The incident
On 30 December 2018, the Republic of the Marshall Islands-registered oil/chemical tanker Mount Olympus, managed by Systemar Ltd was departing the port of Tuapse, Russia to proceed to sea.
At 0418, a Pilot from the tugboat KAPITAN AVDYUKOV boarded MOUNT OLYMPUS from the jetty on the starboard side.
At about 5.00, the weather conditions recorded were wind Beaufort Force 6 from the southwest.
The tugboat KAPITAN AVDYUKOV approached the ship, and the Pilot began descending the ladder.
According to the local authority’s investigation report, the pilot ladder was well lit by searchlights from both the ship and the tugboat.
At approximately 0510, the Master was standing on the portside bridge wing monitoring the Pilot’s disembarkation. At that time, a large wave forced the tugboat away from MOUNT OLYMPUS’ side.
The Pilot lost his balance and fell into the water. The 4/O immediately shouted that the Pilot had fallen into the water.
An OS immediately threw a lifebuoy with light into the water and the Master ordered the main engine to be stopped and initiated a rudder maneuver to swing the MOUNT OLYMPUS’ stern away from where the Pilot had fallen.
The Master also told the port authority of the incident via VHF radio. The Master instructed all available crew members to look out for the Pilot, using the ship’s searchlights. The tugboat turned to try to locate the Pilot.
According to the local investigation report, approximately one to two minutes after the Pilot fell, the deck officer of the tugboat heard calls for help from the Pilot on VHF channel 69 saying “Help, I’m drowning.”
The Pilot was recovered from the water by the tugboat crew after a short time but was later declared deceased. The port authorities instructed the ship to wait in a local anchorage. Later the same day, MOUNT OLYMPUS was cleared to sail.
When the Pilot was lifted out of the water, the life jacket he was wearing was not inflated.
Probable causes
The Administrator’s marine safety investigation determined that the causal factors for the Pilot’s occupational fatality resulted from an accidental fall into the sea. This occurred while he attempted to transfer from MOUNT OLYMPUS’ pilot ladder onto the tugboat’s boarding platform in the dark during poor and deteriorating weather conditions.
According to the forensic report, the Pilot’s death “occurred as a result of drowning in water.” The RMI investigation determined the causal factors that may have contributed to the fatality included:
- improper assessment of risk and decision making by the Pilot and Master by not fully accounting for the deteriorating weather conditions;
- improper delegation by the Master to the Pilot of the decision-making process;
- failure by the Pilot to fully take into consideration the Master’s concerns and recommendations regarding the sea conditions and pilot ladder position;
- poor and deteriorating weather conditions causing random and unpredictable motions of the tugboat; and
- failure of the Pilot’s self-inflating life jacket to properly inflate on entering the water.
The causal factors that may have contributed to the incident include:
- darkness and poor or restricted visibility near the Pilot’s transfer position; and
- failure to wait until the weather and lighting conditions had improved sufficiently to permit safe transfer to the tugboat.
Actions taken
The Company conducted an internal safety meeting to review the circumstances leading up to the incident in order to determine what might have been done to prevent it and what Preventive Actions could be put in place in the future. Based on this review, the company:
- shared details of the incident throughout its managed fleet; and
- Masters were instructed to verbally remind Pilots in the region about the incident with the intent that prevailing conditions be given more careful consideration.
The Federal Transport Inspection Service of the Directorate for State of Maritime and River Supervision in the Russian Federation conducted their own investigation into the incident and have put in place their own Preventive Actions to include:
- ensuring that pilot boarding arrangements onto pilot boats and tugboats are fully compliant with SOLAS Chapter V, Regulation 23.4.2, and paragraph 5.2 of IMO Resolution A.1045(27);
- not permitting Pilots to use inflatable life jackets without annual inspection and maintenance being carried out at certified service stations;
- checking the status of inflatable life jackets being used by Pilots;
- conducting unscheduled training for Pilots of the Pilot Service on observing safety requirements; and
- circulating to other Pilots the circumstances surrounding this incident.
Recommendations
Following the investigation, the company utilizes this incident as a factual case study in future Bridge Team Management courses and senior crew seminars. It is further recommended that emphasis be given to:
- reinforcing the Master’s overriding authority and responsibility to make decisions with respect to safety;
- the Company’s expectations regarding how Masters should exercise their overriding authority and responsibility during pilotage operations; and
- the Company’s expectations regarding how other members of the Bridge Team should best support the Master and Pilot.
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