ATSB releases Gladstone gangway collapse brief

THE AUSTRALIAN Transport Safety Bureau (ATSB) has released an occurrence brief detailing a gangway railing collapse during a pilot boarding about 18km east of Gladstone.

The incident occurred at 1920 on 4 March, when a cargo ship arrived at the pilot boarding ground for the port of Gladstone to board a harbour pilot.

The ATSB said the harbour pilot had travelled to the boarding ground by boat and was planning use the pilot ladder to board the ship. The ship’s crew rigged the pilot ladder in combination with the gangway on the starboard side following shipboard procedures.

“The gangway has an inboard and outboard railing. During the rigging process for pilot embarkation, the gangway is lowered, and the railing latched securely,” the ATSB said in the brief.

“However, on this occasion the tongue piece on the safety latch on the outboard railing was not rotated to lock the tongue at the required 90° angle, resulting in the securing pin not being correctly inserted.

“As the ship rolled and vibrated, the securing pin gradually worked its way loose. This movement eventually caused the pin to completely dislodge from its position, compromising the stability of the outboard railing.”

The ATSB described that the pilot began boarding the ship at 1925 local time, and when they grasped the handrail while transitioning from the pilot ladder to the gangway, the gangway railing on outboard side partially collapsed when the locking pin dislodged.

The bureau confirmed the pilot was not injured in the incident.

Following the occurrence, the ship’s manager reportedly advised that the following safety actions had been taken:

• Crew members have received extra training to ensure they fully understand the importance of properly engaging the securing pin's safety latch, with a focus on the correct procedure for rotating the tongue to the required angle to engage the locking mechanism.
• Additionally, a comprehensive review of the combination ladder securing arrangements has been started, including verification procedures for securing pins and further crew training on proper locking mechanisms
• The ship's maintenance schedule now includes more frequent and thorough inspections of all securing mechanisms, including the securing pins of the pilot ladder and gangway. These inspections aim to identify and fix any potential issues before they lead to incidents
• A new protocol has been implemented requiring a double-check of all securing mechanisms before use. This protocol mandated that two crew members independently verified that the securing pins were properly locked and secure, and
• The ATSB said the lessons from this incident have been shared with all ships managed by the ship manager, including training on how to correctly insert the securing pin in the locked position

The bureau said the occurrence highlights the importance of properly securing pilot transfer arrangements, particularly ensuring that all locking mechanisms, including securing pins, are fully engaged.

“Ship operators, masters, and crew should perform thorough pre-use checks to verify the correct engagement of safety mechanisms before personnel transfers,” it said.

ATSB recommended compliance with SOLAS Chapter V, Regulation 23 and ISO 799-1 standards to assist in preventing similar failures in the future.