Hazards in Low Freeboard Pilot Transfers Costs a Life

Summary

On 5 October 2016, a Port of London Authority sea pilot was in the process of boarding the Bahamas registered general cargo vessel Sunmi from the pilot launch Patrol when he fell and was crushed between the two vessels. He died at the scene despite prompt medical attention from Royal National Lifeboat Institution and local ambulance crew.

Safety Issues

• Low freeboard pilot transfers involve risks that should be included in risk assessments for boarding and landing
• The designated pilot boarding station on board Sunmi was not marked and the deck gate should not have been opened in preparation for the transfer as it was unsuitable
• The pilot had ingested sufficient alcohol on the day of the accident for his blood to contain 122mg alcohol per 100ml of blood approximately 2 hours after reporting for duty. It is likely that the consumption of alcohol contributed to his fall
• The International Maritime Pilots’ Association ‘Required Boarding Arrangements for Pilot’ poster did not include reference to the amendments to pilot transfer arrangements made in IMO Resolution A.1108(29), regarding deck gates

Patrol’s position alongside Sunmi

Conclusions

1. It is likely that the sea pilot’s consumption of alcohol contributed to his fall.
2. Low freeboard transfers introduced additional risks to standard pilot transfers.
3. The designated pilot boarding station on Sunmi was not marked.
4. Sunmi’s deck gate was not part of, nor was it suitable for use as, the designated pilot boarding station, and the crew should not have opened it in preparation for the transfer.
5. The chief officer might have ensured that the deck gate remained closed and that the bulwark ladder was rigged, had he overseen the preparation for pilot boarding.
6. On the day of the accident the sea pilot had ingested sufficient alcohol for his blood to contain 122 mg alcohol per 100ml of blood approximately 2 hours after reporting for duty.
7. The PLA’s risk assessments for boarding and landing did not examine the specific hazards associated with low freeboard transfers.

Representation of Sunmi’s deck gate and pilot boarding arrangements

Actions Taken

• ● Revised its Drug and Alcohol Policy to bring the limits within the regulatory
  requirements for pilots and placed greater focus on the random testing of
  operational staf.
• Introduced a requirement for all pilots’ medicals to be completed by the
  company doctor.
• Provided additional voluntary health checks to pilots.
• ● Reviewed the emergency exercise schedule to ensure that all launch crews
  are participating in training exercises.
• ● Introduced higher levels of training for all frst-aiders, including trauma
  treatment and casualty care.
• Ofered frst-aid refresher training to pilots to supplement their initial training.
• Adopted the national Embarkation and Disembarkation of Pilots Code of Safe
  Practice, written by the UKMPA and the British Ports’ Association in lieu of
  the local PLA code. In addition, the PLA is participating in the revision of this
  code.
• Amended its risk assessments to include an auditable process that shows
  they have been read and understood by operational staf.
• Revised its risk assessments for the transfer of PLA staf to/from ashore
  using PLA vessels so that the hazards involved during pilot transfers may be
  efectively mitigated.
• Developed a database of emergency landing/casualty evacuation points
  throughout the PLA area to enable their prompt identifcation in an
  emergency.
• Installed CCTV on Patrol with the intention to install CCTV on other PLA
  vessels.
• Reviewed the incident checklist for events involving medical assistance to
  PLA staf.
• Issued a notice to mariners to remind river users of the required bridge
  manning levels.
• Introduced guidance that includes operational limits for PLA vessels operating
  in heavy weather.
• Updated the procedures for non-PLA personnel involved in boarding and
  landing operations from PLA vessels.

Recommendations

The International Maritime Pilots’ Association (2017/139) has been recommended to promulgate the requirements for gateways in vessels’ rails or bulwarks intended for pilot boarding operations by updating its ‘Required Boarding Arrangements For Pilot’ poster to include the amendments in IMO Resolution A.1108(29).

A recommendation has also been made to Misje Rederi A.S. (2017/140) to ensure that the designated pilot boarding areas on Sunmi are marked and that pilot boarding operations are overseen by a responsible officer.

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Source: MAIB

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