An investigation into the death of the Port of London Authority sea pilot reveals his blood contained 122mg of alcohol per 100ml of blood on the day the accident

12 October 2017

A Port of London Authority sea pilot, who fell and was crushed to death between two boats on the River Thames, was over the alcohol limit.

Gordon Coates died while trying to board the Bahamas registered general cargo vessel, Sunmi, from the pilot launch, Patrol.

An investigation by the Marine Accident Investigation Branch (MAIB) found that the sea pilot had 122mg of alcohol per 100ml of blood on the day the accident.

The authority’s drug and alcohol policy dictates that staff should not have an alcohol level above that stated in the Road Traffic Act 1988, which is 80mg of alcohol per 100ml of blood, when on duty.

However, the MAIB could not say if the fall was the result of the alcohol in Coates’ system or if it was down to other factors including the sea pilot’s use of Sunmi’s deck gate, a problem with his knee following recent surgery or a combination of all three.

A cargo ship in grey waters

Sunmi. Credit: MAIB Publications

Coates died on 5 October 2016 despite the swift actions of the RNLI and a local ambulance crew.

The accident occurred during a routine changeover of pilots at Gravesend Reach pilot boarding station on the River Thames.

The MAIB said that due to the choppy seas, the crew of the Sunmi had created a lee for the pilot launch to facilitate the boarding process.

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“The difference in freeboard between the two vessels was varying between about 30cm and 130cm. A pilot ladder had been rigged, but the sea pilot attempted to board by stepping up and through an open gate in the railings onto Sunmi’s main deck which, although adjacent to the ladder, did not form part of the vessel’s designated pilot boarding arrangements,” said investigators.

The MAIB found that the designated pilot boarding station on board Sunmi was not marked and “the deck gate should not have been opened in preparation for the transfer as it was unsuitable”.

The investigation also  identified that low freeboard vessel transfers, though not unusual, had not been assessed by the Port of London Authority or international pilot authorities.

Gravesend on the River Thames. Credit: Clem Rutter

Gravesend on the River Thames. Credit: Clem Rutter

Consequently, there were no procedures, guidance or regulation covering the transfer of pilots for low freeboard vessels.

The Port of London Authority carried out its own investigation, and as a result has revised its drug and alcohol policy, risk assessments covering pilot transfers, fitness assessment procedures and training and guidance for operational staff.

The MAIB has also made recommendations to the International Maritime Pilots’ Association aimed at improving the awareness of the requirements for gateways in bulwarks and railings intended for pilot boarding operations.

Recommendations have also been made to the managers of Sunmi aimed at ensuring that designated pilot boarding areas are marked and that pilot boarding operations are overseen by a responsible officer.


07 October 2016

The Port of London Authority (PLA) has confirmed that one of its pilots has died while boarding a cargo ship in Gravesend Reach in Kent.

The ship pilot has been named by the United Kingdom Maritime Pilots’ Association (UKMPA) as Gordon Coates.

On the UKMPA website, the association’s chairman, John Pearn, wrote: “It is with great sadness that I must inform you that one of our colleagues, Gordon Coates, a London Pilot, was involved in an incident whilst boarding a vessel in the Thames on Wednesday evening. Sadly he passed away shortly afterwards.”

“I am sure you will join with me and the UKMPA Executive Committee in passing on our sincere condolences. Our thoughts are very much with his family, friends and colleagues at the Port of London Authority during this tragic time,” added Pearn.

Coates sustained serious injuries while boarding the cargo ship, Sunmi at around 6.10pm on 5 October, 2016.

Despite efforts by the emergency services to save him, he subsequently died.

Both the Marine Accident Investigation Branch (MAIB) and the PLA have begun an investigation into the fatal accident.

No details about the nature of the accident have been released.

The PLA has issued a statement about the incident.

“The Port of London Authority (PLA) has confirmed that last night (Wednesday, 5 October 2016) at around 6.10 pm one of its pilots was involved in an accident while boarding a ship, Sunmi, in Gravesend Reach,” said the statement.

“PLA teams on duty, the emergency services and the RNLI did all they could subsequent to the accident, but tragically the pilot passed away,” it said.

The chief executive of PLA, Robin Mortimer, said: “Our deepest condolences are with our colleagues’ family and friends at this very difficult time.

“We have been in touch with the family and are offering whatever support we can,” he concluded.

The Sunmi is a 1993-built cargo ship, registered in Nassau in The Bahamas. It is operated by the Norwegian firm Misje Rederi.