THE AUSTRALIAN Transport Safety Bureau has issued a report on a troubling incident that resulted in a serious injury to a TasPorts pilot launch deckhand off Devonport earlier this year.
At 0800 local time on 25 May 2025 the pilot launch, with two crewmembers and two marine pilots (one a trainee) was engaged in a transfer to an inbound tanker at the pilot boarding ground. Conditions at the time involved winds of 10 to 15 knots and a swell of 1.5 to 2 metres, both from the northwest.
Image: TasPorts, annotated by the ATSB
As the launch approached the lee side of the ship, those on board assessed the conditions and agreed to proceed with the transfer. Once alongside, starboard side to the ship, the deckhand and both pilots left the launch wheelhouse and moved to the foredeck. Conditions in the lee of the ship were rougher than had been experienced during the recent months, and they waited for the launch’s motion to become more favourable. All three were tethered to the launch safety rail with individual lanyards.
After informing the pilot in charge, the deckhand, in accordance with company pilot transfer procedures, went forward to inspect the ship’s pilot ladder. The deckhand noted that the ladder was new and then took hold of it with both hands and stepped onto it to check if it was securely rigged. While the deckhand was on the ladder, the launch fell away into the trough of a passing wave. The deckhand was pulled by the lanyard, off the pilot ladder and onto the foredeck of the launch, resulting in serious injuries.
The two pilots (who had not seen the approaching wave) quickly rendered assistance to the deckhand and the launch urgently returned to port for medical assistance, with the deckhand transferred to hospital.
The ATSB says TasPorts completed an internal investigation which found, among other things, that there were no swell parameters for Devonport pilot boarding ground transfers. Wind conditions, for which parameters existed, were well within limits during this transfer. The statements of those involved indicated that the conditions in the ship’s lee had not been experienced for several months but were not sufficiently adverse to not proceed with the transfer. However, as the motion of the launch subsided and the deckhand went forward to test the ladder, the pilots did not note the approaching wave trough and were unable to warn the deckhand.
As part of the internal investigation, a DMAIC (define, measure, analyse, improve, control) process was completed. The process identified several areas for improvement, including:
Following the investigation, the pilotage provider released a memorandum which outlined mandatory interim safety controls to be implemented across all pilot transfer operations. The new safety controls required that, prior to commencing the transfer, the launch master was to contact the ship and confirm that the pilot ladder had been rigged as per SOLAS requirements and that the arrangement had been tested.
Further, any manual test by the launch crew was to be conducted using arms only while ensuring the tester’s body remained fully on the pilot launch’s deck.
A review of the safety lanyards in use has led to the implementation of a shorter lanyard which prevents the crewmember from shifting their weight fully onto the pilot ladder (external of the pilot launch). The memo also emphasised that the transfer was to be stopped should any doubt arise.
The ATSB did not launch a formal investigation into the incident but notes pilot transfer operations continue to be a high risk operation.
“This occurrence highlights that the risks also include preparations for the transfer involving other crew members along with the marine pilots. All persons involved in pilot transfer and transport need to be aware of risks involved in this operation. All should pay particular attention to the sea and to the motion it imparts to the pilot launch and the subsequent effects on the actions being undertaken at the time. The pilot launch is a small vessel alongside a much larger and more stable vessel. Transferring from the deck of the launch to the pilot ladder attached to the ship exposes personnel to the risks posed by the relative motion between the two vessels, especially if they remain attached to the launch,” the Bureau said.