Marine Safety Investigation Unit

MARINE SAFETY INVESTIGATION REPORT

Safety investigation into the serious injury on board the

Maltese registered pilot boat

CHARLIE 1

0.6 nautical miles Southeast of Marsaxlokk Port, Malta

on 19 May 2013

201305/015

MARINE SAFETY INVESTIGATION REPORT NO. 14/2014

FINAL

ii

Investigations into marine casualties are conducted under the provisions of the Merchant

Shipping (Accident and Incident Safety Investigation) Regulations, 2011 and therefore in

accordance with Regulation XI-I/6 of the International Convention for the Safety of Life at

Sea (SOLAS), and Directive 2009/18/EC of the European Parliament and of the Council of 23

April 2009, establishing the fundamental principles governing the investigation of accidents

in the maritime transport sector and amending Council Directive 1999/35/EC and Directive

2002/59/EC of the European Parliament and of the Council.

This safety investigation report is not written, in terms of content and style, with litigation in

mind and pursuant to Regulation 13(7) of the Merchant Shipping (Accident and Incident

Safety Investigation) Regulations, 2011, shall be inadmissible in any judicial proceedings

whose purpose or one of whose purposes is to attribute or apportion liability or blame, unless,

under prescribed conditions, a Court determines otherwise.

The objective of this safety investigation report is precautionary and seeks to avoid a repeat

occurrence through an understanding of the events of 19 May 2013. Its sole purpose is

confined to the promulgation of safety lessons and therefore may be misleading if used for

other purposes.

The findings of the safety investigation are not binding on any party and the conclusions

reached and recommendations made shall in no case create a presumption of liability

(criminal and/or civil) or blame. It should be therefore noted that the content of this safety

investigation report does not constitute legal advice in any way and should not be construed

as such.

© Copyright TM, 2014.

This document/publication (excluding the logos) may be re-used free of charge in any format

or medium for education purposes. It may be only re-used accurately and not in a misleading

context. The material must be acknowledged as TM copyright.

The document/publication shall be cited and properly referenced. Where the MSIU would

have identified any third party copyright, permission must be obtained from the copyright

holders concerned.

MARINE SAFETY INVESTIGATION UNIT

Malta Transport Centre

Marsa MRS 1917

Malta

iii

CONTENTS

LIST OF REFERENCES AND SOURCES OF INFROMATION .......................................... iv

GLOSSARY OF TERMS AND ABBREVIATIONS ................................................................v

SUMMARY ............................................................................................................................. vi

1 FACTUAL INFORMATION .............................................................................................1

1.1 Vessel, Voyage and Marine Casualty Particulars .......................................................1

1.2 Description of Vessels ................................................................................................2

1.2.1 The pilot boat ..........................................................................................................2

1.2.2 The vessel ...............................................................................................................4

1.3 Weather Conditions.....................................................................................................5

1.4 The Crew Members on Charlie 1................................................................................5

1.4.1 The deckhand ..........................................................................................................5

1.4.2 The coxswain ..........................................................................................................5

1.4.3 The pilot assigned to the OS Bodrum .....................................................................6

1.5 Narrative .....................................................................................................................6

2 ANALYSIS .........................................................................................................................9

2.1 Purpose ........................................................................................................................9

2.2 Immediate Cause of the Accident ...............................................................................9

2.3 Training and Procedures .............................................................................................9

2.4 Pilot Boarding and Industry Practices .......................................................................10

2.5 The Ship and Pilot Stations .......................................................................................13

2.5.1 The pilot boarding arrangement ...........................................................................13

2.5.2 On board organisation and procedures .................................................................15

2.6 Other Findings - the working relationship between the pilot boat coxswain

and the pilot ...............................................................................................................16

2.7 Accident Dynamics ...................................................................................................16

3 CONCLUSIONS ...............................................................................................................20

3.1 Immediate Safety Factor ...........................................................................................20

3.2 Latent Conditions and other Safety Factors ..............................................................20

3.3 Other Findings ..........................................................................................................20

4 RECOMMENDATIONS ..................................................................................................21

LIST OF ANNEXES ................................................................................................................22

iv

LIST OF REFERENCES AND SOURCES OF INFORMATION

Besnard, D., & Greathead, D. (2003). A cognitive approach to safe violations.

Cognition, Technology & Work, 5(4), 272-282

British Ports Association [BPA], Technical & Training Committee of the United

Kingdom Maritime Pilots Association[UKMPA], UK Major Ports Group

[UKMPG]. (2013). Embarkation and Disembarkation of Pilots – Code of Safe

Practice. Retrieved 01 October 2013 from

http://www.ukmpa.org/downloads/xcH_jksi_Cfsg_s23/boarding_&_landing_cod

e_2013(1).pdf

Coxswain – Charlie 1

Deckhand – Charlie 1

International Maritime Organization [IMO]. (2009). International convention for the

safety of life at sea, 1974 (Consolidated ed.). London: Author

IMO. (2010). Resolution MSC.308(88). Adoption of amendments to the international

conventions for the safety of life at sea, 1974, as amended. London: Author

IMO. (2011). Assembly Resolution A.1045(27). Pilot Transfer Arrangements.

Retrieved 01 September 2013 from http://docs.imo.org/Category.aspx?cid=34

IMO. (2012). MSC.1/Circ.1428. Pilot Transfer Arrangements. Required boarding

arrangements for pilots. Retrieved 01 September 2013 from

http://docs.imo.org/Search.aspx?keywords=%22MSC.1%2FCirc.1428%22

International Maritime Pilots‟ Association [IMPA]. (2012). Guidance for Naval

Architects and Shipyards on the Provision of Pilot Boarding Arrangements.

Retrieved 01 September 2013 from

http://www.impahq.org/admin/resources/guidancefornavalarchitects.pdf

Malta Maritime Pilots

Maritime and Coastguard Agency [MCA]. (2010). Code of Safe Working Practices

for Merchant Seamen. Norwich: TSO (The Stationary Office)

Maritime Pilotage Regulations. Subsidiary Legislation 499.26 of 01 March 2003, as amended

Master of OS Bodrum

Pilot – Charlie 1

Sisson, G. R. (2001). Hands-on training: a simple and effective method for on-the-job

training. San Francisco: Berrett-Koehler Publishers Inc

v

GLOSSARY OF TERMS AND ABBREVIATIONS

BPA British Ports Association

CP Controllable pitch

DOC Document of Compliance

EDP Code Embarkation and Disembarkation of Pilots – Code of Safe Practice

Freeboard The vertical distance from the water level to the ship‟s deck

GM Transverse metacentric height, i.e. the vertical distance between the

ship‟s centre of gravity and ship‟s transverse metacentre

GRP Glass-reinforced plastic

GT Gross Tonnes

ISM International Safety Management

Knot Nautical miles per hour

kW Kilowatts

LOA Length overall

LT Local time

m Metres

MSIU Marine Safety Investigation Unit

MV Motor vessel

NKK Nippon Kaiji Kyokai

nm Nautical miles

SOLAS The International Safety of Life at Sea Convention, 1974, as amended

SWL Safe Working Load

UK United Kingdom

UKMPA United Kingdom Maritime Pilots Association

UKMPG UK Major Ports Group

VHF Very high frequency

vi

SUMMARY

On 19 May 2013, the deckhand on board the pilot boat Charlie 1 suffered serious

injuries whilst the pilot boat was pulling away from alongside the Antigua & Barbuda

registered container ship OS Bodrum. At the time of the accident, the pilot boat had

just transferred a pilot to the ship, inbound for Marsaxlokk port, Malta.

The safety investigation focused mainly on the operating procedures and practices on

board the pilot boat and its personnel as well as the pilot boarding arrangement on

OS Bodrum. These findings were then analysed in the light of regulatory

requirements and established industry safe practices in order to draw conclusions and

to make safety recommendations.

Amongst other factors, this safety investigation established that the pilot boarding

arrangement provided by the ship was not compliant with the relevant SOLAS

requirements due to its close proximity to the ship‟s stern and overhang and therefore

was intrinsically dangerous. Moreover, the pilot and the deckhand did not follow the

industry‟s recommended practice to walk on the outboard side of the pilot boat.

As a result of the safety investigation, the Marine Safety Investigation Unit has made

six recommendations to the ship‟s managers and the Malta Maritime Pilots, with the

aim of enhancing pilot transfer safety.

1

1 FACTUAL INFORMATION

1.1 Vessel, Voyage and Marine Casualty Particulars

Name Charlie 1 OS Bodrum

Flag Malta Antigua & Barbuda

Classification Society Not applicable Nippon Kaiji Kyokai

IMO Number Not Applicable 9193513

Call Sign 9H9274 V2FT2

Type Pilot boat Container (Fully cellular)

Registered Owner P. B. Charlie Limited OS Bodrum Schiffahrts

GmBH

Managers Not Applicable Coral Shipmanagement

GmBH & Co.

Construction GRP Steel (double bottom)

Length overall 10.31 m 129.43 m

Registered Length 10.31 m 118.2 m

Gross Tonnage 6.67 7814

Minimum Safe Manning Not Applicable 12

Authorised Cargo Not Applicable Containers

Port of Departure Marsaxlokk, Malta Unknown

Port of Arrival Marsaxlokk, Malta Marsaxlokk, Malta

Type of Voyage Coastal International

Cargo Information Not Applicable In ballast

Manning Not Applicable Unknown

Date and Time 19 May 2013 at about 1730 (LT)

Type of Marine Casualty or Incident Serious Marine Casualty

Serious Marine Casualty Not Applicable

Location of Occurrence 0.6 nautical miles Southeast of Marsaxlokk Port, Malta

Place on Board Ship – main deck Over side

Injuries/Fatalities One serious injury None

Damage/Environmental Impact None None

Ship Operation Normal service – under

pilotage

Normal service – under

pilotage

Voyage Segment Arrival Arrival

External & Internal Environment Daylight, partly cloudy and dry with force 3 to force 4

Northwesterly wind. A fresh Northwesterly swell was

gaining dominance over an Easterly decaying swell.

Wave height was approximately 0.5 m.

Persons on Board 4 Unknown

2

1.2 Description of Vessels

1.2.1 The pilot boat

Charlie 1 (Figures 1-3) is a dedicated pilot boat, 10.3 m long and 3.4 m wide,

constructed of glass-reinforced plastic (GRP). She has a moulded depth of 1.19 m.

Charlie 1 was built in 1986 by Halmatic Group UK, a well-established firm

specialising in similar crafts and is considered to be a robust boat with good sea-

keeping qualities for a boat of her type and dimensions.

The pilot boat has a deck space of approximately 0.5 m running alongside the pilot

house. Her breadth at the transom is noticeably less than her maximum beam, which

lies around amidships; a design feature which facilitates the manoeuvre to pull away

from alongside a ship when both pilot boat and ship are making way. Propulsive

power is provided by two Perkins, four-stroke high speed, marine diesel engines,

producing 321 kW of power. The engines drive two fixed pitch propellers through a

reduction gearbox.

The Commercial Vessel Certificate, which was issued on 18 August 2012 by the

Ports & Yachting Directorate under the Commercial Vessels Regulations, 2002,

specified Category 1(B) as the area of operation1. The pilot boat was certified to carry

a maximum of six persons. Bearing in the mind the prevailing weather conditions at

the time of the accident, Charlie 1 was fully capable of operating safely and well

within her limits.

Figure 1: Pilot boat Charlie 1

1 Category 1(B): within territorial waters and in favourable weather.

3

Figure 2: Pilot boat Charlie 1 looking aft

Figure 3: Port side deck looking forward

4

1.2.2 The vessel

MV OS Bodrum (Figure 4) is a fully cellular container vessel registered in

Antigua & Barbuda. The 7814 gt vessel was built in 1998 by Yardimci Shipyard in

Tuzla, Turkey. She is owned by MS “OS Bodrum” Schiffahrtsgesellshaft MbH & Co

Kg, managed by Coral Shipmanagement GmbH & Co Kg, Germany, and is classed

with Nippon Kaiji Kyokai (NKK).

The vessel‟s length overall is 129.3 m. Her moulded breadth is 20.5 m and has a

moulded depth of 10.60 m. OS Bodrum has a summer draught of 7.50 m and a

summer deadweight of 11272 tonnes. The vessel has two cranes on deck, each of

40 tonnes SWL.

Propulsive power is provided by a 6-cylinder MAN B&W Diesel AG 6L48/60, four-

stroke medium speed, single acting diesel engine, producing 6212 kW. This drives a

single CP propeller through a reduction gearbox. The vessel‟s service speed is

16.5 knots. Fitted with a bow thruster and a „Becker‟ rudder, OS Bodrum is

considered to have very good manoeuvring characteristics.

Figure 4: MV OS Bodrum

5

1.3 Weather Conditions

The wind prevailing at the time was Northwesterly force 3 to force 4. The sea was

gradually building up from the Northwest with a wave height of approximately 0.5 m

and occasionally giving rise to white breaking crests. At the same time, however,

there were still remnants of an Easterly swell, persisting from the Easterly winds,

which had been blowing for some time during the previous days.

The combination of these two systems gave rise to somewhat confused sea conditions

causing OS Bodrum to roll slightly and Charlie 1 to pitch and roll moderately as she

left the shelter of Marsaxlokk Port on her way out to rendezvous with the ship.

1.4 The Crew Members on Charlie 1

1.4.1 The deckhand

The deckhand was a 24 year old Maltese national. At the time of the accident, he was

duly certificated to serve in his capacity in accordance with the relevant national

legislation.

The deckhand was initially employed on a part-time basis to work on board pilot

boats around September 2012. At that time, he was required to serve as an

„additional‟ deckhand, doubled up with another experienced deckhand, as part of his

familiarisation training and prior to being allowed to serve as a sole deckhand on

board a pilot boat. The pilotage operations, which the deckhand performed as a

„trainee‟ with another experienced deckhand, totalled to between 10 and 15. During

that period, he was also informally briefed on several occasions, both ashore and

while serving on board.

Prior to the accident, the deckhand had served on Charlie 1 on several occasions and

he was familiar with the pilot boat.

1.4.2 The coxswain

The coxswain was a very experienced boat handler. He had been serving as coxswain

on pilot boats for five and a half years. Prior to gaining employment with the Malta

Maritime Pilots, he had served on military patrol sea crafts for 26 years.

6

At the time of the accident, he was duly certificated to serve as coxswain of the pilot

boat.

1.4.3 The pilot assigned to OS Bodrum

The pilot assigned to OS Bodrum was a fully qualified and licensed maritime pilot.

He obtained his first tonnage-restricted pilot license in May 2008 and holds an

unrestricted licence. In total, he had some 3308 ship movements to his credit.

The pilot, who was 46 years old at the time of the accident, holds a Class 1 Certificate

of Competence, which was issued in the year 2000.

1.5 Narrative2

On 19 May 2013, shortly after 1700, the pilot boat Charlie 1 cast off from her station

in Marsaxlokk Port, with two pilots on board. The plan was first to rendezvous with

the inbound OS Bodrum, approximately 1.5 nautical miles (nm) off the breakwater in

order to transfer the first pilot, and then to proceed to the second ship to transfer the

second pilot.

As Charlie 1 exited the Port, she experienced a decaying Easterly swell. A fresh

Northwesterly swell was gaining dominance. The wave height was approximately

0.5 m and the pilot boat was pitching and rolling moderately.

The pilot designated to board OS Bodrum instructed the ship‟s master by VHF to

approach the Port entrance and requested that the pilot ladder be rigged on her

starboard side. At the time, the ship was in ballast condition with some three metres

of exposed boot topping.

As the ship approached the Port entrance, Charlie 1 came around on the ship‟s

starboard quarter in order to go alongside with her own port side to the ship‟s

starboard side. The pilot boat was rolling moderately as she approached OS Bodrum.

The ship was also rolling slightly.

Once the pilot boat had settled alongside the ship, the pilot then used his own

judgement to leave the shelter of the aft part of the superstructure and quickly walked

2 Unless otherwise stated, all times are local.

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out on the boat‟s port side (the inboard side, i.e. the side, which was alongside the

ship‟s starboard side) towards the bow, followed by the deckhand.

At the time, inside the pilot house was Charlie 1‟s coxswain, who was conning the

pilot boat, and the second pilot who was to join the second ship.

The pilot proceeded to the ship‟s pilot ladder closely followed by the deckhand. He

paused and then, at the right moment, grabbed hold of the pilot ladder, placed one foot

on a step and with the deckhand‟s helping push from behind, quickly climbed a few

steps up the ladder. Meanwhile, the deckhand immediately turned round and started

walking back towards the stern of the pilot boat.

Moments later, as the distance between the ship‟s hull and the pilot boat suddenly

decreased, the deckhand got caught between the ship‟s side and the pilot house. He

sustained severe head injuries and consequently collapsed onto the narrow deck of the

pilot boat. Somehow, with his right leg and right arm dangling over the side, he

managed to grab hold of the boat‟s hand rail.

Having witnessed the accident, the pilot immediately realised the gravity of the

situation and from his position, still perched on the lower part of the ship‟s pilot

ladder and holding on with only one hand, he raised the alarm by communicating with

the Port authorities on VHF and requested an ambulance to be immediately made

available at the pilot station in Marsaxlokk Port. At this time, the pilot also

considered the possibility of jumping back onto the pilot boat but by then, the gap

between the ship and the pilot boat was dangerously wide.

Meanwhile, the second pilot inside the pilot house initially thought that the deckhand

had fallen overboard. However, he quickly realised that he had not and rushed out,

grabbed him by his clothing from his chest, and pulled him inside to prevent the

injured man from rolling off over the side and into the sea. By now, the pilot boat had

pulled completely clear of OS Bodrum‟s ship side and was heading towards

Marsaxlokk Port at full speed.

As the pilot boat sped away towards the Port entrance carrying the injured deckhand,

the pilot who had been transferred onto the pilot ladder of the ship, climbed up the

ladder onto the main deck and proceeded directly to the bridge from where he

8

requested that the Port Terminal medic be prepared for the arrival of the pilot boat

with the injured man.

Meanwhile, OS Bodrum proceeded into Marsaxlokk Port and safely made fast

alongside. The pilot disembarked at around 1800 on 19 May 2013.

The injured deckhand was disembarked from Charlie 1 and rushed to Malta‟s main

hospital. He was later admitted to the Emergency Unit. The medical interventions

and care were successful and eventually, the deckhand was discharged from the

hospital.

9

2 ANALYSIS

2.1 Purpose

The purpose of a marine safety investigation is to determine the circumstances and

safety factors of the accident as a basis for making recommendations, to prevent

further marine casualties or incidents from occurring in the future.

2.2 Immediate Cause of the Accident

The safety investigation determined that the immediate cause of the accident was the

deckhand being caught between OS Bodrum‟s ship side and the pilot house.

2.3 Training and Procedures

The Malta Maritime Pilots has an excellent safety track record. Over many years of

service, there have been few accidents recorded, which involved pilot boats and / or

personnel.

In the case of pilots, appropriately qualified navigation officers, who would have

served on board Convention ships, are required to participate in a substantial number

of shipping movements over a number of years. The „shadowing‟ is carried out under

the direct supervision of an experienced, fully qualified and licensed pilot before they

themselves are granted the appropriate license to serve as pilots.

With respect to pilot boat coxswains and deckhands, training is again primarily

experience-based. In fact, evidence obtained during the course of this safety

investigation indicated that the familiarisation training given to the various personnel

within the Malta Maritime Pilots is largely based on experience gained over the years.

The experienced individuals pass over experience-derived knowledge to freshly

joined personnel, in an informal manner.

Whilst it was established that several short practice training sessions were conducted

in the recent past, such as, for instance, man overboard recovery drills, there was no

evidence which indicated a formal, structured approach of familiarisation and

refresher training programmes for personnel. Indeed, at the time of this safety

10

investigation, the Malta Maritime Pilots neither had any formal, written standard

operating procedures or guidelines, nor any training procedures and guidelines for

coxswains and pilot boat crew.

It was deemed legitimate to submit that practical experience has to be completed with

a priori knowledge of a safety-critical domain that incorporates actions within a

complex and dynamic context, such as the boarding of a vessel, which necessitates

that interaction of the pilot boat and the vessel in almost any weather condition.

The MSIU is of the view that whilst effective, experience-derived knowledge may not

necessarily be enough to impart exhaustive knowledge on the specific risks related to

the embarkation and disembarkation of the pilot. This is irrespective of the excellent

safety record which the Malta Maritime Pilots has.

This is not to say that hands-on training does not carry advantages. In fact, new

personnel would be exposed to the (actual) tasks related to embarking and

disembarking from a ship, not to mention the relatively minimal costs involved.

However, academia identifies a series of limitations attributed to hands-on training.

These are:

training may be unstructured and relies on the flow of work for its sequence;

trainee may miss on common events if the focus is unusual events;

instructor is not necessarily a skilled trainer;

no formal standardisation is imposed on the „teaching‟ content and

methodology;

training is based on the individuality of the trainer‟s approach; and

end of the training may be a judgmental call on the part of the „instructor‟.

2.4 Pilot Boarding and Industry Practices

The Embarkation and Disembarkation of Pilots – Code of Safe Practice (the EDP

Code) states that the safer side of the pilot boat is normally the outboard side. The

MSIU concurs with this advice. Whilst recognising that under very particular

circumstances, approaching a ship‟s pilot ladder from the outboard side of the pilot

boat may not be the safer side (e.g. in cases when, due to high freeboard, a

11

combination of pilot ladder and accommodation ladder are in use by a ship, and

particularly when the height of the bottom platform of the accommodation ladder

happens to be at the level of persons on the deck of the pilot boat), in the majority of

cases, the outboard side of the pilot boat is considered the safer side.

Additionally, the EDP Code also states that when the safest route from the pilot house

to the pilot ladder is being analysed, amongst other factors, the following should be

considered:

the width of the deck space on the pilot boat; and

if the inside route is taken, the dangers of the boat rolling against the side of the

ship, restricting the area between the deckhouse of the pilot boat and the flat of

the ship side.

The onboard inspection of Charlie 1 during the course of the safety investigation

revealed that she has approximately 0.5 m of deck space on either side of the pilot

house which, bearing in mind the physical dimensions of the pilot boat (and the worst

weather conditions the pilot boat is expected to operate in), is considered sufficient for

the safe access of a trained person. The pilot boat is fitted with an all-round hand rail

which starts at the aft end of the pilot house, goes forward and around the front end of

the pilot house and returns back to the aft end of the pilot house on the other side

(Figure 5). This same handrail is also fitted with a dedicated safety harness securing

point mounted on a traveller.

Figure 5: Handrail arrangement on Charlie 1

12

Notably, Charlie 1 is also fitted with another stand-alone hand rail right up forward in

a manner so as to provide a safe athwartships passage. It was determined that this

arrangement was adequate to allow a person to leave the shelter of the pilot house aft,

walk up towards the bow on the outboard side, and then cross over to the inboard side

directly towards the pilot ladder. This arrangement also permits the deckhand to

retrace his steps and out of harm‟s way by walking across the pilot boat‟s bow to the

outboard side and hence walk back aft, towards the safety of the pilot house.

The MSIU established that on the day of the accident, the pilot, closely followed by

the deckhand, walked out on the pilot boat‟s deck on the inboard (port) side, i.e. the

side closer to the ship. Indeed, once the pilot had transferred himself onto the pilot

ladder, the deckhand turned round and again walked back on the same side (inboard

side) towards the stern, where the accident occurred.

Although the EDP Code strongly recommends (in Para 7.3) that “whilst on deck, the

deckhand is secured to the pilot boat by an approved method which does not restrict

his freedom of movement”, evidence suggested that on this particular occasion, the

deckhand was not secured by a harness to the pilot boat, despite the fact that there was

full provision for this to be done. Although this was not contributory to the accident,

had the seriously injured deckhand not managed to grab hold of the handrail instances

after he had collapsed, he may have rolled off the limited deck space of the pilot boat

into the sea, with potentially dire consequences.

The EDP Code also states in Para 7.4 that

[p]rovided that the ladder has been rigged at the correct height, the deckhand should

proceed forward, up the safest side of the pilot boat side deck (normally the outboard

side), and be ready to lift the end of the ladder clear as the pilot boat comes alongside

the ship.

This safety investigation revealed that on this particular occasion, it was the pilot who

led the way (on the inboard side), followed by the deckhand. The outcome would not

have been any different had the deckhand preceded the pilot as recommended in the

EDP Code. However, this further highlights a lack of formalised procedure adopted by

the pilot and the crew of the pilot boat.

13

It was the conclusion of this safety investigation that, particularly bearing in mind the

state of the weather at the time, the motions of both the pilot boat and the ship, the

absence of an accommodation ladder, and the design of the pilot boat itself (which

allowed walking on the outboard side of the pilot boat), the decision to walk on the

inboard side of the pilot boat was not a safe decision.

It is hypothesised that the decision to walk on the inboard side may have been

instigated by similar past decisions, perhaps in similar circumstances, which have

been successful and without any accident. Such decision may have been

(subconsciously) based on a heuristic evaluation (at least by the pilot since the

deckhand may have followed the example of the former). If the intuitive trade-off

(cost vs. benefit) led to the perception that the better option was to pass from the

inboard side of the pilot boat, then it is very likely that this perception had been

materialised in this action.

In taking such decisions, risk perception is a key influencing factor. It is highly

probable that if either the risk has not been identified, or there was no relevant

knowledge of the potential consequences (because there were no similar past

experiences), the action would have been determined as acceptable (and hence the risk

accepted).

2.5 The Ship and Pilot Stations

2.5.1 The pilot boarding arrangement

As already stated, OS Bodrum is considered to have very good manoeuvring

characteristics. At the time of the accident, the ship was in ballast condition with a

small number of empty containers on board. Her declared drafts were 3.5 m and

5.5 m forward and aft respectively. Her GM at the time was recorded at 2.5 m.

It was noticed that the ship has very fine lines forward with a pronounced flare and a

wide transom with a very substantial overhang lower down.

The International Convention on Safety of Life at Sea, 1974, as amended (SOLAS)

provides guidance on the provisions for the safe transfer of pilots. Regulation

V/23.3.1 requires that “[a]rrangements shall be provided to enable the pilot to embark

14

and disembark safely on either side of the ship.” Furthermore, it is required in

regulation V/23.3.3.1.1.2 that “[s]afe and convenient access…shall be provided…so

secured that…it is within the parallel body length of the ship and, as far as is

practicable, within the midship half length of the ship.”

Other available literature makes reference to pilot boarding arrangements and their

position with respect to the body length of the ship. The UK‟s Code of Safe Working

Practices for Merchant Seamen (Chapter 18) states that,

[t]he arrangements for boarding should preferably be sited as near amidships as

possible, but in no circumstances should they be in a position which could lead to the

pilot boat running the risk of passing underneath overhanging parts of the ship’s hull

structure3.

Similarly, guidance by the International Maritime Pilots‟ Association to naval

architects and shipyards expands on the importance of the SOLAS requirements on

the rigging position of the pilot ladder (Annex 1).

An inspection of OS Bodrum revealed that the permanent pilot ladder rigging position

is situated on the main deck, just forward of the ship‟s accommodation ladders, on

both port and starboard sides. These positions are actually just about inside the ship‟s

parallel body length when the ship is down to her marks (fully loaded and with

minimum freeboard).

More significantly, however, when the ship is not loaded, the overhang of the stern is

well exposed above the water (Figure 6), effectively putting the pilot ladder almost

right at the end of the ship‟s parallel body length and dangerously close to the

overhang of the ship‟s stern (Annex 2).

3 Italics added for emphasis.

15

Figure 6: View of OS Bodrum’s starboard quarter showing the rigged pilot ladder and the

exposed overhang of the stern

The ship also has a rubbing fender, which runs along most of the ship‟s length. There

is a gap in this fender in way of the pilot ladder rigging position so as to permit the

ladder to rest directly against the ship‟s side when rigged without any obstructions.

This arrangement is effective in this respect so long as the ship is fully loaded.

However, when the ship is in ballast condition, the bottom five or six steps of the pilot

ladder do not rest against the ship‟s hull.

It is the view of this safety investigation that the designated pilot stations on board

OS Bodrum are such that they are neither in accordance with the requirements laid

down in SOLAS, nor in accordance with the industry‟s recommendations.

2.5.2 On board organisation and procedures

The safety investigation did not reveal evidence that the ship had been involved in a

similar accident in the past.

As part of the Company‟s safety management system, the ship was provided with a

checklist (which is the industry‟s standard practice), to ensure that (amongst many

other activities) the ship is well prepared for her arrival in port. However, there was

no evidence of any specific pilot boarding procedures or guidelines, other than a

prompt in the pre-arrival checklist: “[p]repare pilot ladder ready for use” (sic).

16

Furthermore, there was no record available on board to indicate that a risk assessment

had been carried out either by the ship or by her ISM managers with respect to the

pilot boarding arrangements on board OS Bodrum. To this effect, if a risk assessment

had actually been carried out, it had either not recognised the risks involved or else,

the risks were deemed acceptable.

2.6 Other Findings - the working relationship between the pilot boat

coxswain and the pilot

The EDP Code states in Para 7.1 that

the decision whether or not to put a pilot boat alongside a ship is the responsibility of

the coxswain. In all cases, the decision as to whether or not to board the ship must be

the responsibility of the pilot involved.

In contrast to the above, regulation 24(2) of the Maritime Pilotage Regulations4 states

that “[a] pilot, when assigned to an operation, is deemed to have full control over the

pilot launch.”

Whilst the decision for the pilot to board the ship was taken by the pilot himself, the

decision to go alongside may not have been taken entirely by the coxswain. Rather, it

may have been influenced by the pilot. The MSIU is of the view that such practice

may, under certain circumstances, lead to indecision, conflict and potential danger.

Moreover, it does seem that as the subsidiary legislation stands, there exists an

anomaly in that whilst the pilot can have “full control over the pilot launch”5, he

cannot exercise such control over the pilot launch once he transfers onto the ship,

unless of course, the “operation” is deemed to have been completed once the pilot is

transferred onto the ship.

2.7 Accident Dynamics

It has been determined that Charlie 1 approached OS Bodrum‟s starboard quarter with

the plan to go with her port side alongside the ship‟s starboard side.

4 Subsidiary Legislation 499.26 – Maritime Pilotage Regulations, as amended.

5 Maritime Pilotage Regulations, regulation 24(2).

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At the time of the accident, the ship had a high freeboard given that she was in ballast.

The coxswain of Charlie 1 had no choice other than to approach and bring the pilot

boat alongside the ship‟s side in an area outside the parallel body length of the ship to

position the forward part of the pilot boat, which is the normal pilot boarding position,

in line with the ship‟s pilot ladder. In this particular condition, OS Bodrum‟s rubbing

fender happened to be at the same level as the head of the crew member standing on

the deck of Charlie 1.

The events which took place moments after the pilot had transferred himself onto the

pilot ladder happened very rapidly. Once the pilot committed his weight on the lower

steps of the pilot ladder, he started to climb up quickly to ensure that his legs were

clear of the pilot boat, the deckhand turned round and started walking back down

along the pilot boat‟s port (inboard) side towards the stern of the boat. Meanwhile,

the pilot boat‟s coxswain, having just watched the pilot transfer himself safely onto

the pilot ladder, started pulling Charlie 1 away from the side of OS Bodrum by

increasing engine power and applying starboard helm.

In response, and further facilitated by the pilot boats narrower beam towards her stern,

her stern started to swing in and under the ship‟s overhang (Figure 7) whilst her bow

started to swing out to starboard and away from the ship‟s side (Annex 3).

Figure 7: OS Bodrum’s starboard quarter looking aft, showing the close proximity of the pilot

ladder to the vessel’s overhang

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Just when the deckhand was walking past the pilot house, out of the coxswain‟s left

side peripheral vision, and precisely when in line with the mullion between the two

windows of the pilot house (Figure 8), his head got caught in between the pilot boat‟s

superstructure and the ship‟s rubbing fender.

It may be stated that the stern of Charlie 1 would not have swung under OS Bodrum‟s

stern overhang, had it been possible for the pilot ladder to be rigged more towards the

midship part of the vessel and well inside her parallel body length. On the other hand,

it was also crucial for the deckhand to walk back towards the stern on the outboard

side (starboard side) of Charlie 1 rather than her port side (Annex 4).

The presence of mind and correct action which was promptly taken by OS Bodrum‟s

pilot, the coxswain and the second pilot on board Charlie 1 are highly commendable -

they helped avoid potentially far more serious consequences.

Figure 8: The port side of the pilot house (note the position of the windows’ mullion where

accident occurred, relative to the seated position of the boat’s coxswain)

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THE FOLLOWING CONCLUSIONS AND

RECOMMENDATIONS SHALL IN NO CASE CREATE

A PRESUMPTION OF BLAME OR LIABILITY.

NEITHER ARE THEY BINDING NOR LISTED IN ANY

ORDER OF PRIORITY.

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3 CONCLUSIONS

Findings and safety factors are not listed in any order of priority.

3.1 Immediate Safety Factor

.1 The deckhand serving on pilot boat Charlie 1 suffered serious injuries as a

direct result of him being caught between the hull of OS Bodrum and the pilot

house.

3.2 Latent Conditions and other Safety Factors

.1 The pilot embarkation position on board OS Bodrum is situated too far aft and

dangerously close to the overhang of ship‟s stern.

.2 Despite the pilot boat being provided with safe deck access to walk on the

outboard side and then to cross over to the inboard side, as Charlie 1 went

alongside OS Bodrum where the pilot ladder was rigged, the pilot, closely

followed by the deckhand, walked out on the inboard (port) side of the pilot

boat. The deck hand then retraced his steps on the same side.

.3 OS Bodrum‟s pilot embarkation operation was not adequately risk assessed.

.4 OS Bodrum was not provided with adequate procedures or guidelines to follow

with respect to pilot embarkation arrangements.

.5 The Malta Maritime Pilots did not have formalised familiarisation and training

procedures to cover, amongst others, the recommendation to walk on the

outboard side of the pilot boat, unless specific prevailing circumstances

dictated otherwise.

3.3 Other Findings

.1 Whilst the decision to board OS Bodrum was taken by the pilot himself, the

decision to go alongside may have been influenced by the pilot, rather than

taken entirely by the coxswain.

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.2 The immediate actions taken by the pilot on OS Bodrum, the second pilot, and

the coxswain of Charlie 1, were crucial and served to avert potentially more

serious consequences.

4 RECOMMENDATIONS

In view of the conclusions reached and taking into consideration the safety actions

taken during the course of the safety investigation,

Coral Shipmanagement GmbH & Co Kg is recommended to:

14/2014_R1 carry out a detailed risk assessment of the vessel‟s pilot embarkation /

disembarkation provisions, taking into consideration the applicable SOLAS

requirements and industry safety guidelines;

14/2014_R2 amend its safety management system in order to ensure that adequate

documented procedures for the pilot‟s safe access to / from the ship are

available on board.

Malta Maritime Pilots is recommended to formally:

14/2014_R3 review its activities, taking into consideration industry‟s standard safe

practices and lessons learnt and establish formal operating procedures. These

procedures should be periodically reviewed with the aim of ensuring that risk is

kept as low as reasonably practicable;

14/2014_R4 establish formal familiarisation training for all its personnel, which

should include, inter alia, a thorough knowledge of the Organisation‟s operating

procedures;

14/2014_R5 implement systematic periodical „refresher‟ training sessions to all

personnel to ensure the highest possible safe practices;

14/2014_R6 review the requirements laid down in regulations 23 and 24(2) of

Subsidiary Legislation 499.26 (Maritime Pilotage Regulations) in order to

determine whether the text on the pilot‟s responsibility vis-à-vis the pilot launch

requires amendments.

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LIST OF ANNEXES

Annex1 Extract from IMPA‟s “Guidance for Naval Architects and Shipyards on the

Provision of Pilot Boarding Arrangement” – Revised Edition 2012.

Annex 2 Sketch showing Charlie 1 alongside OS Bodrum just before the pilot

transfer.

Annex 3 Sketch showing Charlie 1 pulling away from OS Bodrum at the time of

accident.

Annex 4 Sketch showing the safe (outboard) path on Charlie 1 as she pulls away

from OS Bodrum.

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Annex1 Extract from IMPA‟s “Guidance for Naval Architects and Shipyards on the

Provision of Pilot Boarding Arrangement” – Revised Edition 2012.

2. A Pilot Ladder must be rigged “within the parallel body length of the ship and, as far

as is practicable, within the midship half length of the ship”.

There is a trend in recently built ships to place the pilot ladder aft on the quarter…

This creates a dangerous situation for pilot boats for the following reasons:

– When the pilot boat must operate in the low pressure area of a ship‟s quarter, it is sucked

in for hard landings.

– Once alongside, it is difficult to separate from the ship after pilot transfer.

– Operating the pilot boat near a ship‟s quarter exposes the boat to being drawn under the

counter.

– When boarding ships at sea, the pilot boat will surge fore and aft as it works a ladder in

the ocean swell. When the ladder is rigged aft, the boat does not have a length of flat ship

side to work against and is exposed to the suction at the quarter and the hazards of the

counter.

– Pilot boats have been placed in extremis on occasions when a ship‟s master, in haste to

depart, has put his rudder over and increased speed after the pilot has transferred but

before the boat has cleared away. With the ladder too far aft, the pilot boat has been

pinned alongside as the ship turns away from the lee and accelerates.

– Hazards at the quarter increase as weather worsens.

Rigging the pilot ladder at the mid-length of the ship would eliminate all the dangerous

conditions listed above.

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Annex 2 Sketch showing Charlie 1 alongside OS Bodrum just before the pilot

transfer.

Not to Scale

Plane of Rubbing Fender

Deckhand

Pilot

Waterplane

Pilot ladder

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Annex 3 Sketch showing Charlie 1 pulling away from OS Bodrum at the time of

accident.

Not to Scale

Deckhand

Plane of Rubbing Fender

Waterplane

Pilot ladder

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Annex 4 Sketch showing the safe (outboard) path on Charlie 1 as she pulls away

from OS Bodrum.

Not to Scale

Deckhand

Plane of Rubbing Fender

Pilot ladder

Waterplane