Confidential Human Factors Incident Reporting Programme
|Poor choice of knot puts pilot in jeopardy
Report TitlePoor choice of knot puts pilot in jeopardy
While boarding a vessel at sea a pilot found that the combination ladder was affixed solely by overhand knots (see pictures) . These easily unravel if there is strain from the standing part of the rope, e.g., under the weight of a pilot as they ascend or descend the ladder. This type of knot must never be used in the rigging of a pilot ladder or gangway.
The correct knot in these circumstances is either a round turn and two half hitches or a bowline. The rigging of a gangway which is to be used as part of a combination ladder arrangement is a task normally undertaken by 2-3 deck crew. It should then be inspected by the officer detailed to meet the pilot.
The repeated use of overhand knots in this case indicates that either the officer did not correctly supervise and inspect, or that the crew have become desensitized to a deviance from standard procedures: the local practice on the ship or within the company for securing the pilot ladder rope with an overhand knot had become the accepted norm.
Despite being incorrect there appears to be no culture of challenge by the crew or officers to secure the ropework with the correct knot.
Capability – Knowing which knot to use in a particular situation is an essential seamanship skill that every deck hand should learn at the start of their career, but in this incident, it appears that neither the crewmember who tied the knot nor those working with them recognised that this was the wrong knot to use. Is this a training gap?
Culture – The wrong knot was used repeatedly but appears not to have been challenged. This is known as a ‘normalisation of deviance’ which indicates that there is a culture either of acceptance of poor practice or a lack of empowerment to challenge obvious safety deficiencies.
Teamwork – A high-performing team is one where individuals are open to supportive and constructive challenges from other team-members. This ensures that standards are maintained (or even enhanced) and everyone learns from each other.
By contrast, members of poorly performing teams may not speak up either because they lack confidence (“Will I look silly if I’m wrong?”) or because they fear reprisals (“Will I get into trouble for speaking up?”) or because they don’t want to embarrass another team member (“I don’t want to get them into trouble”). As a result, opportunities to improve are missed and dangerous situations are created.
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