MV WILSON LEITH

MV Wilson Leith 201305/024 1

Marine Safety Investigation Unit

SAFETY INVESTIGATION REPORT

201305/024 REPORT NO.: 15/2014 May 2014

MV WILSON LEITH Pilot ladder failure resulting in

an injury to the pilot

in position 53° 32’N 000° 13’E

31 May 2013

SUMMARY

At 2230(UTC) on 31 May 2013,

Wilson Leith arrived off Spurn

Point, UK. A pilot boat came

alongside to pick up the pilot.

Soon after the pilot stepped on

the pilot ladder, the side ropes

parted. The pilot fell on the pilot

boat, injuring his right foot and

ankle.

Stereomicroscopy of rope

filaments sampled from near the

failed ends showed signs of

abrasion damage.

The MSIU has made two

recommendations to the ship

manager. Moreover, a

recommendation has been

made to the manufacturer of

the pilot ladder, with the scope

of preventing similar accidents

in the future.

The Merchant Shipping (Accident and Incident Safety Investigation) Regulations, 2011 prescribe that the sole objective of marine safety investigations carried out in accordance with the regulations, including analysis, conclusions, and recommendations, which either result from them or are part of the process thereof, shall be the prevention of future marine accidents and incidents through the ascertainment of causes, contributing factors and circumstances.

Moreover, it is not the purpose of marine safety investigations carried out in accordance with these regulations to apportion blame or determine civil and criminal liabilities. NOTE

This report is not written with litigation in mind and pursuant to Regulation 13(7) of the Merchant Shipping (Accident and Incident Safety Investigation) Regulations, 2011, shall be inadmissible in any judicial proceedings whose purpose or one of whose purposes is to attribute or apportion liability or blame, unless, under prescribed conditions, a Court determines otherwise.

The report may therefore be misleading if used for purposes other than the promulgation of safety lessons.

© Copyright TM, 2014.

This document/publication (excluding the logos) may be re-used free of charge in any format or medium for education purposes. It may be only re-used accurately and not in a misleading context. The material must be acknowledged as TM copyright. The document/publication shall be cited and properly referenced. Where the MSIU would have identified any third party copyright, permission must be obtained from the copyright holders concerned.

MV Wilson Leith


FACTUAL INFORMATION

Vessel

Wilson Leith, a 2446gt general cargo vessel

was built in 1997 and is registered in Malta.

She is owned by Wilson Shipowning AS,

managed by Wilson Ship Management AS,

Bergen and is classed with Bureau Veritas.

The vessel’s overall length is 87.90 m and

has a moulded depth of 7.10 m. Wilson Leith

has a summer draught of 5.51 m and summer

deadweight of 3698 tonnes.

Propulsive power is provided by an

8-cylinder MWM SBV8M628, four stroke

medium speed diesel engine, producing

1500 kW at 900 rpm. This drives a fixed

pitch propeller through a reduction gearbox.

The vessel has a service speed of about

10.5 knots.

On Wilson Leith, the pilot ladder was rigged

about midship on the main deck for the

transfer of pilot. At this section, a rounded

insert plate was fitted over the sheer strake to

prevent cutting through the pilot ladder’s side

ropes. Two shackles secured the sides of the

pilot ladder to the pad-eye, fitted close to the

sheer strake.

Manning

Wilson Leith’s Minimum Safe Manning

Certificate required a crew of 9. However, as

a special condition, the second engineer may

be omitted if the vessel held UMS

documentary evidence issued by the vessel’s

Classification Society. This was applicable

for Wilson Leith and therefore, there were

eight crew members on board at the time of

the accident.

All the crew members were Russian

nationals and held the necessary certificates

and endorsements to serve on board.

The pilot

The pilot assigned to Wilson Leith was 38

years old at the time of the accident. He was

a fully qualified and licensed maritime pilot,

authorised for the entire Humber area (First

Class), for vessels of up to 40000 DWT and

11.0 m in draft. The pilot had joined the

Associated British Pilots – Humber Estuary

Services in January 2002 as a trainee pilot

and was eventually authorised (First Class) in

July 2010.

Environment

The wind was Northeast, force 3, and slight

seas with a 1.0 m to 2.0 m Northeasterly

swell. Visibility was good.

Narrative

On 31 May 2013, Wilson Leith departed

Immingham Docks with a pilot on board.

She was in ballast drawing about 3.0 m,

having previously carried salt, stone, coal,

and pet coke in bulk.

At 2230, Wilson Leith arrived at Buoy Alpha

off Spurn Point, a designated pilot

disembarkation area. The pilot ladder was

rigged on the starboard side main deck

(Figure 1), in accordance with the Humber

VTS instructions.

Figure 1: Pilot ladder on starboard side main deck

The pilot ladder was passed over the widened

section of the sheer strake and secured to the

deck fitting (Figure 2).


Figure 2: Sheer strake and pilot ladder securing

arrangement on deck

The lowest step was one metre above the

water1. The master, who was also the OOW,

supervised the rigging of the pilot ladder.

Although it was dark, the deck and the pilot

ladder over the ship’s side were well lit.

The master, the pilot, and the pilot boat’s

coxswain agreed that a course of 090° and a

speed of six knots would be satisfactory to

disembark the pilot. After confirming with

the master that the pilot ladder was properly

rigged, the pilot left the bridge.

An AB escorted him while the master

monitored the pilot’s disembarkation from

the bridge. Before disembarking, the pilot

visually examined the pilot ladder. Though

dirty, he found its condition satisfactory and

well secured2.

Wilson Leith slowed down to 6 knots as pilot

boat Saturn (Figure 3) manoeuvred towards

the pilot ladder.

1 Evidence indicated that the height of the lower step

was discussed on board, since the master had

initially suggested that the lowest step should be

1.5 m above the water. However, following

confirmation from Humber VTS, the pilot assured

the master that it was normal practice in Humber

to rig the pilot ladder with the lowest step 1.0 m

above the water. The pilot ladder was eventually

rigged at this height.

2 In a statement released on 10 March 2014, the AB

claimed to have tested the pilot ladder in the

presence of the pilot by jumping on the first step of

the pilot ladder over the ship’s side.

Figure 3: Pilot boat Saturn

At the same time, the master altered course to

starboard to shelter the pilot boat from the

swell. At 2232, the pilot boat was alongside

and the pilot stepped on the pilot ladder. As

soon as he transferred his hands from the

ship’s rails, the side ropes resting on the

sheer strake broke.

The pilot fell on the pilot boat’s deck, a

height of about two metres. The broken

section of the pilot ladder fell on him but was

later carried away by the sea. As a result of

the fall, the pilot injured his right foot and

ankle, which had taken the weight of the fall.

The coxswain and the pilot boat’s deck hand

administered first aid and headed for

Grimsby to transfer the injured pilot to the

hospital. At 2240, Wilson Leith called

Humber VTS and reported the accident.

Injuries sustained by the pilot

A medical examination and X-rays at the

hospital diagnosed a severely sprained ankle.

Due to severe swelling and pain in the ankle

region, a hairline fracture was not ruled out.

The pilot was advised additional X-rays and

medical treatment at Hull Royal Infirmary.


Survey and certification of the pilot ladder Wilson Leith had one pilot ladder on board,

manufactured by PTR Holland B.V. The

pilot ladder carried an EC Type Examination

Certificate as per Council Directive 96/98/EC

on marine equipment. The Certificate was

issued by Bureau Veritas on 31 July 2009,

with an expiry date of 31 July 2014

(Figure 4).

Figure 4: EC Type Examination Certificate

The certificate attested that the pilot ladder

met the requirements of SOLAS regulation

V/23 and X/3, IMO Resolution A.889(21),

MSC/Circ.528/Rev.1 and ISO 799:2004. A

permanent identification tag marked the pilot

ladder (Figure 5).


Figure 5: Pilot ladder identification tag

The pilot ladder was supplied in October

2009 and brought into service the following

month. The ladder came with the

manufacturer’s warning label on operational

use and maintenance on board (Figure 6).

The master stated that when not in use, the

pilot ladder was covered and stowed on a

wooden grating on the poop deck.

On 12 May 2013, the pilot ladder was

inspected by a Bureau Veritas (BV) surveyor

in accordance with SOLAS regulation

V/23.2.3. The results of the inspection were

satisfactory.

Figure 6: Warning label supplied by the manufacturer


ANALYSIS

Aim

The purpose of a marine safety investigation

is to determine the circumstances and safety

factors of the accident as a basis for making

recommendations, and to prevent further

marine casualties or incidents from occurring

in the future.

Cooperation

During the course of this safety investigation,

the MSIU received all the necessary

assistance and cooperation from the UK’s

Marine Safety Investigation Branch (MAIB).

Destructive and non-destructive testing

The section of the pilot ladder, which

remained on board Wilson Leith (Figure 7)

was couriered to Malta and sent to an

engineering laboratory for analysis.

The pilot ladder was visually inspected and

the failed ropes thoroughly examined using

optical stereomicroscopy, electron

microscopy scanning and tensile testing for

the residual strength of the rope.

Figure 7: Pilot ladder – made of natural fibre and

wood3

3 The rope lengths at the top left of the pilot ladder

were cut for tensile testing purposes.

Visual examination showed that the entire

rope length had signs of fraying and

weathering (Figure 8).

Figure 8: Photograph of rope material showing

damage representative of almost the entire rope

length

Moreover, the 3-strand hawser laid rope had

sustained failure of all four side ropes (two

on each side) just below the aluminium

fastening clamp (Figures 9(a) and (b))

holding the rope together under each step.

Figures 9a & 9b: Pilot ladder rope sides and

aluminium fastening clamp

[a]

[b]


It was also determined that the bent shape of

the rope between the steps was the result of

the method used on board to secure the pilot

ladder (Figure 10(a)) to the deck. This

securing arrangement created a bend and

possibly forced the ropes to slide and wear

over the shear strake (Figure 10(b)). The

ends of the side ropes terminated with a

splice to a single piece rope on each side

(2 m in length) and taped to avoid fraying.

Figures 10a & 10b: Securing method over the

shear strake

A closer examination of the failed ends of the

ropes showed the fibre strands fragmented

into short segments and could easily be

pulled out. The low-magnification

stereomicroscopy of rope filaments sampled

from near the failed ends (Figures 11(a) to

11(d) showed the individual filaments either

broken or had a furry finish. Both are

common signs of abrasion damage.

Figure 11: (a) Photograph of three rope samples;

(b) Stereomicrograph of natural fibres from the

failed end of the rope, (c) Stereomicrograph of

entire strand pulled from the end of a side rope

and (d) Stereomicrograph of ‘healthy’ portion cut

from a protected portion of a rope

For instance, whilst Figure 11(b) shows that

the failed ends of individual fibres appeared

abraded, Figure 11(c) shows that the fibres in

the vicinity of the failure region, which were

not yet severed, exhibited signs of wearing

and breaking.

The morphological characteristics of the

fibres under high-magnification are shown in

Figure 12. The damage sustained by the

fibres did not only involve cutting and

unfolding of the micro strands but also

appeared to deteriorate first into short

sections and then progressively break down

at the micro scale (Figure 12(a) and 12(b)).

The fibres which were protected from

abrasion and external elements (Figure 12(c)

and 12(d)) were intact with no signs of wear

and cracking when observed at a high

magnification of 1000.

Tensile testing

Three sections of rope approximately 60 cm

in length were tested using a tensile testing

machine, as shown in Figure 13. The three

sections were taken from the service ropes at

the end of the pilot ladder.

Sheer strake Clamping fixtures


Figure 12: SEM micrographs of (a, b) damaged

and (c, d) undamaged rope fibres

Figure 13: Tensile test of rope specimen no. 1 at a

loading rate of 10 mmmin-1


Since slippage occurred at the clamping jaws

before the specimen could fail, the residual

breaking strength of the rope (comparable to

BS ISO 799:2004) could not be determined.

However, the test results reliably established

that each side rope was able to support a

minimum load of 3.1 kN, equivalent to

316 kg (Figure 13) without signs of failure.

Figure 13: Representative Load-Extension plots for

rope specimen no. 1

Disembarkation of the pilot

As already explained, Wilson Leith had

rigged the pilot ladder at a height requested

by Humber VTS, although the master pointed

out to the pilot that 1.5 m was a better

alternative. However, following a discussion

with the pilot, no changes were made to the

pilot ladder’s rigging. The pilot boat’s

coxswain reported that the last step was in

level with the pilot boat’s deck.

Wilson Leith had reduced speed to 6 knots

and the pilot, escorted by an AB, left the

bridge. The master watched what he

described as the pilot boat’s unsteady

approach. Without advising the pilot or the

pilot boat’s coxswain, he altered course to

starboard for a heading of 120° to provide the

pilot boat a good lee.

The intended action, however, exposed the

vessel’s broadside to the swell. Wilson Leith

was in ballast and therefore easily susceptible

to rolling. The pilot boat, alongside under

the pilot ladder, waited for the pilot to

disembark. The master stated that as soon as

the pilot commenced his descent, the pilot

boat pressed against the pilot ladder and tore

off the ropes at the sheer strake. On this

point, however, neither the pilot nor the pilot

boat’s crew provided compelling evidence as

to whether or not the pilot boat made contact

with the pilot ladder.

Thus, whilst it was not possible to positively

determine that the pilot boat made contact

with the pilot ladder, in view of the dynamic

situation at the time of the accident off Spurn

Point and there being no other clear

evidence, the MSIU was unable to exclude

the possibility of Wilson Leith rolling away,

the pilot ladder momentarily striking the pilot

boat and the shock load instantly snapping

the four side ropes.

Environmental effect on the pilot ladder

Natural fibre ropes (such as manila) used in

the construction of the pilot ladder are

susceptible to degradation by dry rot,

mildew, oil, salt, and exposure to wet and dry

cycles. The ingress of abrasive material and

chemical reaction from cargoes that Wilson

Leith carried could have further degraded the

natural fibres.

Exposure to sunlight cause actinic UV

degradation which weaken and fray natural

fibres similar to the one shown in Figure 2.

Although the MSIU was informed that the

pilot ladder was stowed away when not in

use, it is likely that it had weakened over

time, particularly those sections of the rope

fibres that were exposed and stressed over

the sheer strake.

Residual strength of the failed ropes

The tensile testing machine in the

engineering laboratory could only establish

3.1 kN load (before slippage occurred) on a

pilot ladder that had previously supported the

pilot’s embarkation on arrival at Humber,

although pilot’s physiology and the pilot


ladder’s rigging geometry may have been

different.

Thus, the result suggested that the four side

ropes should have been able to support the

pilot’s weight. However, taking into account

the general condition (fraying, abrasion and

wear) the four side ropes may have further

deteriorated by sliding and rubbing under

load over the sheer strake, the precise value

of which could not be obtained in the

engineering laboratory test.

SOLAS Regulation V/23 and Resolution

MSC 308(88) and the UK Maritime Pilot

Association’s Code of Practice

IMO Convention for Safety of Life at Sea

(SOLAS Chapter V, regulation 23) sets out

the requirements of pilot ladders and

Resolution MSC 308(88) makes their

inspection mandatory. The amendments

came into force on 01 July 2012.

The pilot ladder on Wilson Leith carried an

EC Type Examination Certificate valid for

five years, attesting compliance with Council

Directive 96/98/EC of 20 December 1996 as

amended, SOLAS regulation V/23 and X/3,

IMO Resolution A.889(21),

MSC/Circ.528/Rev. 1 and ISO 799:2004.

The pilot ladder was type tested and

witnessed by a Classification Society

surveyor.

Six months prior to the accident, no defects

were reported. On 12 May 2013, a surveyor

from BV carried out an annual Statutory

Safety Equipment survey. Accordingly, the

pilot ladder was inspected as required by

SOLAS regulation V/23.2.3. This included

checking the specification and maintenance

records, dates when it was brought into

service, visual examination, and repairs

carried out, if any. The surveyor found the

pilot ladder fit for the embarkation /

disembarkation of pilots.

The UK Maritime Pilot Association’s Code

of Practice directs pilots to visually inspect

the pilot ladder. On 31 May 2013, before

disembarking the pilot inspected the pilot

ladder and found it in satisfactory condition.

The accident on Wilson Leith clearly

demonstrated the difficulties to determine the

physical condition solely by visual

examination and to accurately assess the

effect on rope fibres caused by abrasion, cuts

or excessive wear. Equally, it is difficult to

determine the derogation in tensile strength

or the point at which the pilot ladder

becomes unsafe.

During the course of the safety investigation,

PTR Holland, the ladder’s manufacturers,

emphasised compliance with the

requirements listed in EC Type Examination

Certificate issued to Wilson Leith, including a

load test every 30 months from the date of

the pilot ladder manufacture. However, the

MSIU noted that this important requirement

had been omitted from the manufacturer’s

warning label / operational instructions

(Figure 6) issued to the vessel.

CONCLUSIONS

1. Visual examinations and a mandatory

Statutory survey found the pilot

ladder satisfactory and fit for pilot

transfer;

2. Laboratory tests indicated a general

poor condition of the pilot ladder.

The failed side ropes had evidence of

fraying, abrasion and excessive wear;

3. The pilot ladder manifested

characteristics of sea and spray

exposures, wet and dry cycles,

possible cargo residues and exposure

to UV radiation;

4. The anchoring of the pilot ladder

close to the ship’s side led to abrasion

and progressive weakening of the


rope fibres resting over the sheer

strake;

5. The pilot ladder was not made fast

using the side ropes;

6. The laboratory tensile tests

established 3.1 kN load (before

slippage) on each service rope;

7. Examination by the engineering

laboratory established that the

permanent bend of the side ropes

between the steps had weakened over

time; the precise value of which could

not be ascertained during the

laboratory tests.

8. The possibility of a vessel rolling

away and the pilot ladder

momentarily striking the pilot boat

was not ruled out;

9. Production tests approved the pilot

ladder as conforming to

ISO 799:2004 Standard. No

subsequent load tests were done as

required by section 9.3 of the

Standard;

10. Wilson Leith did not have a

responsible officer in attendance

during the disembarkation of the

pilot;

11. The pilot and the pilot boat’s

coxswain were unaware of the course

deviation made by the master, which

exposed the vessel’s broadside to the

swell.

SAFETY ACTIONS TAKEN DURING

THE COURSE OF THE SAFETY

INVESTIGATION4

Since the accident happened,

Wilson Leith’s managers have implemented

the following safety actions:

Updated the safety management

system manual and checklists with

respect to the use of pilot ladders;

A renewal schedule of pilot ladders

has been introduced, requiring pilot

ladders to be replaced every three

years. This change has been

implemented through the Company’s

Planned Maintenance Programme.

Association British Ports HES, as the

Harbour Authority, now requires that all

vessels to verbally confirm that the pilot

ladder is properly constructed and recently

inspected, is in good condition and will be

rigged as per IMO requirements. This

confirmation is being required prior to

attempting any embarkation or

disembarkation operation. Moreover, to this

effect, Humber Notice to Mariners H69/2013

has been issued and circulated.

PTR Holland has now introduced a more

detailed pilot ladder instruction note, which

is being supplied with all the pilot ladders

that are manufactured by PTR Group. The

detailed instruction note now makes specific

reference to the requirement of a load test on

the pilot ladder at 30 month intervals in

accordance with the requirements prescribed

in the ISO Standard 799:2004.

4 Safety actions and recommendations should not

create a presumption of blame and / or liability.


RECOMMENDATIONS

Wilson Ship Management is recommended

to:

15/2014_R1 ensure that the conditions of

pilot ladders remain in compliance with

the requirements specified on page 1 of

the EC Type Examination Certificate;

15/2014_R2 consider appropriate securing

arrangements which prevent local

deformation of the pilot ladder ropes;


SHIP PARTICULARS

Vessel Name: Wilson Leith

Flag: Malta

Classification Society: Bureau Veritas

IMO Number: 9150509

Type: Dry cargo

Registered Owner: Wilson Shipowning AS

Managers: Wilson Ship Management AS, Norway

Construction: Steel

Length Overall: 87.90 m

Registered Length: 82.10 m

Gross Tonnage: 2446

Minimum Safe Manning: 9*

Authorised Cargo: General cargo

VOYAGE PARTICULARS

Port of Departure: Immingham, UK

Port of Arrival: Rotterdam, The Netherlands

Type of Voyage: Short international

Cargo Information: Ballast

Manning: 8

MARINE OCCURRENCE INFORMATION

Date and Time: 31 May 2013 at 2232(LT)

Classification of Occurrence: Serious Marine Casualty

Location of Occurrence: Spurn Point Pilot Station

Place on Board Pilot ladder / Over side

Injuries / Fatalities: One injury

Damage / Environmental Impact: None

Ship Operation: Disembarking pilot

Voyage Segment: Departure

External & Internal Environment: Wind Northeast 10 knots, Swell Northeast 1 m to

2 m. Visibility was 5 miles.

Persons on board: 9 (including pilot)

* Second engineer officer may be omitted if vessel carries a UMS notation.

MV WILSON LEITH

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