Three lessons emerge from the report from the Danish Maritime Authority, DMA, into an incident in which a pilot fell overboard because his backpack caught in boarding arrangements and was saved from hypothermia by the timely actions of the pilot boat crew: backpacks may not be a good idea, thermal protection isn’t much use if you leave your pants off and ‘procedure creep’ can create hazardous situations.
The pilot used a self-inflating lifejacket. Apparently the lifejacket did not inflate automatically. It was possible to inflate the lifejacket manually by pulling the release-cord. It has not been ascertained whether the reason for the lifejacket not self-inflating was because of the pilot pulling the release-cord before the lifejacket could register being in the water, or if the missing automatic release was caused by other factors.
One result of the investigation is that only the online version of the DANPILOT handbook, the Fartøjshåndbogen, is to be regarded as authoritative.
During embarkation of two pilots on to the bulkcarrier Deep Sea from the pilot-vessel Skawpilot I on 26 November 2009, the backpack of the second embarking Pilot was caught between the steps of the pilot-launch’s embarkation arrangement, while the pilot was climbing the Deep Sea pilot-ladder. The pilot was torn off the pilot-ladder and into the sea between the bulk-carrier and the pilot-launch.
Thanks to a quick response from the two-man crew of the pilot-launch, the pilot was picked up by the pilot-launch after approximately five minutes, using the pilot-launch’s ”Man-over-board”-equipment.
The pilot was conscious during the hole sequence of events. Apart from the effects of the cold, he was uninjured.
· The Pilot was torn off the pilot-ladder due to his backpack, which was carried on the Pilot’s back, being caught by the steps of the pilot-launch’s embarkation arrangement.
· The fact that the pilot was using only a thermal protection jacket, but did not use his thermal protection trousers, meant that the equipment used would not have ensured the Pilot’s survival for an hour as prescribed. The use of both thermal protection jacket and thermal protection trousers would have reduced the risk of hypothermia severely, thereby extending the time available to rescue the Pilot.
· It is the opinion of the investigation division, that the position and design of the pilot-launch’s embarkation arrangement was the cause of the pilot’s backpack being caught between the steps, thereby tearing the pilot off the pilot-ladder.
It is the opinion of the investigation division, that the lack of maintenance and updates to the Fartøjshåndbogen – the main guidance publication regarding procedures and so on within DANPILOT through a long period, has caused local and private practices being used instead of the prescribed procedures in the Fartøjshåndbogen.
Says the DMA report: “In connection with the consultation procedure, DANPILOT has informed that the following preventive measures has been established as a consequence of the incident:
· It has been announced in the organisation, that the carrying of backpacks etc. on the back is not allowed during embarkation or disembarkation of vessels.
· A committee that will find and recommend live saving equipment and thermal protection gear to the safety organisation has been established.
· A list of new life saving equipment already approved by the safety organisation has been prepared and released. A new thermal protection jacket with an integrated life saving vest as been introduced.
· A new introductional video regarding the risks of using backpacks etc. has been prepared and introduced in the organisation.
· It has been clarified within the organisation, that only the on-line version of the ’Fartøjshåndbogen’ is updated and therefore the only valid version.”