Routine is risky. Over the previous two months the crew of the containership MSC Siena had rigged the pilot ladder 30 times. The 31st time, on 17 November 2011 off Fremantle, a man was lost. No risk assessment had been done to take account of the weather conditions says Australia’s Transport Safety Board, ATSB, report on the incident.
The account is harrowing: “At about 1123, as the bosun watched the OS, he saw a ‘large wave suddenly rise up’ and strike the underside of the bottom platform of the accommodation ladder with force (the rope lashing the ladder to the shipside lugs parted). A loud bang was heard on deck and the bosun then saw the OS hanging from his harness rope, under the accommodation ladder’s bottom platform. Seeing that the OS had fallen off the ladder, the bosun began yelling.
“On hearing the yells, the seaman and the cadet looked over the side and saw the OS suspended about 1 m below the bottom platform. He was shouting for help while trying to hold on to the lower part of the pilot ladder. His legs were often submerged in the rough seas which were pounding his body against the ship’s side, the platform and the pilot ladder, and repeatedly breaking his hold on the ladder.
“The bosun, helped by the other two men on deck, tried to pull the OS up by heaving on the harness rope. However, he was caught under the accommodation ladder’s bottom platform and they could not pull him up.
“Just after 1124, the bosun reported to the bridge on his hand-held radio that the OS had ‘fallen’ off the ladder. The third mate asked the bosun to repeat the message because he had not understood it. The bosun tried to explain the situation, telling the third mate that the OS was ‘hanging’. Still unsure about what had happened, the third mate went out onto the port bridge wing to have a look.
“The seaman on deck watched in shock as the OS, who appeared injured, went limp as he hung suspended by the harness rope, swinging fore and aft and side to side. Meanwhile, the cadet had run aft to the ship’s accommodation and telephoned the bridge.
“From the bridge wing, the third mate saw the OS hanging and ran back inside. He answered the telephone just after 1126, and the cadet told him that the OS had fallen off the ladder and asked him to turn the ship to port. The third mate said that he would call the master.
“At 1127, the third mate used the public address (PA) system to announce an ‘emergency’ and asked for the ‘master to come to the bridge immediately’. At the same time, the bosun, whose voice indicated panic and urgency, reported to the bridge that the OS had fallen into the sea. The bosun did not know at the time that the OS had come out of his harness. MSC Siena was about 3 miles west of Rottnest Island, in position 32º 00.85’S 115º 23.95’E.
“The bosun threw a lifebuoy toward the OS but it landed 5 m from him. The OS was submerged and making no attempt to swim as he drifted aft. To keep him in sight from the moving ship, the bosun and the seaman ran aft. When they were abreast of the accommodation, the cadet came out on deck and saw the submerged OS. He threw another lifebuoy into the water before losing sight of the OS”.
Says the report: MSC Siena’s usual freeboard meant that the crew always rigged a combination pilot ladder. The task was a normal part of port calls and the crew had carried out the task more than 30 times in the 2 months before the accident.
Rigging the combination pilot ladder involved the risk of working over the side on the accommodation ladder. Exposure to rough weather when rigging the combination ladder increased the risk and the difficulty of the task. The accommodation ladder’s bottom platform was normally about 3.5 m above the waterline (in calm seas) and the pilot ladder’s lower steps closer to the water. Therefore, the sea, swell and wind were important considerations when undertaking this work over the side.
From the early hours of 17 November, MSC Siena’s port side was fully exposed to gale force winds and 2 to 4 m waves. However, with regard to rigging the pilot ladder, no one on board the ship properly considered these weather conditions before the rigging task was started.
The chief mate felt that it was sufficient to advise the bosun of the expected pilot boarding time but not to discuss the actual rigging of the pilot ladder. Neither was the subject discussed at the change of watch between the chief and third mates. It was not until the master reminded the third mate to check the pilot ladder requirements that the side on which the ladder was required was
given any thought.
However, once the pilot ladder requirements were obtained, the precautions to safely rig the ladder by taking into account the weather and other risks were not considered. Other than passing on the ladder requirements, no communication took place between the crew on deck and the bridge. The bosun was not instructed when he should rig the ladder nor did he ask when it should be rigged. Neither was there any communication when the task was started.
The crew’s usual lunch time of 1200 may have been a factor in deciding when to rig the pilot ladder. Starting the task at 1100 meant that the ladder would be ready by about 1130, allowing the crew sufficient time to clean up, have lunch and then standby to receive the pilot at 1230.
The 016o (T) to 071o (T) course alteration, expected at 1135, would have reduced exposure to weather on the ship’s port side. However, no one considered the ship’s course, weather or an appropriate time/opportunity to rig the pilot ladder. Consequently, while various crew members knew the pilot ladder was required at 1230, there was little planning and preparation to ensure it
was rigged at the safest possible time.