The transfer of pilots to and from seagoing vessels should not be based on trust in each other’s good intentions. The pilotage system must draw up equal and clear work instructions for the sailing service and for registered pilots. The Dutch Safety Board (DSB) says this after investigating a fatal accident with a pilot tender.
In the evening of Thursday 30 March 2023, a crew member of the Dutch pilot tender Lacerta was fatally injured off the coast of IJmuiden. The Lacerta was en route to the cargo vessel Wilson Monsoon, sailing under the flag of Barbados, to bring a registered pilot on board.
The crew member was to assist the pilot in embarking the cargo vessel. As the pilot tender came alongside the cargo vessel, the crew member of the pilot tender became trapped between the two vessels. The casualty sustained serious injuries, which resulted in his death later that evening.
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Described methods and actual practice
In its report after investigating the accident, the DSB goes into actual practice: In the safety compendium of the Pilotage Service, several methods are outlined for safely bringing a pilot tender alongside a vessel. However, in practice, these methods cannot always be used due to differences in ships and circumstances. Therefore, based on the knowledge and experience of the pilot tender crew, alternatives are devised for common situations to allow the pilot to embark.
These methods are often generally known, but are not documented in procedures or work instructions. There is a discrepancy between the written procedures described for pilots and the operating instructions for the pilot tender crews, finds the DSB.
Additionally, in practice, several commonly used, but undescribed procedures have emerged. The pilot tender crew adapts to the variation in practice based on their experience, but the risk in this particular situation was not recognised.
Shape and movement of the vessel
The Wilson Monsoon was a relatively small cargo ship with a low freeboard. The ship rolled due to waves and its heading. No method for embarking has been determined for ships without a pilot ladder due to their low freeboard, adds the DSB. Because the weather conditions at the time of the incident were just below the limits of the storm procedure, there was an increased risk of damage when landing at a ship with a relatively low freeboard.
Based on experience, the pilot tender crew made a decision for the most suitable method, choosing to land behind the pilot boarding gate at the rising hull plates. The risk posed by the swept-back shape of the stern of the Wilson Monsoon was not considered, states the DSB.
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Location on board the tender
The deck hand used the side deck on the side of the tender facing the vessel (the inner side) to move forward. This is standard practice and not part of a preliminary discussion of the job. The crew was not aware of the risk of getting trapped while walking on the side facing the vessel.
Due to the wide gangway, this risk is small when the tender is positioned along the vertical hull plates of a vessel. However, warns the DSB, in this incident, the tender could end up under the vessel due to the shape of the stern. Under these circumstances, the choice of the timing of going on deck and the route inside or outside was crucial.
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Communication and coordination
Finally, the DSB found that the pilot tender crew was experienced and knew each other well and that they relied on each other’s expertise, so little was discussed or communicated. Everyone assumed that the other understood what was intended. There were unspoken automatic behaviours, where unexpected dangers were not considered in the routine of work.
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Recommendations
The DSB tells the Dutch Pilot Service to share experiences and best practices as these can help improve safety and reduce risks when transferring pilots to and from seagoing vessels.
The DSB wants unambiguous work instructions to be developed and implemented and to improve them regularly. DSB: ‘Establish equal and clear work instructions for the pilot tender crew and for the register pilots and keep them up to date. Make use of practical experiences, risk analyses and best practices. Ensure that the pilot tender crew and the pilots regularly discuss and practice the work instructions with each other.’
The Safety Board also advises to continue to communicate with each other on board and name the risks. ‘Due to the wide variety of situations and ship shapes, it is important for the tender crew to identify risks and keep communicating about them. Incorporate the insights gained into the work instructions afterwards,’ states the DSB.
Picture: Pilot tender Lacerta (from PxHere).
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