Picture Netherlands Loodswezen, Pilot Boat "Lacerta"
The transfer of pilots to and from seagoing vessels should not rely solely on mutual trust and good intentions. Instead, the pilotage system must establish consistent and clear work instructions for both the sailing service and registered pilots. This recommendation comes from the Dutch Safety Board (DSB) following their investigation into a fatal accident involving a pilot tender.
In the evening of Thursday 30 March 2023, a crew member of the Dutch pilot tender Lacerta was fatally injured off the coast of IJmuiden. The Lacerta was en route to the cargo vessel Wilson Monsoon, sailing under the flag of Barbados, to bring a registered pilot on board.
The crew member was to assist the pilot in embarking the cargo vessel. As the pilot tender came alongside the cargo vessel, the crew member of the pilot tender became trapped between the two vessels. The casualty sustained serious injuries, which resulted in his death later that evening.
Actual practice
In its report following the investigation of the accident, the DSB highlights the gap between theory and practice: While the safety compendium of the Pilotage Service outlines several methods for safely bringing a pilot tender alongside a vessel, these methods are not always applicable due to variations in ships and circumstances. Consequently, the pilot tender crews often rely on their knowledge and experience to develop alternative methods for common situations, allowing pilots to embark.
These methods, although generally known, are not formally documented in procedures or work instructions, creating a disconnect between the written procedures for pilots and the operating instructions for pilot tender crews, as observed by the DSB.
Moreover, the investigation revealed that several commonly used but undocumented procedures have evolved in practice. While these adaptations reflect the crew's experience, the specific risk in this situation was not recognized.
Shape and movement of the vessel
The Wilson Monsoon was a relatively small cargo ship with a low freeboard, which made it prone to rolling due to waves and its heading. The DSB notes that no specific method has been established for embarking pilots on ships without a pilot ladder because of their low freeboard.
Given that the weather conditions at the time of the incident were just below the threshold for storm procedures, there was an elevated risk of damage when approaching a ship with such a low freeboard.
Relying on their experience, the pilot tender crew opted for what they deemed the most suitable method, choosing to land behind the pilot boarding gate at the rising hull plates. However, the DSB points out that the potential risk posed by the swept-back stern of the Wilson Monsoon was not taken into account.
Location on board the tender
The deck hand used the side deck on the side of the tender facing the vessel (the inner side) to move forward. This is standard practice and not part of a preliminary discussion of the job. The crew was not aware of the risk of getting trapped while walking on the side facing the vessel.
Due to the wide gangway, this risk is small when the tender is positioned along the vertical hull plates of a vessel. However, warns the DSB, in this incident, the tender could end up under the vessel due to the shape of the stern. Under these circumstances, the choice of the timing of going on deck and the route inside or outside was crucial.
The transfer of pilots to and from seagoing vessels should not rely solely on mutual trust and good intentions. Instead, the pilotage system must establish consistent and clear work instructions for both the sailing service and registered pilots. This recommendation comes from the Dutch Safety Board (DSB) following their investigation into a fatal accident involving a pilot tender.
In the evening of Thursday 30 March 2023, a crew member of the Dutch pilot tender Lacerta was fatally injured off the coast of IJmuiden. The Lacerta was en route to the cargo vessel Wilson Monsoon, sailing under the flag of Barbados, to bring a registered pilot on board.
The crew member was to assist the pilot in embarking the cargo vessel. As the pilot tender came alongside the cargo vessel, the crew member of the pilot tender became trapped between the two vessels. The casualty sustained serious injuries, which resulted in his death later that evening.
Actual practice
In its report following the investigation of the accident, the DSB highlights the gap between theory and practice: While the safety compendium of the Pilotage Service outlines several methods for safely bringing a pilot tender alongside a vessel, these methods are not always applicable due to variations in ships and circumstances. Consequently, the pilot tender crews often rely on their knowledge and experience to develop alternative methods for common situations, allowing pilots to embark.
These methods, although generally known, are not formally documented in procedures or work instructions, creating a disconnect between the written procedures for pilots and the operating instructions for pilot tender crews, as observed by the DSB.
Moreover, the investigation revealed that several commonly used but undocumented procedures have evolved in practice. While these adaptations reflect the crew's experience, the specific risk in this situation was not recognized.
Shape and movement of the vessel
The Wilson Monsoon was a relatively small cargo ship with a low freeboard, which made it prone to rolling due to waves and its heading. The DSB notes that no specific method has been established for embarking pilots on ships without a pilot ladder because of their low freeboard.
Given that the weather conditions at the time of the incident were just below the threshold for storm procedures, there was an elevated risk of damage when approaching a ship with such a low freeboard.
Relying on their experience, the pilot tender crew opted for what they deemed the most suitable method, choosing to land behind the pilot boarding gate at the rising hull plates. However, the DSB points out that the potential risk posed by the swept-back stern of the Wilson Monsoon was not taken into account.
Location on board the tender
The deck hand used the side deck on the side of the tender facing the vessel (the inner side) to move forward. This is standard practice and not part of a preliminary discussion of the job. The crew was not aware of the risk of getting trapped while walking on the side facing the vessel.
Due to the wide gangway, this risk is small when the tender is positioned along the vertical hull plates of a vessel. However, warns the DSB, in this incident, the tender could end up under the vessel due to the shape of the stern. Under these circumstances, the choice of the timing of going on deck and the route inside or outside was crucial.
Download full report (PDF) from DSB here
Download full report (PDF) from DSB here
Communication and coordination
Finally, the DSB observed that the pilot tender crew was experienced and familiar with each other, leading them to rely heavily on each other's expertise. As a result, there was minimal discussion or communication, with everyone assuming that their intentions were mutually understood. This led to unspoken, automatic behaviors where unexpected dangers were not adequately considered in the routine work.
Recommendations of the DSB:
The DSB tells the Dutch Pilot Service to share experiences and best practices as these can help improve safety and reduce risks when transferring pilots to and from seagoing vessels.
The DSB wants unambiguous work instructions to be developed and implemented and to improve them regularly. DSB: ‘Establish equal and clear work instructions for the pilot tender crew and for the register pilots and keep them up to date. Make use of practical experiences, risk analyses and best practices. Ensure that the pilot tender crew and the pilots regularly discuss and practice the work instructions with each other.’
The Safety Board also advises to continue to communicate with each other on board and name the risks. ‘Due to the wide variety of situations and ship shapes, it is important for the tender crew to identify risks and keep communicating about them. Incorporate the insights gained into the work instructions afterwards,’ states the DSB.
Finally, the DSB observed that the pilot tender crew was experienced and familiar with each other, leading them to rely heavily on each other's expertise. As a result, there was minimal discussion or communication, with everyone assuming that their intentions were mutually understood. This led to unspoken, automatic behaviors where unexpected dangers were not adequately considered in the routine work.
Recommendations of the DSB:
The DSB tells the Dutch Pilot Service to share experiences and best practices as these can help improve safety and reduce risks when transferring pilots to and from seagoing vessels.
The DSB wants unambiguous work instructions to be developed and implemented and to improve them regularly. DSB: ‘Establish equal and clear work instructions for the pilot tender crew and for the register pilots and keep them up to date. Make use of practical experiences, risk analyses and best practices. Ensure that the pilot tender crew and the pilots regularly discuss and practice the work instructions with each other.’
The Safety Board also advises to continue to communicate with each other on board and name the risks. ‘Due to the wide variety of situations and ship shapes, it is important for the tender crew to identify risks and keep communicating about them. Incorporate the insights gained into the work instructions afterwards,’ states the DSB.
