M2755

Factors relating to this report

Communication – issues are evident in both weather decision-making and pilot ladder preparation, with concerns either not shared effectively or not acted upon despite repeated raising.

Alerting – the crew did not challenge unsafe ladder rigging or escalate concerns prior to the pilot’s intervention.

Complacency – is suggested by acceptance of substandard pilot ladder arrangements and the initial willingness to proceed into adverse weather without sufficient reassessment.

Teamwork – The lack of teamwork is evidenced by the absence of cross-checking and shared responsibility, particularly for a safety-critical task such as rigging the pilot ladder, and is reflected in the captain’s limited presence on the bridge during a developing risk situation and in the lack of oversight of critical safety preparations.

Situational Awareness – is present in both environmental risk perception and the failure to recognise the severity of an improperly secured ladder.

Local practice – Norms are strongly indicated, with unsafe practices (poor lashings, unsecured ladder ends) appearing routine rather than exceptional.

Capability –  is suggested by incorrect rigging techniques and inappropriate materials being used.

Takeaways

Regulators – Compliance on paper does not guarantee safety in practice. There is a need to ensure that compliance with pilot transfer regulations and procedures is not only documented but consistently verified in practice, particularly where routine tasks may drift from standards over time. Greater emphasis on auditing real-world behaviours, especially around pilot ladder rigging and bridge resource management, would help identify gaps between “work as imagined” and “work as done.” Strengthening oversight of how safety-critical procedures are trained, assessed, and reinforced could address latent cultural issues that allow unsafe norms to persist.

Managers (Operators / Companies) – What leaders tolerate becomes the standard crews follow. This report highlights the importance of actively reinforcing safety culture onboard, particularly around supervision, communication, and challenge. Bridge leadership behaviours set the tone; an absence of, or limited engagement during key operational phases can weaken standards and reduce crew responsiveness. There is also a need to ensure that crews are both trained and empowered to stop unsafe acts, with clear expectations for verification of critical equipment like pilot ladders. Routine tasks require the same discipline as high-risk operations, as this is where complacency and norm drift often develop.

Seafarers – If something is unsafe, stopping the job is the safest course of action. The event demonstrates the importance of speaking up, cross-checking, and not accepting “good enough” when safety is involved. Even familiar tasks like rigging a pilot ladder carry significant risk if not completed correctly. Repeated instructions from the pilot were required before action was taken, highlighting the need for clearer communication and immediate response to safety concerns. Every crew member has a role in maintaining standards, and timely intervention can prevent escalation into serious incidents.