M2065 - Failure to communicate a change for the pilot boarding arrangement

Initial Report

Combination ladders: Trapdoor Type Combination

The pilot who reported this incident had reported the same non-compliant transfer arrangements on this vessel 2 months earlier. At that time, the master was advised, including drawings of required modifications. The port state was also informed. On arrival at the port two months later, nothing had been done to rectify the situation.

The new master on board knew nothing of the previous non-compliance report. The new pilot ladder could not rest against the ship’s side as part of the trapdoor combination. It was hanging free of the ship’s side by 200mm. This time the formal notification was given to the PSC authorities to attend the vessel.

CHIRP Comment

This incident report highlights several issues in the reporting culture of the company.

CHIRP is very surprised that the ship manager was not informed, so plans using the drawing provided by the pilot were not utilised to make the arrangements compliant.  What is equally worrying is that the next master who would visit this port because it is on a liner service would have the same non-compliance matter raised against the vessel. From a pilot’s safety perspective, this deficiency is very unsafe, and the ship’s staff seems to have given scant regard to the deficiency.

Pilotage and port state authorities are generally considerate when genuine first mistakes are made, and advice is given to rectify the problem. They are not so receptive when the advice is completely ignored. Port States or individual port authorities are strongly encouraged to empower their pilots with “stop work” authority, that is, to refuse to board vessels that have non-compliant or unsafe pilot ladders. They could make this clear to visiting vessels in their pre-arrival documentation.

Alerting- Alerting the company of deficiencies is a difficult thing to do. It is unclear why, but it is likely that management does not react to bad news, and therefore, it is not delivered. The new master is left with a more severe deficiency, and the company’s reputation is damaged.

Culture- There would appear to be a poor communication culture in the company where bad news is not encouraged. Have you experienced similar issues on your ship? Does nobody want to listen to your concerns? Contact CHIRP if your safety management process is not working and you are not being heard.