Confidential Human Factors Incident Reporting Programme
Report TitleFailure to challenge authority leads to dangerous occurrence
A pilot boarded a tanker at anchor. When they arrived at the top of the ladder, they discovered that it was tied to a rotten railing, there were no suitable hand-holds nearby, and there were many trip hazards on the deck near the embarkation point.
When the pilot raised this with the master, he was told that the ladder was not usually rigged in that position but had instead been moved to accommodate the pilot station’s direction to rig a 7m ladder. This was higher than the 5m maximum height at the normal embarkation point, so the ladder had been moved.
The master should have challenged the pilot station’s request if it meant moving the ladder from its designated position, on the grounds of safety. In many cultures, authority figures are not challenged, and this might have been the case in this situation, however the master and crew know their vessel best! If the request was made because of a high sea state or swell, CHIRP would question whether safe embarkation would have been possible in such conditions.
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.