The reasons for Mr Simpson’s fall from the ladder could not be determined.

However, the MAIB expressed a general concern about the ergonomics of the ladder from which Mr Simpson fell, and such quayside ladders in general.

Consequently, the MAIB recommended that HSE review accidents from quayside ladders to determine if they were a major risk to safety and whether the design needed to be changed, and to feed the results of this work into the review of the Approved Code of Practice to the Docks Regulations 1988. HSE accepted the recommendation.

The subsequent review concluded that:

• Reports of accidents from such ladders are relatively rare.
• After considering this, and other evidence and information, HSE does not believe that these ladders present a significant risk to health and safety.
• While there is evidence that these ladders are not well suited for regular use as a means of access to vessels, and have limitations as a means of self-rescue from the water, we do not believe that there is not a case for wholesale change to existing ladders, or to the relevant regulatory requirements.
• We also do not believe that there is a case for HSE or the industry prohibiting their use as a means of access to vessels.
• However, there is potential to make further sensible reductions in risk to ladder users, subject to a local assessment and timetabling. Port or quayside developments or refurbishments offer good opportunities to design in these risk reduction measures.
• Throughout any consideration of improvements to new or existing ladders, it is important that port operators and others do not inadvertently introduce additional risks under the cloak of improved standards.

The review did not include analysis or consideration of other equipment, such as mitigation measures (e.g. lifejackets), nor how these work in combination with quayside ladders.

Subsequent to the start of the review, the Health and Safety Commission published its Strategy for workplace health and safety in Great Britain to 2010 and beyond. In the light of the Strategy, HSE looked again at the proposal to revise the ACOP and discussed with the ports industry whether a revised ACOP would make real impact on accidents and ill health. HSE’s opinion was that it would not, and the review of the ACOP was halted.

However, the review report still makes some recommendations. We believe that the ports industry, in consultation with port users should consider:

• At the design stage of refurbishments or new quaysides:
  • Assess the access needs of vessels likely to use the facility, including small vessels such as fishing boats and pilot boats;
  • Consider whether access can and should consist of walkways, pontoons and other similar equipment, rather than quayside ladders;
  • Where there is no alternative but for access by ladders, the ladders should be purposely designed with this in mind, including consideration of good ergonomic practice;
• At new and existing ladders used for access and/or rescue (presuming no alternatives are available):
  • Consideration is given to the use of anti-fouling and anti-slip agents;
  • Opportunities for improved lighting, including lighting or marking with LED systems, are considered;
  • Any proposed improvements should be subject to a suitable and sufficient assessment of the risk to ensure that:
    • There is not simply a transfer of risk from one activity to another (e.g. from use to maintenance) and/or to an overall increase in the level of risk;
    • Proposals are sensible, prioritised and timetabled to ensure the most health and safety return on the investment

A copy of the full report is available from HSE’s Transportation Section on request (020 7556 2131, tim.galloway@hse.gsi.gov.uk).