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.