A newly released accident investigation from the UK has detailed a series of systemic failures that led to the death of an experienced marine pilot during a routine vessel boarding operation near the Humber Estuary in northern England.

The Marine Accident Investigation Branch (MAIB) found that the pilot fell from a ladder while attempting to board the roll-on/roll-off cargo vessel Finnhawk from the pilot boat Humber Saturn on January 8, 2023. Investigators concluded the pilot likely suffered a cardiac event during the transfer, causing him to lose consciousness, strike the deck of the pilot boat, and fall into the water.

Although the pilot was quickly recovered onto Humber Saturn’s semi-submerged man-overboard recovery platform, mechanical defects prevented the system from being raised. As a result, he remained partially submerged in cold water for more than 40 minutes before being transferred to a lifeboat. He was later evacuated by coastguard helicopter and pronounced dead at hospital.

“Pilot transfers are challenging and potentially hazardous and fortunately most are conducted without incident,” said Chief Inspector of Marine Accidents Andrew Moll OBE. “Tragically, however, on 8 January 2023 this was not the case and a respected and experienced marine pilot lost his life.”

The investigation identified significant shortcomings across medical oversight, equipment reliability, training, and emergency response procedures.

Medical findings were among the most serious. The seafarer’s medical certificate issued six months prior to the accident should not have declared the pilot fully fit for duty, given multiple chronic health conditions that could have impaired his ability to perform physically demanding transfer operations.

In addition, the port authority’s “stop work” procedure failed to prevent the pilot from working on the day of the accident, despite colleagues raising concerns about his fitness. Investigators also found the authority had not conducted a formal assessment of the physical demands required of pilots, leaving no defined occupational fitness standard for the role.

Equipment failures compounded the emergency. The defective recovery platform on Humber Saturn prevented timely extraction from the water, significantly reducing the pilot’s chance of survival. The MAIB said the vessel lacked any effective alternative recovery method for an unconscious person.

The MAIB issued multiple safety recommendations, including calls for the Maritime and Coastguard Agency to require non-SOLAS vessels to carry secondary recovery systems for incapacitated persons. Associated British Ports was urged to revise its risk assessments, upgrade pilot protective equipment to improve cold-water survivability, and align safety training with industry best practice.

Port industry bodies were also advised to develop guidance on occupational fitness standards and personal protective equipment for pilots.

“While the MAIB has been encouraged by the actions of the port and industry bodies to address these safety issues, I strongly urge all harbour authorities with a pilotage service to learn the lessons of this accident and take action,” Moll said.

The findings underscore the high-risk nature of pilot transfer operations and highlight how failures in medical screening, equipment maintenance, and emergency preparedness can combine with fatal consequences.

The full report can be found on the UK MAIB website here.

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