Whilst disembarking from an outward bound vessel a pilot fell from the pilot ladder and spent eight minutes in the sea before he could be rescued by the pilot launch. The evidence from the pilot and crew of the launch suggests the fall was caused by slackness in the ladder taking up when the pilot’s weight on the ladder became effective. Image for representation purpose only After leaving the berth the Third Mate (3/O) left the bridge to supervise rigging the pilot ladder on the starboard side. The crew were busy securing containers on deck, so the 3/O rigged the ladder on his own. He said that, after rigging the ladder, he tested it by putting his weight on it; he was, however, of light build. He did not know where the manropes for the starboard ladder were stowed and he did not get the manropes from the port side. When he later escorted the Pilot from the bridge the 3/O did not take a torch or a hand held VHF radio to communicate with the bridge. The pilot did not have a torch either. Illumination of the ladder was provided by a gangway light facing forward and a searchlight from the bridge, although the ship’s side was very well lit, the deck area was partly shadowed by the adjacent stow of containers. The Pilot did not make a thorough security check of the ladder due to the inadequate lighting on deck. He requested manropes and was offered a totally inadequate heaving line which he refused. He was wearing a life jacket of old design which did not have an automatic light. When the Master saw the Pilot fall he immediately ordered ‘stop engine’ and ‘hard a starboard’, he also called the pilot launch but they were to busy to answer until they had retrieved the Pilot, the Master then offered any assistance he could provide. The 3/O did not watch the pilot go down the ladder and only heard the splash. He ran to the bridge shouting “Man overboard” as he could not make himself heard against the noise of the wind and rain. He did not throw the life buoy and marker stowed alongside the pilot ladder, a set was thrown from the bridge. The inboard end of the ladder was permanently secured with shackles through thimbles on the end of each set of side ropes. Rope lashings were then used to seize the side ropes in order to adjust the ladder length. Access over the side was through an opening in the bulwark set inboard 400/500 mm from the sheer strake. The opening in the bulwark was not full depth but stopped 200/300 mm above deck level. The ladder, when hanging over the side, passed from the securing eye pads on the deck up over the lip of the bulwark opening, then down at approximately 450 to the point where it crossed the sheer strake and then vertically down the ship’s side. There were three places at which the ladder treads could foul: 1. On the underside of the bulwark plating immediately above the securing lashings. 2. On the top lip in the bulwark access. 3. On the inboard side and top of the sheer strake. In an area of poor lighting, these points could easily be overlooked. It would need more than a cursory glance to see if they were holding back quite a large amount of slack in the ladder, this can be a common fault and has been noted on several occasions. The pressure of a light weight person testing the ladder may not be sufficient to take up the slack. The investigators concluded that, for whatever reason, there was slack somewhere inboard of the point where the ladder passed over the sheer strake. As the Pilot’s weight, and movement of