Dorval Ship Management advised the ATSB that in response to this incident, it has revised its navigation manual procedures for the conduct of pilot transfers to include the mandatory use of a deck party consisting of a supervising officer and at least one other crew member for all transfers, day or night, as follows:
There shall always be one (1) seaman (deck rating) at stand-by to assist the OOW during pilot boarding / disembarkation.
Additionally, Dorval Ship Management has incorporated a requirement specifically for the assurance of the correct deployment of the pilot ladder and manropes into its navigation manual procedures, as follows:
The OOW and deck rating must always ensure that manropes are not partially coiled on deck immediately before pilot's boarding / disembarkation and shall confirm by pulling that they are made well tight and secure.
The ATSB is satisfied that the action taken by Dorval Ship Management will adequately address this safety issue.