Marine safety investigations & reports
Fall from the pilot ladder on the bulk carrier Atlantic Princess, Whyalla, South Australia on 3 July 2013
300-MO-2013-007
Summary
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.
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Safety Issues
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.
| 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.
| 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.
| 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.
| 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 | Occurrence category: | Accident | ||
| Report status: | Final | Highest injury level: | Fatal |
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 |