Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2162
Initial Report
The pilot reported that after disembarkation to the awaiting pilot launch, the accommodation ladder (part of a combination rig) was seen trailing in the sea when the wires for the accommodation ladder parted.
CHIRP Comment
The disembarking pilot could have been seriously injured if they had been on the accommodation ladder just a few minutes later. Why does this continue to happen?
A similar incident M1852 was published in MFB Edition 66 page 3 in which, fortunately, there was no serious injury to the pilot.
Wires need regular maintenance and regular replacement in accordance with SOLAS and company SMS maintenance procedures. The wire’s function deployed on gangways is to break out/stow the gangway and position the gangway to a required angle in azimuth or elevation so personnel, including pilots, can gain access to the ship. Given that the position of most gangways is located where sea and spray impact the ladder and can accelerate corrosion, CHIRP advocates that the wires must be replaced more frequently than the current regulations stipulate. Also, lowering the ladder to approximately the same position regularly will place a more significant load and wear on that part of the wire and cause it to fail quicker despite the rest of the wire looking in good condition.
In our Annual Digest (2022-23), we advocate for a replacement period of 12-month intervals due to the high number of wire failures. CHIRP has received several reports where the wire has parted while in use and wants to collate these reports to provide objective evidence that the regulations must change to a 12-monthly frequency for renewal.
CHIRP encourages manufacturers to reconsider gangway design so crew members can easily inspect and maintain the wires.
Reference: Pilot ladder Safety – Do it right the first time
Key Issues relating to this report
Design – You need to be able to see the wire to inspect it. A lot of the wire is hidden, especially at the terminations. Manufacturers must look at the design with a focus on maintenance by the crew. Does your ship have a spare gangway wire on board?
Capability – Improvements in inspections require the crew to be trained in what to look for. Have you ever been given any formal equipment maintenance training? Or have you just picked it up from the other crew members?
Situational Awareness – Think of the vulnerability of the gangway and apply more stringent measures concerning maintenance. Please think of the people who must use the gangway as part of their job, e.g., pilots, and increase safety factors for the moving parts. Consider halving the periods for maintenance and replacements.
Alerting – If you inspect your gangway and find the wire condition in a poor state, will you notify the rest of the fleet?