Communication: Vessels should challenge any direction that means a departure from authorised procedures, particularly where safety could be compromised as a result.
Situational awareness: Prior to any activity, and particularly one which deviates from normal procedures, a dynamic risk assessment is vital to ensure that the area is safe. Had this been undertaken effectively then the crew should have noticed that the ladder’s fixing point was unsuitable.
Culture: The poor state of maintenance indicates that the vessel’s safety and maintenance culture was inadequate. This also suggests a lack of external inspections and audits at the organisational level.
Pressure: The crew put themselves under self-imposed pressure to provide a pilot ladder at 7m despite knowing that this would be less safe than the designated embarkation point.
