Factors relating to this incident

Capability – The master’s assertion that an embarkation ladder and a pilot ladder are equivalent indicates a gap in understanding of regulatory and safety-critical distinctions. This aligns with a breakdown in technical knowledge required for safe pilot transfer operations.

Complacency – The acceptance or normalisation of a non-compliant ladder suggests the risk may have been underestimated, possibly due to routine exposure without prior negative outcomes.

Alerting – Appears in a limited sense within the shipboard context. While the pilot demonstrated appropriate assertiveness, there is no indication that crew members challenged the arrangement internally, suggesting a possible reluctance to question decisions.

Communication – The mismatch between the pilot’s expectations and the vessel’s preparation includes both procedural communication (requirements not clearly understood or conveyed) and operational communication between the ship and the pilot authority.

Teamwork – A lack of teamwork may also be inferred, particularly if the bridge or deck crew did not engage collectively in verifying compliance or supporting safe pilot transfer preparations.

“A routine task became unsafe not through a single failure, but through a shared misunderstanding of what ‘correct’ looked like.”

Key takeaways

Regulators –“Standards only improve safety when they are consistently understood, not just published.” This incident highlights the importance of ensuring that regulatory requirements, especially those concerning pilot transfer arrangements, are not only clearly outlined but also effectively understood and implemented in practice. Regulators might also consider whether guidance documents adequately distinguish between similar equipment types and whether additional focus is needed during inspections, audits, or awareness campaigns to address common misconceptions. The event underlines the value of strengthening practical understanding, not merely procedural existence.

Managers (Operators / Companies) – “If crews are improvising compliance, the system has already drifted from safety.” Managers should consider whether pilot transfer procedures are actively reinforced and whether crews are routinely exposed to the correct standards through drills, inspections, and supervision. There may also be a need to examine whether “work as done” has diverged from “work as intended,” particularly if non-compliant substitutions are being accepted in practice.

Seafarers – “When something ‘looks about right,’ that is the moment to check more closely.” For crew members, the incident underlines the importance of recognising that seemingly similar equipment can have very different safety implications. Maintaining an accurate understanding of requirements, particularly for pilot transfer arrangements, is essential. The situation also highlights the value of speaking up and cross-checking, especially when there is uncertainty about compliance. A questioning mindset and willingness to verify assumptions remain key contributors to safe operations.

Human Factors Relevant to this Report

Fatigue – Cumulative sleep debt, repeated night shifts, and poor recovery reduce alertness, concentration, and decision‑making ability.

Pressure – Commercial and operational demands may encourage continued operation despite reduced fitness for duty.

Communication – Concerns were raised without effective resolution. When people believe concerns will not lead to change, reporting may decline and morale will certainly suffer.

Complacency – Microsleeps, near misses, or fatigue may become normalised if not challenged or addressed.

Alerting – Individuals may continue working while fatigued rather than removing themselves from duty or escalating concerns. It is vital that crew members remain alert and stop work if they suspect they are fatigued.

Teamwork – Reduced staffing and fewer experienced personnel increase workload and reduce system resilience. Teamwork is vital in these circumstances.

Norms – Extended sequences of night work may become culturally accepted even when unsafe. Question this false normality and make the necessary changes to roster patterns to change it.

SHIELD Taxonomy identified

Acts – What goes wrong – Unintentional lapses in attention, reduced monitoring, delayed reactions, and fatigue‑related errors.

Preconditions – Factors influencing performance – Sleep debt, circadian disruption, stress, poor recovery, high workload, and degraded vigilance.

Operational Leadership – Policies affecting work – Rosters, crewing decisions, task allocation, and day‑to‑day management of fatigue risk.

Organisational Influences –  Influence of the company/external environment – Staffing models, recruitment pressures, commercial priorities, safety culture, and the effectiveness of fatigue management systems.

Key Takeaways

Minimum crewing does not always mean optimum crewing. Compliance on paper does not ensure fatigue risk is controlled in practice.

Regulators – Documented compliance should be assessed against actual workload, administrative burden, and operational tempo to determine whether fatigue controls are effective.

 Operators / Managers – Systems that rely on tired people coping are unsafe. Crewing levels, schedules, and workloads must reflect operational reality. Fatigue indicators, like equipment alarms, should prompt management intervention.

Seafarers / Contractors – Professionalism is an important safety barrier, but it should not be the only one. Remain alert to early warning signs such as reduced concentration, irritability, or repeated mistakes. Raise concerns early, support colleagues, and cross‑check critical tasks when fatigue risk is elevated.

Factors relating to this report

Communication – issues are evident in both weather decision-making and pilot ladder preparation, with concerns either not shared effectively or not acted upon despite repeated raising.

Alerting – the crew did not challenge unsafe ladder rigging or escalate concerns prior to the pilot’s intervention.

Complacency – is suggested by acceptance of substandard pilot ladder arrangements and the initial willingness to proceed into adverse weather without sufficient reassessment.

Teamwork – The lack of teamwork is evidenced by the absence of cross-checking and shared responsibility, particularly for a safety-critical task such as rigging the pilot ladder, and is reflected in the captain’s limited presence on the bridge during a developing risk situation and in the lack of oversight of critical safety preparations.

Situational Awareness – is present in both environmental risk perception and the failure to recognise the severity of an improperly secured ladder.

Local practice – Norms are strongly indicated, with unsafe practices (poor lashings, unsecured ladder ends) appearing routine rather than exceptional.

Capability –  is suggested by incorrect rigging techniques and inappropriate materials being used.

Takeaways

Regulators – Compliance on paper does not guarantee safety in practice. There is a need to ensure that compliance with pilot transfer regulations and procedures is not only documented but consistently verified in practice, particularly where routine tasks may drift from standards over time. Greater emphasis on auditing real-world behaviours, especially around pilot ladder rigging and bridge resource management, would help identify gaps between “work as imagined” and “work as done.” Strengthening oversight of how safety-critical procedures are trained, assessed, and reinforced could address latent cultural issues that allow unsafe norms to persist.

Managers (Operators / Companies) – What leaders tolerate becomes the standard crews follow. This report highlights the importance of actively reinforcing safety culture onboard, particularly around supervision, communication, and challenge. Bridge leadership behaviours set the tone; an absence of, or limited engagement during key operational phases can weaken standards and reduce crew responsiveness. There is also a need to ensure that crews are both trained and empowered to stop unsafe acts, with clear expectations for verification of critical equipment like pilot ladders. Routine tasks require the same discipline as high-risk operations, as this is where complacency and norm drift often develop.

Seafarers – If something is unsafe, stopping the job is the safest course of action. The event demonstrates the importance of speaking up, cross-checking, and not accepting “good enough” when safety is involved. Even familiar tasks like rigging a pilot ladder carry significant risk if not completed correctly. Repeated instructions from the pilot were required before action was taken, highlighting the need for clearer communication and immediate response to safety concerns. Every crew member has a role in maintaining standards, and timely intervention can prevent escalation into serious incidents.

Factors relating to this report

This event shows a cluster of high-risk human and organisational behaviours, rather than a single failure.

Communication – No clear communication regarding the work scope and associated hazards (hot work, diesel enclosed-space tank environment). Possibly, a power gap between office management and the crew prevented people from speaking up.

Complacency – The work activity was treated as a routine repair, and, due to a lack of effective control measures, it appeared to normalise unsafe practice.

Capability – Failure to recognise the work as a high-risk work environment and the need for basic safety controls.

Teamwork – was missing because if the crew had been operating as a team, there would have been a challenge to the work activity

Capability – Missing from the work were the following: a permit to work, gas-monitoring equipment, rescue equipment, and standby personnel with communications equipment.

Pressure – Likely urgency due to seawater ingress and the need to maintain operational readiness may have overridden safe decision-making

Norms (Unsafe Practices Becoming Standard) – Absence of a PTW strongly suggests:  “This is how we normally do it in this company”, so that deviations from standard operating practice have become accepted standards.

Key Takeaways

If the permit isn’t in place, we may not yet understand the risks well enough to start.

Regulators (Flag State / Class) – This case highlights the need to actively verify compliance with fundamental safety controls, including permit-to-work, gas monitoring, and enclosed-space procedures. Greater oversight is needed to ensure that requirements are consistently applied in practice, with clear accountability among the Flag State, Class, and operators. Targeted inspections and follow-up on reported concerns can help close the gap between procedures and on-board reality.

Managers / Operators – This incident reflects a failure to enforce core safety management system barriers. Managers must ensure that critical controls are treated as non-negotiable, regardless of operational pressure. Stronger oversight of contractors and superintendents is essential, alongside reinforcing a culture in which unsafe work is challenged, and stop-work authority is fully supported.

Seafarers – This report reinforces that work should not proceed without essential safety measures in place. The absence of a permit-to-work, gas testing, or rescue arrangements should be clear grounds to stop the job. Seafarers should remain vigilant, challenge unsafe conditions, and avoid accepting risk as routine.

Factors related to this report

Complacency – is evident in that the towing line was correctly rigged without a positive verification once the load was applied. The operation appears to have been treated as routine, reducing vigilance at a critical moment.

Situational Awareness – is reflected in the failure to fully recognise the hazard posed by a tensioned and fouled line, particularly the risks associated with stored energy and snapback zones.

Communication – may have contributed, as although there was contact between bridge and deck, there is no indication that a shared mental model of the developing hazard (fouling under load) was established.

Teamwork/Assertiveness – is suggested by the absence of challenge or pause before intervention, with no evidence of cross-checking or escalation before attempting to clear the line.

Capability – (or insufficient application of training) is indicated in the choice to physically intervene on a tensioned line, contrary to widely taught safe line-handling practices.

Key Takeaways

Regulators – Known risks are not the same as managed risks. This case emphasises that well-known hazards such as snapback and stored energy still occur despite extensive guidance, indicating that current safety messages are not consistently influencing operational behaviour. There is an opportunity to better embed, assess, and reinforce guidance such as MGN 520 across the industry, particularly regarding dynamic risk assessment and intervention thresholds.

Managers (Company / Operators) – Procedures only protect people when they shape real behaviour on deck. The incident indicates a gap between procedures and practice, especially in stopping work when conditions deviate from the plan. Managers should consider how effectively crews are trained and empowered to pause operations, how clearly snapback risks are demonstrated, and whether supervision and onboard culture actively reinforce conservative decision-making in routine tasks.

For Seafarers – If it’s under load, don’t touch it, make it safe first. This event is a reminder that tensioned lines are inherently dangerous and can become lethal without warning. Intervening before removing the load, even with simple actions, can lead to serious consequences. Taking a moment to stop, reassess, and make the situation safe is always the safer option, even under perceived pressure to continue.

Factors relating to this report

Communication – is evident in the gap between identifying the problem and resolving it. Although the issue was known (PSC and DPA), the lack of inspection detail and corrective action indicates that critical safety information was not effectively shared or acted upon.

Complacency – may be present in the continued operation despite known infestation and water concerns. Deferring action suggests acceptance of degraded conditions, possibly influenced by past experience of operating without immediate consequences.

Lack of assertiveness – is suggested by the persistence of the issue. While escalation was reported, it may not have been sufficient to prompt timely intervention, particularly given the health risks.

Pressure – likely operational or commercial, appears to have influenced decisions. Deferring rectification to a later port suggests that schedule or cost considerations outweighed immediate risk mitigation.

Lack of resources – may have contributed to the failure to address the issues at the time of identification, including limitations in time, equipment, or access to contractors.

Lack of leadership – is indicated by the absence of effective action despite shore-side awareness, suggesting insufficient prioritisation or follow-through on a known welfare issue.

Lack of awareness – may also be a factor, particularly regarding the health risks of prolonged exposure to contaminated water and infestation, which may not have been fully appreciated.

Norms – appear relevant, as deferring defects and continuing operations in degraded conditions may reflect an accepted but informal practice.

Key Takeaways

Regulators – “If you don’t verify it, you don’t control it.” When certification is treated as a formality rather than a verification process, assurance is weakened, and risk is displaced rather than controlled.

Managers – “What you allow today becomes the standard tomorrow.” Deferring known health hazards to maintain the schedule can unintentionally signal that safety is negotiable, reinforcing normalisation of degraded conditions across the system.

Seafarers – “Raising it once is reporting—seeing it through is safeguarding.”
Reporting concerns is essential, but persistent follow-up and escalation are equally important when conditions continue to pose a risk to health and safety.