Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2558
Initial Report
A pilot raised serious concerns about non-compliant pilot ladder arrangements on board. When attempting to embark, the pilot found that the ladder was not rigged in accordance with SOLAS requirements. Specifically, no heaving line was readily available, a tripping line had been incorrectly fitted, and the embarkation point on deck was obstructed. Most worryingly, the ladder itself was poorly secured. It had been fastened outside the vessel using improvised knots and was not secured to strong points on deck. Instead, crew members were standing on the bitter end of the ladder to stop it from slipping.
When challenged, crewmembers stated, “There is no problem, pilot, this is how we always rig it.” The pilot requested that the ladder be re-rigged. On making a second attempt to board, the ladder dropped while the pilot was on it. A third attempt, supervised by the vessel’s chief officer, resulted in the ladder being rigged correctly and the boarding being completed safely.
The pilot was unable to confirm the presence of lifesaving appliances such as a lifebuoy at the embarkation point due to the time and circumstances.
CHIRP Comment
This report emphasises the importance of maintaining full compliance with SOLAS and IMO requirements for pilot transfer arrangements. Even when PTAs are rarely used, for example, when the master has a pilotage exemption certificate (PEC), crews must stay competent and confident in rigging and checking pilot ladders correctly. Regular training, drills, and supervision are essential to keeping this competence, especially on vessels operating under a PEC. Masters and senior officers should actively ensure that all personnel understand the correct rigging procedures and recognise the safety implications of any deviation. A proactive safety culture – where concerns are raised, discussed, and promptly addressed – remains the most effective safeguard against recurrence.
This report raises significant concerns about the safety of PTAs on board the vessel. The ladder rigging was non-compliant with SOLAS and IMO Resolution A.1045(27), creating a serious risk to pilot safety. Unsafe improvisations and a lack of procedural understanding indicate weaknesses in training, supervision, and compliance oversight. CHIRP contacted the pilotage authority to understand how such poor practices had developed and persisted. Following receipt of the pilot’s report, the ferry’s master took prompt action to rectify the failings, and other pilots have since noted improvements in PTA safety. While this response is positive, CHIRP questions how such deficiencies went undetected for so long and whether similar issues reported elsewhere have led to effective corrective action.
The national maritime authority was notified, but it is unclear if any follow-up occurred at the management level. CHIRP has raised the matter with the Flag State and requested that management be informed of these failings.
It is to the pilot’s credit that they persisted in their attempts to board safely. The fact that the master and chief officer appeared aware of the correct method of rigging, while the deck crew were not, highlights a gap in competence assurance and supervision. This incident underlines the need for regular training, active oversight, and verification of crew competence – particularly on vessels operating under a PEC, where pilot ladders may not be rigged frequently. Ensuring full compliance with SOLAS and IMO standards, supported by an open and proactive safety culture, remains essential to prevent recurrence and safeguard pilot boarding operations.
Key Issues relating to this report
Local Practices – Deviations and shortcuts become the norm. “This is how we always rig it”: noncompliance institutionalised.
Culture – Culture erodes when leadership fails to challenge deviations.
Alerting – No speaking up or challenging unsafe practices. Only the pilot challenged; the crew did not.
Communications – Communications were unclear and did not provide a closed loop of information. It was dismissive: “No problem, pilot”.
Complacency – The crew assumed that nothing would go wrong with an unsecured pilot ladder.
Key Takeaways
Regulators: Paper safety does not save lives.
Rules on paper mean nothing without verification—oversight must ensure that the work done matches the work as imagined.
 Managers: What you permit becomes the standard.
Unsafe shortcuts become habits—leaders must enforce standards, strengthen training, and build a culture where compliance is standard.
 Seafarers: Your safety depends on how you act today.
Complacency kills. Know the procedures, speak up, and never accept unsafe practices as “the way we do it around here.”