The Taiwan Transportation Safety Board (TTSB) published the final report on the investigation of a pilot who went overboard and died during the pilot transfer from the pilot boat to the Hong Kong-registered container ship “Blue Ocean”.

At 1113LT(local time) on Feb. 21, 2022, a container ship Hong Kong registered “BLUE OCEAN”, with a gross tonnage of 9949 and the official no. 8813611, was at the pilot boarding area of Taichung Port to meet with the pilot boat “GTIE 101”. The pilot planned to embark the “BLUE OCEAN” via the pilot ladder from the “GTIE 101” to perform inbound navigation services. While the “GTIE 101” was alongside the right side of the “BLUE OCEAN” at the pilot ladder placement location, the pilot fell into the sea while attempting to climb the pilot ladder to embark the “BLUE OCEAN”, and was rescued but unfortunately died after medical treatment. The occurrence did not cause any damage to the ship structure or environmental pollution.

In accordance with the Transportation Occurrences Investigation Act[1], and the relevant content of the Casualty Investigation Code of the International Maritime Organization, the TTSB is an independent transportation occurrence investigation agency, and responsible for conducting the investigation. The investigation team also included members from Maritime and Port Bureau, Ministry of Transportation and Communications (MOTC), Coast Guard Administration of the Ocean Affairs Council, Port of Taichung, Taiwan International Ports Corporation, Ltd., Taichung Harbor Pilot Office, GTIE CO., Ltd, and TRANS REAL CO Shipping Agency CO. Ltd.

On the basis of comprehensive factual information and analyses, TTSB proposes the following 15 findings from the final report, and 8 safety recommendations issued to the related organizations.

Findings

Findings related to probable causes

1. The reason for the pilot involved in the marine causality fell overboard involves two factors: waves and the behavior standards, operating procedures, and cooperation mode of the pilot (boat) boarding safety.

• At the time of the occurrence, the weather was poor, with a Beauport scale of 7 and waves about 2 to 3 meters, causing the ship to sway. The pilot lost balance while climbing the ladder with one hand and one foot and fell into the water.
• The overall operation of the pilot boat and pilot did not comply with the behavior standards for pilot (boat) boarding safety, as well as the operating procedures and cooperation mode for pilot boarding/disembarking, which increased the difficulty of pilot boarding/disembarking operations. This includes the method of the pilot boat approaching the large ship and the professionalism of its crew in assisting in climbing the ladder, the waiting, climbing, and methods of the pilot at the side of the pilot boat.

Findings related to risk

1. The Taichung Harbor Pilot Office stated that after the pilot involved in the marine causality was rescued, the inflatable life jacket he was wearing was fully inflated. However, the pilot was wearing a raincoat on the outside of the inflatable life jacket, which does not comply with the precaution to "wear a life jacket on the outermost layer of all clothing."
2. The pilot involved in the marine causality was still wearing a mask after falling into the water. A wet mask may hinder breathing through the mouth and nose, which is not conducive to self-rescue after falling into the water.
3. The pilot boarding area of Taichung Port is only 0.6 nautical miles from the south breakwater entrance, which does not meet the safety conditions for pilots to board ships. This has caused the pilot involved in the incident to rush board the ship, which is a long-term risk. If a similar incident occurs again, the ship's captain entering the port may not be able to safely navigate the vessel into the main channel, resulting in significant risks for Taichung Port's navigation control.
4. The pilot boats of Taichung Port are all used for transportation and do not have dedicated pilot boats. The current rescue equipment on Taichung Port pilot boats is unable to rescue an unconscious pilot who has fallen into the water. Compared with international pilot rescue equipment, there is still room for improvement.
5. The Maritime Port Bureau, MOTC disaster prevention and rescue operation plan and the Port of Taichung, Taiwan International Ports Corporation, Ltd disaster prevention and rescue operation plan did not consider the severity of pilots falling into the water during navigation and contingency provisions.
6. The competent port authority has not established standards for filling out the "Pilot Physical Examination Form" and has not provided guidance documents for examining physicians to evaluate the qualifications of each item on the form. It is unclear which instruments and specimen inspection items should be included, which may lead to differences in examination results among different hospitals or inaccurate examination results, thereby affecting pilot navigation safety.

Other findings

1. The “BLUE OCEAN” is equipped with one captain and 19 crew members at various levels, all of whom hold valid certificates issued by the competent authority.
2. The Pilot Boat “GTIE 101” is equipped with one captain and one crew member, both of whom hold valid certificates issued by the competent authority.
3. The pilot involved in the marine causality holds a professional certificate and registration certificate for pilots in the Republic of China and has served in Taichung Port for about 10 years. There were no abnormalities in the rest hours of the pilot before the incident.
4. The pilot involved in the marine causality suffered from coronary artery blockage/narrowing disease. Compared to those with completely normal heart function, the risk index of falling into the sea under extreme conditions of hypothermia, tension, and pressure would be higher before and after undergoing bypass surgery.
5. GTIE CO., Ltd and the Taichung Harbor Pilot Office held two man-overboard exercises, but the gap between the content of the exercises and the actual situation was too large, and the rescue procedures were not carefully considered. This resulted in a lack of standard operating procedures for the pilot boat captain and increased the difficulty of rescue.
6. The Maritime Port Bureau, MOTC and the Port of Taichung, Taiwan International Ports Corporation, Ltd. did not arrange joint educational training or exercises for pilot fell overboard events, which may have affected the response to emergency situations.
7. The Port of Taichung, Taiwan International Ports Corporation, Ltd. has established regulations for handling maritime accidents, general and routine disasters, and VTS and monitoring center responsibilities. However, the implementation details are not clear enough, which may affect the efficiency of emergency communication and rescue results. The on-duty personnel at the monitoring center of Taichung Port Authority lacked educational training and were unable to fulfill their duties to assist in requesting rescue resources.
8. The Australian Maritime Safety Authority (AMSA) has developed comprehensive medical examination standards for seafarers and provided guidance documents that outline the inspection focus and evaluation process. These documents are intended to be followed by examining physicians when conducting physical examinations. For pilots and seafarers who are elderly or whose health conditions have changed, examining physicians can adjust the frequency of medical examinations, validity period of medical certificates, additional conditions, re-examinations, and follow-up based on these guidelines to ensure that their physical fitness and health are sufficient to perform maritime work safely and efficiently. This is worth considering for our country.

Transportation Safety Recommendations

To Maritime Port Bureau, MOTC

1. Referring to IMO Resolution A.960(23) and taking into account the port facilities and hydrological conditions of the Port of Taichung, the location of the pilot boarding area for incoming cargo ships at the Port of Taichung should be reviewed and improved as appropriate.
2. Review the equipment of international commercial port pilot boats and align with international standards, taking into account the geographical relationships and weather conditions of each port, to establish pilot boats suitable for the port to ensure the safety of pilots boarding and departing ships and to achieve the goal of mandatory pilotage to ensure the safety of navigation and shipping in Taiwan's international commercial ports.
3. Using this case as an example, all of national pilots shall be informed that "life jackets must be worn on top of all clothing" to ensure that life jackets can be used effectively in case of accidental falling into the sea.
4. Referring to the practices of other countries' pilot associations, formulate operational guidelines for pilots boarding and departing ships to protect the safety of pilots and crew members.
5. Evaluate and improve Taiwan's physical examination system and supporting measures for national pilots, including at least:

• Strengthening relevant standards for pilot physical examinations, providing guidelines to explain the focus of various inspections and evaluation processes for examining physicians to ensure consistency in physical examination results.
• Increasing the level of detail in pilot physical examinations to ensure that their health is sufficient to perform their work and maintain the safety of themselves and ships entering and leaving ports.

To Port of Taichung, Taiwan International Ports Corporation, Ltd.

1. Review the contents of the disaster prevention and rescue operation plan of each port subsidiary under its jurisdiction, to ensure that VTS officer and monitoring center duty personnel have the necessary abilities to deal with various disasters.
2. Develop standard communication terms for the disaster emergency response procedures of the maritime disaster prevention and rescue operation plan, in order to enhance communication efficiency and rescue results for maritime disasters and emergencies.
3. Re-examine the drill plan for man overboard in the port area, to ensure that the drill content is close to real crisis situations.

Full final report is in Chinese only and available for download at website: https://www.ttsb.gov.tw

Vivi Yang, Secretariat Office

Tel: +886-2-7727-6217

E-mail: viviy2314@ttsb.gov.tw

Michael GUAN, Deputy Chief Investigator

Marine Occurrence Investigation Division

Tel: +886-2-7727-6202

E-mail: michael@ttsb.gov.tw

[1] https://law.moj.gov.tw/ENG/LawClass/LawAll.aspx?pcode=K0090057