The Incident

Santa Maria, a double hull oil tanker, registered in Malta, was alongside a vessel in Bunkering Area 3 West, about 12 nautical miles East by North from Malta’s Grand Harbour. The bosun and another crew member were assigned with the mooring operation on the forecastle deck.

While on the mooring operation, the bosun let go of the windlass control lever and left it in the full heaving position trying, in the meantime, to place a rope stopper on the mooring line the minute it was brought under full tension.

When the bosun tried to reach the stopper, he passed over the mooring rope, where he lost his balance and tripped over the mooring rope, in close proximity of the warping drum. This had as a consequence for the bosun to trap his legs between the incoming rope as well as the slack rope coming off the warping drum being handled by the deck rating and the rotating warping drum.

The bosun immediately got help by the other crew members and was airlifted from the vessel and taken to a local hospital. The immediate cause of the accident was considered to be the crew member’s fall in close proximity to the rotating warping drum.

Credit: Transport Malta

Probable Cause

The immediate cause of the accident was thought to be the crew member’s fall in close proximity to the rotating warping drum.


  • The crew member had accepted a certain degree of risk during the mooring operation;
  • The actual number of crew members at the forward mooring station may have been the result of ‘production pressure’ at the cost of safety, albeit not intended;
  • The crew members on board found themselves in a situation where they had to trade thoroughness with efficiency;
  • Circumstances, such as ensuring that the vessel is made fast alongside in order to start the bunkering operation eventually took higher priority over safety;
  • This trade-off may have also been the result of past, similar, successful mooring operations;
  • The operating lever was left unattended and in the heaving position, with the warping drum rotating and the mooring rope still being heaved in;
  • The adaptation by the bosun, leaving the lever in the operating position whilst working the rope, was actually an approach to suit his demands, commonly known as ‘task tailoring’, related to workload management;
  • The safety investigation did not come across evidence which suggested that fatigue was a contributing factor to this accident;
  • The bosun was wearing the appropriate personal protective equipment that would typically be worn at mooring stations.

Actions Taken

The Company has implemented several safety actions on all its fleet during the course of the safety investigation:

  • Organising further training to crew designated for mooring operations and reporting of equipment problems;
  • Revision in the number of crew members on the forward and aft mooring stations;
  • Assigning of a deck officer in charge of each mooring team;
  • Enhanced means of communication to each mooring team;
  • Application of anti-slip paint at each mooring station;
  • Enhanced maintenance regime with respect to the mooring equipment; and
  • Distribution of a Fleet Circular to compliment the Mooring Operations. Procedure within the Company’s SMS.

The conclusions and safety actions shall in no case create a presumption of blame or liability.

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