A deck cadet fell over board during the recovery of the pilot ladder.

Narrative
A general cargo ship of 150 m length departed from a German port. A deck cadet was ordered to stand by on deck to await the disembarkation of the river pilot. After the pilot had disembarked, the cadet was instructed by the duty mate to recover and to secure the pilot transfer equipment. Afterwards he should report to the bridge.
After 20 minutes, the mate realised that the cadet had not reported the completion of his job, so the mate called the cadet via the VHF handheld radio but received no answer. An alarm was raised from the bridge and a ship search was initiated. The search remained without success so that it had to be assumed the cadet must have fallen over board. After alarming local authorities and the consequent search and rescue operation no sign of the missing was found.

Findings
It was not possible to prove that the seafarer fell overboard; neither screams were heard nor traces found.
None of the chapters of the company’s SMS provides rules or regulations while performing functions related to pilot embarkation equipment rigging. There was no risk assessment or standing orders of the master. A procedure on how to recover the pilot ladder after use was not available. After the accident, it was found that the pilot ladder stayed rigged during the pilots stay on board. The deck cadet most probably fell overboard due to the fact that he was not using the Personal Protective Equipment he should have (safety harness or belt…).

Recommendation
The company was recommended to review and to amend its SMS. The company’s designated person should use his responsibility for advanced safety training and the monitoring of regular safety measures, as well as routine work performance during the vessels operation.

Lesson to Learn
While the vessel is in operation, the pilot ladder should only be rigged in a team of at least two deck crew; a supervising deck officer has to be assigned. During the process of rigging, each team member has to wear a safety harness secured on deck.  Additionally, a permanent communication between the rigging crew and the bridge is essential and if the construction allows, a visual contact is recommended.
In order to foster the safety awareness, a regular training is fundamental and especially new crew members should be familiarised with risky operations like pilot embarkation preparation and clearing.