Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2681
Initial Report
A safety concern was reported via a company’s SMS involving a merchant vessel during pilot embarkation operations. At the time of the report, the vessel had a relatively low freeboard of approximately 2.5 metres.
It was identified that the vessel’s SOLAS-approved pilot ladder had been positioned directly in front of a recessed, built-in ladder located in the ship’s hull. This configuration created a serious hazard during embarkation. In the event of a slip while transferring from a pilot boat, there was a clear risk that a foot could become trapped in the recessed ladder opening. With the normal rise and fall between the vessel and the pilot boat, this could result in severe injury, including crushing or amputation.
Because of the reduced freeboard at the time, the pilot ladder was not used, and boarding was carried out by stepping directly across. The Master was informed of the hazard and agreed to continue operations without using the pilot ladder. Photographic evidence of the arrangement was provided.
While this avoided immediate use of the ladder, the underlying risk remained. The pilot ladder was not positioned clear of obstructions, which is not compliant with SOLAS requirements. Any change in freeboard or operational conditions would immediately reintroduce the hazard. The recessed hull ladder represents a design-related risk that could affect future pilot transfer operations and regulatory inspections.
To address the issue, the pilot ladder should be relocated to a position clear of all obstructions. This would require structural modification, including the provision of an additional compliant boarding gate on deck.
This report emphasises the importance of ensuring pilot transfer arrangements are safe under all normal operating conditions and not reliant on temporary or procedural workarounds. The issue will be raised with the relevant authorities to support learning and prevent recurrence.
CHIRP Comment
This report highlights a structural and procedural safety issue rather than an individual error. Pilot transfer arrangements must be safe under all normal operating conditions, not only in favourable weather or when the vessel’s draft is optimal.
In this case, the pilot ladder was not used due to a credible risk, reinforcing serious safety concerns – particularly in light of a very recent fatality during a pilot transfer elsewhere. This underlines that the hazard is real and immediate.
The use of a recessed hull ladder is a design-related risk, not an isolated arrangement. It is understood that five or six vessel types have been constructed with similar features. Design elements that introduce trapping or crushing hazards should be formally assessed and, where necessary, corrected. Temporary or operational workarounds do not remove the underlying risk and may not be considered acceptable during Port State Control inspections.
CHIRP also questions how this arrangement was approved at the design stage. Recesses in high-stress areas of the hull girder are vulnerable to notch stresses and are more likely to experience accelerated corrosion at internal welds. The entrapment of seawater within these spaces further increases the risk of corrosion and potential leakage into the hull.
It is important to reiterate that SOLAS requirements are not open to interpretation; they are to be complied with as written.
Given the number of vessels affected and the fundamental nature of the design concerns, CHIRP is considering whether this warrants a separate report focused on the risks associated with this class of vessel.
CHIRP will raise these issues with the relevant authorities to support wider learning and help prevent recurrence.
Key Issues relating to this report
Design – Original design has created the impression that the arrangement is acceptable and safe
Communication – An absence of exchanging safety-critical information.
Overconfidence – Reduced vigilance due to familiarity, routine, and past acceptance has allowed this unsafe situation to go unchallenged by multiple actors.
Lack of Teamwork – Poor coordination, cross-checking, or shared situational awareness.
Lack of Awareness – Poor situational awareness of hazards or consequences.
Key Takeaways
Regulators – This case highlights that compliance alone does not guarantee safety.
Equipment and arrangements should be assessed in terms of how they function in real operating conditions, particularly during dynamic activities such as pilot transfer. Confidential reports provide valuable early warning of design-related risks and should be used to support wider learning and prevention, not just local resolution.
Managers and Company Leadership – Workarounds used to remain safe indicate underlying system or design weaknesses that require correction.
Access and pilot ladder arrangements should be addressed through design and engineering solutions rather than reliance on procedural avoidance. Near-misses involving human–equipment interfaces should be treated as important learning opportunities within the safety management system.
Crew – If the job isn’t safe using standard arrangements, report it — even if nothing went wrong.
If a task can only be carried out safely by adapting or avoiding standard arrangements, the condition should be reported even if no incident occurs. Unsafe configurations should not become normalised through familiarity. Clear, factual reporting helps protect others and supports long-term improvements in safety.