.46MB]
 
 
Alternate: [Download  DOCX: 546KB]
 

Safety Issues

Go to MO-2013-008-SI-01 - Go to MO-2013-008-SI-02 - Go to MO-2013-008-SI-03 - Go to MO-2013-008-SI-04 - Go to MO-2013-008-SI-05 -

Visual and manual checking of ladder and manropes by pilots

The pilotage company’s procedures did not explicitly require the pilot to check the pilot ladder and manrope arrangements before disembarking the ship.

Safety issue details
Issue number: MO-2013-008-SI-01
Who it affects: Pilotage companies
Status: Adequately addressed

Communication of readiness for pilot disembarkation

The pilotage company’s procedures for positive communication of readiness between the pilot and the launch crew were adequate. However, it was common for employees to vary these communication protocols, leaving perceptions of readiness open to error and misinterpretation.

Safety issue details
Issue number: MO-2013-008-SI-02
Who it affects: Pilotage companies
Status: Adequately addressed

Use of a deck party to assist with the pilot transfer

The ship’s pilot transfer procedures did not specify a requirement for additional crew members to assist the supervising officer. As a result, the supervising officer was actively involved in deploying the pilot ladder and manropes, and transferring the pilot’s belongings to the launch, and could not focus his efforts on properly checking the arrangements and supervising the transfer.

Safety issue details
Issue number: MO-2013-008-SI-03
Who it affects: Owners and operators of ships employing coastal pilots.
Status: Adequately addressed

Communication of requirements for manropes

The pilotage company’s procedures did not require pilots to inform launch crews whether manropes would or would not be deployed in advance of the transfer.

Safety issue details
Issue number: MO-2013-008-SI-04
Who it affects: Pilotage companies
Status: Adequately addressed

Securing of manropes to the deck

The ship’s pilot transfer procedures had not been revised to incorporate the most recent SOLAS requirements that manropes be secured at the rope end to a ring plate fixed to the deck.

Safety issue details
Issue number: MO-2013-008-SI-05
Who it affects: Owners and operators of ships employing coastal pilots.
Status: Adequately addressed
General details
Date: 04 July 2013   Investigation status: Completed  
Time: 0240 UTC+10   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): off Goods Island, Torres Strait    
State: Queensland    
Release date: 20 March 2014    
Report status: Final   Occurrence category: Incident  
  Highest injury level: None  

Vessel details

Vessel details
Vessel Golden Concord  
Flag Singapore  
IMO 9274006  
Type of operation Pilot transfer  
Damage to vessel Nil  
Departure point Gladstone, Qld  
Departure time 27 June 2013  
Destination Lahad Datu  
Last update 14 November 2018