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

Safety summary

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.