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Three People Tried to Stop Him: What the Finnhawk Pilot Ladder Death Means for Every Vessel Receiving a Pilot

🕑 5 min read words Safety • Incident

Humber Estuary, 8 January 2023 — 13:00

Francesco Galia, a 67-year-old Class-2 Humber pilot with more than two decades at ABP Humber, was 2.5 metres up the pilot ladder of the Finnish RoRo cargo vessel Finnhawk when he stopped climbing. He looked up at the two crew members at the top of the ladder, then leaned suddenly backwards and released both hands simultaneously. He fell without making a sound.

He landed on the deckhouse and safety rail of the pilot vessel Humber Saturn, breaking the shell of his safety helmet on impact, before slipping into the gap between the two vessels. His lifejacket inflated. His PLB activated. He floated upright, head above water.

The pilot vessel crew responded immediately — the MateSaver pole had him within two minutes. They got him onto the recovery platform. And then the recovery platform’s hydraulic system failed, and could not be raised.

Francesco Galia lay partially submerged in 7°C water for over 40 minutes. When the RNLI reached him, he was unconscious. He was transferred to hospital by coastguard helicopter and pronounced dead at 14:52.

Three of his colleagues had tried to stop him boarding that day. None had the authority — or the mechanism — to make it stick.

What the Investigation Found: Three Failures That Stacked

1. A Medical Certificate That Did Not Reflect the Reality

The pilot’s postmortem found compelling pathological evidence that he had suffered a cardiac event at the moment he let go of the ladder. His medical history included a heart attack in 2011, atrial fibrillation and stroke in 2018, chronic kidney disease, and lower back pain. His BMI placed him in the obese category. He had received an ENG1 seafarer’s medical fitness certificate six months before the accident.

MAIB Report 2/2026 is careful and precise about what the ENG1 is and what it is not. It is a standard seafarer fitness-to-sail certificate — designed to confirm that a person is medically able to work at sea. It is not an occupational fitness assessment for a role that requires regular physical activity — climbing ladders of up to 6.5m in wind, swell, and variable weather — at sea, at speed, at any time of day or night.

ABP Humber had no occupational fitness standard for its pilots. There was no requirement for pilots to demonstrate physical ability to climb a pilot ladder. The Approved Doctor issuing the ENG1 was not informed of the specific physical demands of the pilotage role. The gap between the certificate and the task went unaddressed until after someone died.

The MAIB found that the ENG1 should not have been issued as fully fit, given the pilot’s history. It also found that the port authority had not established what “fit for pilotage” actually meant, so there was no framework for anyone to question whether a certificate adequately covered the job.

2. A Stop-Work Culture That Could Flag but Not Refuse

The sequence of raised concerns on 8 January 2023 is one of the most instructive passages in any recent MAIB report:

During the car journey to the MCC, the trainee pilot mentioned to the pilot that he had been seen walking slowly. The pilot said he had back pain and sciatica and was taking painkillers.
At the MCC, the trainee pilot suggested to the tanker pilot that either the jobs could be swapped (shorter ladder for the pilot) or the trainee could do the tanker job so the pilot could stay ashore. The tanker pilot was content with either proposal. The pilot rejected both options.
The trainee pilot informed MCC staff that the pilot had back pain. MCC staff told VTS, who watched on CCTV as the pilot walked slowly to the boat.
At 12:38, VTS staff contacted Humber Saturn’s coxswain, who asked the pilot if he wanted to proceed. The pilot emphatically said yes.
Before the ladder, the coxswain asked again. The pilot again said yes.

Five separate interventions. A “Beyond Zero” stop-work programme that ABP had introduced in 2016 and described as empowering employees to stop others from working to prevent an unsafe act. And yet the pilot boarded.

The MAIB does not attribute blame to any individual who raised concerns. The systemic finding is harder: the Beyond Zero programme created a reporting culture, not a refusal culture. The pipeline for concerns existed. The endpoint — a mechanism where someone had authority to say “you are not boarding this vessel today” — did not.

3. A Recovery Platform That Failed When It Was Needed

Humber Saturn carried a PIW recovery platform — a hydraulically-operated platform designed to bring an unconscious or incapacitated person out of the water from the stern of the vessel. When the pilot was in the water, the crew could not lower the platform using the mobile control box. The coxswain entered the aft void space and manually operated the hydraulic solenoid valve to lower it.

They got the pilot onto the lowered platform. Then they tried to raise it. The mobile control box did not work. The solenoid valve in the void space did not work. The secondary manual hand pump did not work. The platform could not be raised.

The coxswain had to keep the vessel moving at slow speed to prevent water washing over the pilot on the semi-submerged platform. The trainee pilot jumped down onto the platform and held the pilot’s head clear of the water — standing chest-deep in 7°C seas — for the duration of the wait for the RNLI. The deckhand sustained a hand injury during the recovery attempt.

The MAIB investigation found that the recovery platform’s hydraulic system had not been load-tested or properly maintained in a way that would have identified the fault before the accident. The failure was not a random catastrophic event. It was a system that had never been confirmed to work when it needed to work most.

What If? — The Decision Points That Changed Everything

What if the port authority had established an occupational fitness standard for pilotage? A standard that said “you must be able to climb a 6.5m ladder in these conditions, and your medical assessment must specifically address that requirement” would have given the Approved Doctor a framework for the ENG1 assessment — and would have given the port a mechanism to address the pilot’s fitness before the 8th. The MAIB found six previous pilot ladder incidents in the UK and abroad. The absence of an occupational standard is not a surprise finding; it is an industry-wide gap.

What if one person in the chain had formal authority to ground the pilot? Not to report a concern upward. Not to ask a question. But to say “you are stood down today.” The Beyond Zero programme created the language and the reporting pathway. It did not create the authority. In safety-critical aviation, a fit-to-fly declaration is not optional and a medical concern raised by ground crew creates a formal hold. Maritime’s equivalent — for pilots, for watch officers, for anyone performing a physically demanding safety-critical task — does not consistently exist at port level.

What if the recovery platform had been load-tested under realistic conditions in the 12 months before the accident? The fault that prevented the platform from raising was not a sudden failure. A proper load test under realistic conditions — not a demonstration with a manakin in a calm harbour — would have been likely to identify it. The crew on Humber Saturn were not poorly trained. They attempted every manual override they had. The platform had simply never been tested to the point of failure, so the failure was found at the worst possible moment.

What if Francesco Galia had been wearing an immersion suit rather than a lifejacket integrated into a waterproof coat? At 7°C, cold water shock is immediate. Effective swimming time is 10 to 15 minutes. Unconsciousness follows within 30 to 60 minutes depending on condition and body composition. His lifejacket kept his face above water. It provided no thermal protection. The 40 minutes he spent in cold water — even on a recovery platform — caused the drowning confirmed in his lung histology. An immersion suit would not have removed the cardiac risk, but it would have dramatically extended his survivable window and may have changed the outcome.

Role-Based Lessons

For Masters and Chief Officers

Your responsibilities under SOLAS V/23 go beyond rigging the ladder correctly. Before any pilot transfer: confirm the ladder type is correct for your freeboard; confirm spreader spacing; confirm side rope continuity; confirm who is physically attending the embarkation point. If those things are not confirmed by the officer attending — not just assumed to be in order — the transfer does not meet the standard.

More importantly: your SMS should specify what your duty officer does if the pilot appears unfit to board. The Finnhawk investigation found no SMS guidance on this scenario. If yours is the same, that is the gap to close. The Master’s overriding authority under ISM Section 5.2 covers this decision explicitly — but authority without a procedure is frequently not exercised under social pressure.

The MAIB’s Safety Recommendation R2(2026) to ABP Humber covers occupational health standards and PPE for pilots — but the underlying principle — that ENG1 is not a role-specific fitness confirmation — applies to any physically demanding task assigned to a seafarer. Does your SMS address fitness for task, or only fitness to be aboard?

For Officers of the Watch

When a pilot is boarding, your job is not to watch until something goes wrong. The signs were visible on Finnhawk’s deck — slow movement, upper body away from the ladder — before the fall. If you see those signs, the correct action is to inform the Master immediately and have your AB at the embarkation point on MOB readiness, not to continue monitoring and hope the pilot makes it up.

The Vessel Checks section below includes specific actions you can take before your next port call. Do them now, not after a drill reminder.

For All Crew

The trainee pilot who stood chest-deep in 7°C water holding Francesco Galia’s head clear of the sea for 40 minutes did everything right in the moment. He also spent that time being treated for hypothermia in hospital afterwards. The lesson for ratings is not complex: the moment a person enters the water, shout the alarm, point and do not look away, throw everything that floats. Your job in the first 30 seconds is to keep eyes on the casualty so the coxswain or bridge can manoeuvre. Your job is not to jump in.

Vessel Checks: Do These Before Your Next Pilot Transfer

Pilot ladder: Locate it and physically confirm: spreader steps at maximum 9m intervals; lowest step within 2m of the waterline; side ropes continuous with no joints below the upper platform; manropes correctly led from above the gunwale. SOLAS V/23 and IMO A.1045(27).
MOB recovery system: When was it last load-tested and logged? Not just operated — tested under realistic load. If it has not been tested in the last 3 months and logged, raise it as a defect in the ISM system before the next operation that depends on it.
SMS pilot embarkation checklist: Does it specify who checks the ladder, who attends the embarkation point, and what to do if the pilot appears unfit to climb? If any of those are missing, that is the gap to raise at the next safety meeting.

Test Your Knowledge

Think you know the SOLAS requirements for pilot ladders — and what to do when the system fails? Put it to the test in Crew Connect’s free Knowledge Checker — try a quick safety round based on this incident, including oral-style questions pitched at OOW and Master level.