Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2262
Initial Report
While boarding a small tanker moored in port, a trainee pilot fell into the water when the bulwark ladder tipped over. The pilot boarded from the stern of the pilot boat onto the bulwark ladder platform without using a pilot ladder. This occurred because the tanker was fully loaded and had very little freeboard, and the shape of the hull made it difficult for the pilot boat to come alongside parallel.
To climb onto the ship, the pilot held onto one of the ladder’s stanchions. The ladder was not fixed to the deck, something that only became clear after the fall. As the pilot pulled on the stanchion, the ladder swung out over the side, unbalancing him and causing him to fall backwards into the water. The ship’s crew reacted quickly, helping the pilot back onto the deck. From there, he could return to the pilot boat sitting higher in the water than the loaded tanker.
CHIRP Comment
This report highlights the risks of using non-standard or non-compliant pilot boarding arrangements. Unless this was a training evolution for the trainee pilot, one wonders why they did not board from ashore using the ship’s gangway since the tanker was alongside.
In this case, the pilot stepped from the stern of the pilot boat onto a bulwark ladder platform, which was not secured to the deck. This suggests a lack of supervision when the platform was rigged. The ladder moved as the pilot grabbed a stanchion, causing him to lose balance and fall.
Fortunately, the crew responded quickly and helped the pilot recover safely.
Key Issues relating to this report
Communication—The pilot was not informed that the bulwark ladder was unsecured. This is a systemic issue that operators and owners should address.
Situational Awareness– The pilot did not visually identify the unsecured ladder. The simplicity of the arrangement may have led to a false sense of safety.
Complacency– The absence of a pilot ladder may have led to underestimating the risk. Any deviation from standard practice should warrant a dynamic risk assessment before boarding the vessel.
Teamwork—The ship’s crew and pilot coordination was limited. Shared mental models and clear roles are essential, particularly during high-risk transfers.
Key Takeaways
Seafarers, “If it is not secured, it is not safe.”
Always check that pilot ladders and transfer gear are correctly rigged and secure—every time. Unusual arrangements or last-minute changes must be clearly explained. When in doubt, pause and verify. Shared safety starts with shared understanding.
Ship managers, “Non-standard should not mean unsafe.”
If a vessel routinely uses non-standard pilot arrangements, you must ensure that proper equipment and procedures are in place. Do not rely on workarounds. High-risk transfers need leadership, training, and the right gear, not assumptions.
Regulators, “Pilot transfer safety is a systemic issue.”
Recurring failures in pilot transfer arrangements show a gap between regulation and reality. Strengthen oversight on compliance and equipment. Encourage audits that include transfer observations and act where unsafe norms have developed.