The incident

The accident took place during a routine changeover of pilots at Gravesend Reach pilotboarding station on the River Thames. Due to the choppy seas, the outbound general cargo vessel had created a lee for the pilot launch to the boarding process easier. The difference in freeboard between the two vessels was varying between about 30cm and 130cm. A pilot ladder had been rigged, but the sea pilot attempted to board by stepping up and through an open gate in the railings onto 'Sunmi’s' main deck which, although adjacent to the ladder, did not form part of the vessel’s designated pilot boarding arrangements.


  1. The pilot had ingested sufficient alcohol on the day of the accident for his blood to contain 122mg alcohol per 100ml of blood approximately 2 hours after reporting for duty. It is likely that the sea pilot’s consumption of alcohol contributed to his fall.
  2. Low freeboard transfers introduced additional risks to standard pilot transfers. 
  3. The designated pilot boarding station on Sunmi was not marked and the deck gate should not have been opened in preparation for the transfer as it was unsuitable.
  4. Sunmi’s deck gate was not part of, nor was it suitable for use as, the designated pilot boarding station, and the crew should not have opened it in preparation for the transfer. 
  5. The chief officer might have ensured that the deck gate remained closed and that the bulwark ladder was rigged, had he overseen the preparation for pilot boarding.
  6. On the day of the accident, the sea pilot had ingested sufficient alcohol for his blood to contain 122mg alcohol per 100ml of blood approximately 2 hours after reporting for duty. 
  7. The PLA’s risk assessments for boarding and landing did not examine the specific hazards associated with low freeboard transfers.
  8. The International Maritime Pilots’ Association ‘Required Boarding Arrangements for Pilot’ poster did not include reference to the amendments to pilot transfer arrangements made in IMO Resolution A.1108(29), regarding deck gates.


  • The International Maritime Pilots’ Association has been recommended to promulgate the requirements for gateways in vessels’ rails or bulwarks intended for pilot boarding operations by updating its ‘Required Boarding Arrangements For Pilot’ poster to include the amendments in IMO Resolution A.1108(29).
  • A recommendation has also been made to Misje Rederi A.S. to ensure that the designated pilot boarding areas on Sunmi are marked and that pilot boarding operations are overseen by a responsible officer.

Further details can be found by reading the full report: