Why do non-compliant pilot ladders exist – and how do they get that way?

–Winston Singh CMMar AFNI–

Your thoughts on the picture right? Believe it or not, this was a pilot ladder rigged for one of my colleagues. It tells a tale of neglect, negligence, poor safety culture, an ineffective quality management system and lack of inspection/maintenance. That tale raises many questions. Was a risk assessment done prior to rigging and if so, what were the results? Who authorised its rigging and use? This ladder clearly did not become dangerously unsafe overnight. Was this pilot ladder inspected as part of the Safety Equipment Survey carried out by the Classification Society?

Stakeholders and compliance
On a daily basis, pilots encounter non-compliant pilot ladders worldwide, use of which can lead to injuries and in some cases death when transferring to and from vessels. The question is why and how that happens, despite all the regulations and safeguards which should be in place.

From conversations with stakeholders and my own observations as a pilot over the last 16 years, there are many possible issues which give rise to non-compliant pilot ladders, some of which are detailed below:

Safety culture (or the lack of it)
I’ve asked Masters to accompany me on deck when alongside and before disembarking to look at glaring non-compliances in their pilot ladders. Clearly, most Masters are unaware of these deficiencies. Some are horrified and can’t believe that the crew actually rigged a pilot ladder due for disposal when there were new ladders still in packaging in the forecastle – but who’s in charge? Are crew members reporting deficiencies and non-conformities as required by the ISM Code? There can be no safety culture without a healthy reporting culture.

Masters must prioritise both psychological safety and a strong safety culture. Both concepts are essential for fostering a healthy work environment where seafarers feel empowered to contribute to the overall safety and well-being of the company. Focus on relationships and build trust with crew members. Trust is a key predictor of safety performance and an essential component of a proactive safety culture.

The Master’s responsibility and authority are clearly set out in the ISM Code: Sections – 5.1 & 5.2. The Master has the overriding authority and the responsibility to make decisions with respect to safety and pollution prevention and to request the company’s assistance as may be necessary. How many Masters are willing to exercise this overriding authority?

At the same time, that authority must be recognised by the company. One Master practically begged me not to file a non-compliance report because he had a long list of outstanding deficiencies to deal with and this report could lead to him being sacked. He also said that he ordered two new pilot ladders a long time ago but the request was denied. Why was he denied? Is the reporting of deficiencies by the Master regarded as a problem, rather than an opportunity to improve safety?

Onboard inspections and use of checklists
In a Nautilus International Telegraph article from February 2019, marine insurers urged ship Masters to revive the practice of regular ‘Sunday routines’ to check safety and quality standards on their vessels. The London P&I Club said many of the problems found by their inspectors are easily detectable, and should be spotted by Masters and officers.

Knowing the causes and appearances of damage is essential to good rope inspection and determining retirement criteria. Deck Officers, Flag State and or Classification Society Surveyors must all be trained to look for not only abrasion damage but fatigue damage, hockling and points of failure during visual examination of pilot ladder side ropes. A review of more than 200 pilot ladder incidents reported to the UK MAIB in 2021 identified several which involved failure during pilot use. The failures were a consequence of the side ropes’ poor condition, which a routine visual examination would almost certainly have detected.

When the Master endorses that the relevant personnel are competent to perform the risk assessment prior to using the ladder, they are confirming that all checks are correctly done. When I observe ladders rigged with loose chocks and seizings, whippings wrapped using duct tape, sideropes with paint residues, I often wonder about the thoroughness of onboard inspections. It suggests the pre-, post- and three-monthly inspection checklists required by ISO 799-2 are just tick box exercises.

The problem, to be clear, is not with the checklists in and of themselves. There is considerable evidence from other fields and disciplines showing that the proper use of checklists reduces the probability of incidents occurring. However, care must be taken to ensure that the checklists are appropriate for their intended use, and not just being filled in for the sake of it. There is limited value in having a checklist to complete an activity if there is no way to make sure the items on the list have actually been completed. There is just too much scope for human variable performance to introduce errors which may cost a pilot their life. The checklists must be properly used to be effective.

PSC and Classification Society checks
I am always puzzled when ships manage to continue trading with the non-compliances in their pilot ladders going undetected. Surely, the flag state administration or Recognized Organization auditors and inspectors would have picked these up during external audits? Surely, Port State Control inspectors would detect these deficiencies when they attended the vessel?

In principle, flag state inspectors/surveyors are mandated to conduct in-depth inspections, while Port State Control officers carry out verifications of compliance because they do not have time for in-depth verifications during initial inspections. I have spoken to classification Feature: The missing step Read Seaways online at www.nautinst.org/seaways March 2025 | Seaways | 25 society surveyors who admit that little or no attention is paid to pilot ladders during inspections. A Lloyds Register report detailing the Port State Control deficiency analysis of ships flying the Panama flag from 1 January 1995 to 23 May 2020 listed a total of 11,196 deficiencies. Of these, there were only 20 deficiencies related to pilot ladders listed under code 10101. In contrast, over the same period, there were 256 deficiencies related to code 0116 Nautical Publications. The data indicates that pilot ladders attracted limited attention from enforcement agencies worldwide. Does this convince me that the same due diligence was paid to the inspection of pilot ladders as nautical publications?

In an article entitled ‘Slipping Standards’ concerning defective pilot ladders, published in Nautilus International Telegraph in February 2019, British Ports Association Chief Executive Richard Ballantyne said, ‘Global rules set by the IMO bring consistency but they must be followed. Equally, these rules must be enforced uniformly and port state control practices should be firm – including, where needed, measures to prosecute and detain ships.’ Flag state inspections must take a tougher stance.

(In)effective auditing
The reality is that audits and inspections tend to be somewhat superficial, and are often restricted to ensuring that certain paperwork has been completed properly.

This applies both to internal and external audits. In carrying out internal ISM audits, companies measure the effectiveness of their own systems. The internal audit is potentially more important than external audit for controlling the effectiveness of the system. It should be at least equal to if not exceed the thoroughness of the external ISM audit process. However, when internal auditing is poorly developed, its ineffectiveness leads to many hours of wasted resources and fails to effectively identify and eliminate non-conformances, eventually resulting in an inevitable quality management system breakdown. Frequently, it appears that very little effort has gone into the overall internal audit which is carried out once a year to tick another box. There is so much inefficiency and ineffectiveness with this practice. Internal /external audits should not exclusively rely on paperwork but opportunities to assess the safety culture. There must be a willingness to go beyond paperwork to properly address critical issues and hazards.

Complacent pilots
Many pilots are the first to complain and the last to report. As pilots, we often rant and rave with the crew upon reaching the deck about the condition of the ladder and or the incorrect rigging procedure – but let’s not blame them. Crews, being at the sharp end, are normally the ones who have inherited the flawed rules, procedures and equipment from those at the blunt end. They are simply adapting to the circumstances and making good with the resources available. Nobody has trained them how to rig or inspect a pilot ladder correctly, nobody supervises them, so they’re simply getting on with the job using the available resources.

As the foreword of International Maritime Pilots’ Association’s (IMPA) Safety Campaign 2010 report puts it, ‘It would be complacent to believe that pilots were not to a degree involved in this state of affairs, even just for their tacit acquiescence. Pilots have a ‘can-do’ mentality that can lead them to use less than satisfactory boarding equipment, sometimes to their great cost. Pilots are also notoriously reluctant to report defects to Port State Control, which is a legacy for many of their previous life as Masters.’

According to the IMPA annual safety campaign reports over the last seven years (2017-2023), approximately 90% of non-compliant pilot transfer arrangements were not reported to the appropriate authorities. This is alarming. While it could be due to a number of reasons, including missing or dysfunctional maritime authority, fear of reporting, lack of trust and just culture, clunky and awkward reporting system or poor safety culture, pilots have options to report non-compliant pilot transfer arrangements. One of these is confidential reporting through CHIRP Maritime. It provides a voice to those pilots who feel that they cannot otherwise speak out or feel that their concerns are not being heard.

The IMPA 2024 safety campaign survey results showed a noncompliance rate of 13%, with pilot ladders remaining the leading source of non-compliant observations. There has been no significant change to historic non-compliance trends. Overall, there were 1,334 less returns in 2024 compared to the previous year – and yet, there were thousands of ship movements worldwide which occurred during the two weeks of reporting. Why aren’t all IMPA members taking part in the survey? Clearly, there are issues with pilots under-reporting both internally and externally. Individual pilot organisations must address this issue.

In 2022, the UK’s Maritime Accident Investigation Branch (MAIB) canvassed 105 UK Competent Harbour Authorities for their pilot transfer statistics. The survey indicated that there were over 400 incidents or accidents over the period covered. In its 2022 annual report, MAIB Chief Inspector Captain Andrew Moll said he was disturbed that a full analysis of accidents could not be carried out because barely half of the incidents mentioned in the survey had been officially reported.

How do we address these issues?
Although non-compliant pilot ladders are recognised as a serious issue by stakeholders throughout the industry, the same systemic issues continue and are not adequately addressed. This is mainly caused by a lack of enforcement of the regulations by certain Flag States, and a failure by certain Port State regimes to effectively verify that the ladders comply with the requirements of international regulations. Also, some companies are not even interested or willing to accept non-compliant pilot ladder reports, and there is an unwillingness from many seafarers and pilots to report, both because of fear and because it is a pointless exercise if nothing is being done to address the issues.

The Maritime Safety Committee of the IMO has approved the amendments to SOLAS V/23 and the associated mandatory performance standards for pilot transfer arrangements. Will this bring about a change in safety culture across the industry when it comes into force on January 1st 2028?

An active safety culture can only be developed by effective leadership, commitment and setting a good example. Psychological safety is essential for creating an optimal safety culture. In essence, it means the absence of interpersonal fear. It is about ensuring people are comfortable reporting incidents, reporting near-misses, discussing challenges with following procedures, etc. all without fear of being criticised or experiencing retaliation. Companies should invest in psychological safety training and promote the concept of a just culture to strengthen their reporting systems.

Without collective and global action by all stakeholders to fix these systemic issues, non-compliant pilot ladders will no doubt continue.

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