Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M1877
Initial Report
A fisher returned to their vessel with a guest in the late evening after they had met ashore. Both had drunk alcohol. It was low tide, and the vessel was approximately 6m below the quay edge due to the tidal range in that port.
As they climbed down the vertical quayside ladder, the guest fell off the ladder and hit the vessel’s hull before falling, injured, into the water. The sea temperature was approximately 10° C (50° F).
The fisher was unable to recover the person in the water and entered the water himself in an attempt to keep the guest from drowning.
A crew member from another fishing vessel moored nearby heard the commotion and managed to recover the injured person and the crew member from the water back onto the deck of the fishing vessel. Due to the effects of the cold water and the injuries, the guest was unresponsive and not breathing.
The port authority’s security team called an ambulance and commenced CPR on the casualty until the emergency services arrived, but it took over an hour to lift them from the vessel and up the 6m to the quayside and into the ambulance where they made a full recovery within a few days.
Due to the range of the tide the vessel did not put out a gangway and instead relied on the vertical metal ladder secured to the quay wall. At low tide this generated a significant risk of falling from height and onto the steel deck of the vessel and/or into cold water.
Design (latent factor) – Vertical ladders are exposed to the elements and prone to damage by vessels berthed alongside. There is no fall protection inherent within the design and unless regularly maintained they are prone to rusting and marine growth
Fit for duty – Alcohol increases the likelihood of an incident occurring and CHIRP recommends that Safety Management System (SMS) risk assessments include alcohol/intoxication as a factor when appropriate, particularly in cases where access arrangements include a climb up and down vertical ladders.
Local practices – CHIRP acknowledges that high tidal ranges preclude the use of gangways, and that many ports lack the space, water, and money to install pontoon berths, so must therefore rely on the use of vertical ladders as the safest means of access.
Is there a shared understanding between the port authority and the vessels regarding who is responsible for providing the means of safe access? This can vary by country and regulatory area. Does your vessel adhere to the local regulations?
Culture – To be effective, there must be a shared safety culture between vessels and port authorities, particularly where regulations on the provision of a safe means of access can be interpreted differently by the port authority and a vessel’s Master. Port safety forums are one way of developing this shared safety culture with everyone working to a shared understanding of risks and their control measures.
Capability – Do ports have the correct equipment to facilitate recovery of a casualty from a vessel at low tide, and is this operation regularly practised?
Report Ends……………………
CHIRP Comment
The Master is responsible for ensuring a safe means of access to their vessel. This can be difficult, especially for small vessels that lack the space on board to carry or rig a gangway, or where the tidal range would make the gangway too steep to safely use. In these cases, Masters consider that they have no option but to use the vertical ladders as the only means of access or request a more suitable berth. By contrast, many port authorities view the vertical quayside ladders as ‘self-rescue’ equipment for anyone who falls into the water. They do not consider them as a safe means of access onto vessels, especially those that lie some distance below the quay edge at low tide. The rules that determine whether it is the port authority or the master that is responsible for providing safe access onto vessels vary by country and are not always clear. CHIRP urges regulators in those jurisdictions to reduce the scope for different interpretations wherever possible.
The need to recover casualties from vessels at low tide is reasonably foreseeable, so ports are strongly encouraged to conduct thorough risk assessments to deal with this scenario and develop an emergency recovery plan. This might require the purchase of specialist equipment or the nomination of a suitable ‘casualty recovery’ berth.
Ports and vessels’ masters are also encouraged to ensure that visiting crews are aware of the local arrangements for summoning emergency assistance and can describe their location to the emergency services when doing so.
Key Issues relating to this report
Design (latent factor) – Vertical ladders are exposed to the elements and prone to damage by vessels berthed alongside. There is no fall protection inherent within the design and unless regularly maintained they are prone to rusting and marine growth
Fit for duty – Alcohol increases the likelihood of an incident occurring and CHIRP recommends that Safety Management System (SMS) risk assessments include alcohol/intoxication as a factor when appropriate, particularly in cases where access arrangements include a climb up and down vertical ladders.
Local practices – CHIRP acknowledges that high tidal ranges preclude the use of gangways, and that many ports lack the space, water, and money to install pontoon berths, so must therefore rely on the use of vertical ladders as the safest means of access.
Is there a shared understanding between the port authority and the vessels regarding who is responsible for providing the means of safe access? This can vary by country and regulatory area. Does your vessel adhere to the local regulations?
Culture – To be effective, there must be a shared safety culture between vessels and port authorities, particularly where regulations on the provision of a safe means of access can be interpreted differently by the port authority and a vessel’s Master. Port safety forums are one way of developing this shared safety culture with everyone working to a shared understanding of risks and their control measures.
Capability – Do ports have the correct equipment to facilitate recovery of a casualty from a vessel at low tide, and is this operation regularly practised?