SAFE T Y


Briefings


Fatal pilot ladder accident has enduring lessons is report finding Managers of the two vessels involved in a fatal crew transfer accident


off Brisbane, Australia, had not ensured personnel had a common and complete understanding of how the transfer would be conducted, an Australian Transport Safety Bureau (ATSB) investigation has concluded.


On 9 August 2021, crew were being transferred to and from the bulk carrier Formosabulk Clement via the launch boat PT Transporter in the Port of Brisbane anchorage, about five nautical miles off the coast. The operation involved multiple visits from PT Transporter to transfer crew on and off the anchored bulk carrier. While the vessels were separated during a break from transfers before the accident, the bulk carrier turned about its anchor, exposing the transfer area to prevailing weather.


Safety warning issued by MAIB after serious injury during a rigid inflatable boat ride


On 7 June 2023, a passenger on a sea safari rigid inflatable boat (RIB) suffered a spinal injury that left them paralysed from the waist downwards. Twelve passengers had boarded the RIB and, once it was clear of the jetty, the two crew gave them a safety briefing and instruction on the wearing of lifejackets. The RIB then proceeded out to sea and was increasing speed in choppy sea conditions when it encountered a steep-sided wave. The boat fell off the wave and slammed violently into the trough, dislodging the passenger from a seat at the forward end of the boat.


Safety issues


– there is a significantly higher risk of spinal fractures to people seated in the front area of RIBs, regardless of speed;


– seated individuals may have little or no understanding of boat movement or how to mitigate its effects.


Safety lessons


Owners and operators of small commercial passenger vessels are strongly advised to: – urgently review operations and risk assessments, referencing the guidance linked below to mitigate risks outlined in the safety bulletin;


– review passenger pre-departure briefings and bring into line with current guidance.


A full investigation report into the accident will be published by the MAIB in due course.


Download the safety bulletin at https://bit.ly/48zZwYX. Or scan the QR code.


Download the report at https://bit.ly/46utZpz.


Language difficulties between the crews meant the bulk carrier’s main engine was not used to correct this issue, prior to the launch coming back alongside. As PT Transporter approached, a crewmember of the bulk carrier climbed down the vertical pilot ladder without the knowledge of the ship’s master, or the skipper of the launch.


A wave, larger than previously encountered, then lifted the PT Transporter higher than expected, sufficient for the smaller vessel to make contact with the crewmember, knocking them into the water. While the crewmember was quickly recovered from the water, they had sustained fatal injuries.


“This was a tragic accident, involving a seafarer who had been at sea for more than 400 days due to global border restrictions during the COVID-19 pandemic,” ATSB Chief Commissioner Angus Mitchell said.


Mitchell said the investigation highlights clear safety lessons for all operators conducting crew transfers like this one, as there was no common or complete understanding amongst the personnel on board either vessel in terms of how the transfer would be conducted.


Since the accident, the operator of the launch has updated crew transfer arrangements and procedures, with a traffic light system for operational assessment and control. The system is designed to be less constrained by language, and amenable to being shared beforehand to assist in achieving the shared mental model of the task among all participants.


The operator of the bulk carrier has also completed investigations and held multiple safety meetings and training exercises to share details of, and lessons learned from, the accident.


THE REPORT | DEC 2023 | ISSUE 106 | 23


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