Safety Insights Paper – Pilot Ladder Arrangements

The purpose of this RightShip Insights Series is to highlight important trends and provide industry partners with key learnings, best practices, and safety observations to mitigate/reduce the risk of incidents including fatalities, and lengthy delays related to pilot ladder arrangements.



Over the past two years, RightShip has reviewed more than 21,000 PSC inspections, assessed over 2,500 incidents, and inspected over 4,600 vessels. This is in addition to the reviewing a large number of SIRE reports as part of the vetting process. Despite the industry’s efforts and campaigns to educate, we have observed an upward trend in deficiencies and non-conformities involving pilot ladders and arrangements. The data gathered from RightShip Inspections indicates that the pilot ladder related non-conformity percentage rate is in excess of 16%. Some of the recurring observations include, but are not limited to:

  • Pilot ladders secured to deck with shackles, deck tongues, or bars so that the weight is transferred to the steps and not to the stronger side ropes.
  • Ladder secured with ropes which are not strong enough to carry the weight.
  • Ladder not secured to a designated strong point (secured to railings or other unsuitable structures).
  • Ladder rigged over the sharp deck edge damaging side ropes.
  • Broken, worn out, or non-horizontal steps or spreaders.
  • Pilot ladder side ropes not of proper size, frayed, deteriorated, or found with splices.
  • Side ropes found with rot under the metal clamps.
  • Unsafe manropes.
  • Ladders stored and exposed to sun and weather.
  • Pilot ladder stored next to a decommissioned ladder, so the crew accidentally mixed up the two.
  • Retrieval line attached incorrectly (not leading forward, or at or above the lower spreader)
  • In combination ladder, lower platform of accommodation ladder not horizontal or not secured to the ship’s hull.
  • Accommodation ladder too steep (over 45 degrees).
  • Pilot ladder not secured to the side of the ship, or at the right height above the platform.
  • Stanchions on lower platform of accommodation ladder damaged or incorrectly rigged.
  • Inadequate marking, inspections and maintenance.
  • Lifebuoy with self-igniting light missing from its designated place next to the pilot ladder.
Broken Step on ladder that was still in use_0

Image: Broken step on ladder that was still in use

Improperly rigged ladder over railing and with shackles.

Image: Improperly rigged ladder over railing and with shackles. 

Pilot Ladder 3_0

Image: Steps and Spreaders not horizontal

These are some of the deficiencies that are usually identified while the ladders are not in use. However, critically, it is when an inspector is not present, and ladders are being rigged or utilised, that those deficiencies with high-risk potential can result in incidents such as the cases below:

Case (1) Summary of events:

A ship in normal ballast was completing its pilotage transit out of port on a relatively calm winter morning. The pilot ladder was rigged according to the pilot’s request and the Chief Officer escorted the pilot down from the bridge. Once the pilot boat was safely alongside, the pilot started his descent. When he was about two meters down, a side rope parted, and the ladder swung violently causing the pilot to fall the approximately 5 meters into the icy waters. The pilot was recovered and was treated for shock. Upon reviewing the records, it was discovered that the monthly safety equipment inspection had recently been completed, including the pilot ladder, and which was documented as in satisfactory condition.

RightShip Comment: Regular equipment inspections are one means of identifying hazards and non-conformities that can result in incidents. Two barriers against incidents are the Safety Management System (SMS) and the Planned Maintenance System (PMS). The SMS is a collection of structured processes, policies, practices, and procedures that provides for effective risk-based decision-making during daily operations and reinforces overall safety culture. A documented SMS in itself is not going to prevent undesirable events. It must be effectively implemented, and the associated PMS must be consistently complied with.

The following are a few cases where an SMS was not effectively implemented with serious consequences:

Case (2) Summary of events:

As the freeboard was over 9 meters, the crew of a light tanker rigged a combination ladder in preparation for the harbour pilot to board. When the launch came alongside, everything looked in order and the pilot started his ascent to the main deck. As the pilot boat pulled away from the ship, a retrieval line attached to the bottom step caught on one of the launch’s cleats and pulled the ladder away from the side of the ship which caused it to part. The pilot, who was still climbing the ladder fell from height into the water. To complicate matters further, part of the broken ladder attached to the launch fell into the water and subsequently fouled the propellor, causing a delay in rescue efforts. When the pilot was finally recovered, he had to be treated for a serious head injury.

Case (3) Summary of events:

A laden tanker with 11.45 m draft was underway in the Mediterranean Sea, en route to the discharge port. The weather conditions were reported as favourable with light South-easterly winds, good visibility, with air temperature at 15 degrees C and sea temperature at 16 degrees C. At 0500, instructions were received to prepare a combination pilot ladder arrangement on the port side for pilot boarding. Risk assessment was completed, and a toolbox meeting held by the vessel’s Master with the experienced Bosun and AB. The 4th Officer, the Officer of the Watch, monitored the operation from the bridge wing, while the Master had the conn.

The Bosun and AB donned Personal Protective Equipment (PPE) including lifejackets and safety harnesses with safety lines. The accommodation ladder was lowered, moveable railings were raised up and secured, and the lower platform was fixed. The Bosun and AB then returned to the main deck and removed their lifejackets and safety harnesses to facilitate the lowering of the pilot ladder. Once completed and the ladder was secured, the AB descended the accommodation ladder to adjust the angle of the lower platform without the prescribed PPE. Once he reached the platform, he crouched to remove the safety pin and the outside guard line was used to raise the platform to the desired angle. When AB reinserted the safety pin, he inadvertently inserted the pin into the incorrect hole and the platform was not properly secured. When he stood up the platform gave way, and the AB fell into the water. The Bosun alerted the bridge of the Man Overboard (MOB) and threw a non-lighted lifebuoy from the stern. The Bosun lost sight of the AB when he was approximately 100 m from the stern. The bridge did not deploy the lighted MOB lifebuoy with smoke signal, due to communication breakdown.

From that point on, all MOB protocols were followed, and the rescue boat launched. Notifications were made and all vessel traffic in the vicinity halted for Search and Rescue (SAR) operations. In addition to the ship’s efforts, three pilot boats and two helicopters were dispatched to aid in the search. Tragically, the lifebuoy was the only thing ever recovered.

Case (4) Summary of events:

Early morning, a bulk carrier dropped anchor in preparation for a Ship-to-Ship cargo operation in the Bay of Bengal. After the lightering vessel had come alongside, an agent, several surveyors, and other representatives boarded the Ship to be Lightered (STBL) to complete pre-transfer draft surveys during which Yokohama fenders were fitted between the ships. Discharging commenced mid-morning. Approximately 45 minutes after cargo operations began, paperwork was finalized and one of the surveyors and the other attending personnel disembarked over the shipside railing and onto the fender of the lightering vessel. One surveyor, reportedly an experienced mariner, was disinclined to disembark in a similar fashion and requested the pilot ladder be rigged between the STBL and the lightering vessel. Once the pilot ladder was in place, the 3rd Officer of the STBL observed the lateral distance, which was approximated at 1.5m, and decided the safer approach was to rig a combination ladder. The surveyor did not consider the gap to pose a significant risk and insisted that the pilot ladder be pulled tight by the lightering vessel. Allegedly, he also refused to don a safety harness.

The officers of both vessels acquiesced to his wishes, and the surveyor proceeded down the ladder at approximately a 45 -degree angle. When the ladder was unable to be maintained taught under the weight of the surveyor and slacked, the surveyor fell from a 4 to 5 meter height, between the ship and the fenders. Two crew members from the lightering ship jumped into the water to render aid. Miraculously, the crew members and the surveyor were extracted, the surveyor in an unconscious state. The crew rendered CPR, however the surveyor never regained consciousness and was later pronounced dead.

What went wrong?

Below is a list of root causes and/or contributing factors that have been sighted in investigation reports following Port State Control deficiencies or incidents:

  • Inadequate Leadership.
  • Inadequate Supervision.
  • Substandard Equipment.
  • Lack of procedures.
  • Lack of familiarization with procedures.
  • Failure to follow procedures.
  • Lack of training.
  • Positive reinforcement of negative behaviour.
  • Lack of Situational Awareness.
  • Failure to store pilot ladder correctly allowing exposure to the elements.
  • Complacency i.e., “Rigging pilot ladder is routine job.”
  • Improper decision making.
  • Failure to properly and accurately assess risk involved with the task.
  • Safety Culture and Attitude lacking.
  • Failure of crew members of all ranks to exercise Stop Work Authority.

Preventative Actions and Best Practices.

Our observations demonstrate that the development and implementation of an effective SMS and PMS act to prevent these recurring non-conformities and incidents. ISM (International Safety Management) Code Part A, Section 10 describes what a company should do to ensure a vessel conforms to applicable rules and regulations. SOLAS Chapter V, Regulation 23 and associated IMO (International Maritime Organization) Assembly Resolutions A.1045(27) and A.1108(29,) clearly define the minimum standards for pilot ladder equipment and arrangements.

The following policies, actions, and best practices have been observed being implemented to manage safe personnel transfers:

  • Certified Equipment from Reputable Manufacturer – Outfitting vessels with quailty equipment from a reputable manufacturer ensures that ladders meet regulatory standards and demonstrates the company’s commitment to welfare of the personnel utilizing them.

  • Maintenance, Stowage, and Testing – The International Organization for Standardisation (ISO) published a three-part series outlining in depth standards regarding pilot ladders. Additionally, reputable suppliers provide manuals that provide detailed instructions regarding the inspection, maintenance, drying process, and storing of the ladders. As with the regulations on pilot ladders, we have seen some managers incorporate the ISO standards and/or the manufacturer recommendations into the PMS, inspection procedures, and training for officers and crew.

  • Ladder Service Life – Properly maintained ladders have a finite lifespan and, although there is no specific retirement age defined by regulation, some managers have adopted industry best practice to replace pilot ladders every two years.

  • Risk Assessment for Critical Tasks – Rigging pilot ladder accommodations is considered critical and a task-specific Job Safety Analysis that identifies risks and mitigation measures is carried out prior to every operation, no matter the frequency.

  • Training – In addition to detailed procedures, effective managers provide thorough initial instruction followed by regular refresher training for reinforcement.  Training effectiveness is essential, and good operators routinely provide remedial training when a vessel has pilot ladder related non-conformities identified during inspections.

  • Supervision – All inspections, maintenance, rigging, and personnel transfers are overseen and checked by a trained officer. This officer also ensures that applicable PPE is donned throughout the process.

  • Two-person Verification – An industry best practice observed is that good managers implement two-person verification. This is a process where two trained individuals capable of detecting faulty equipment or improper rigging check pilot ladder arrangements prior to the transfer of personnel.

  • Stop Work Authority (SWA) – Safety conscious managers not only empower crew members of all ranks to stop work when the conditions are unsafe without retribution, they make it their responsibility and obligation.

  • Clearance under the combination ladder - It is important to allow a free space of more than 5 meters under the lower platform of the accommodation ladder, to let the pilot boat come alongside safely.

Where to find more information?

Further reference and guidance material:

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