UK MAIB has issued an investigation report on an incident where a crew member suffered fatal injuries due to being struck by a mooring line in August 2021.
The incident
On the morning of August 26, 2021, the second officer of the Isle of Man-registered bulk carrier Mona Manx suffered fatal injuries after being struck by a recoiling mooring line. The incident occurred while the vessel was berthing at Puerto Ventanas, Chile. The mooring line became trapped between the vessel and the berth, likely near a fender, and was suddenly released as the vessel maneuvered astern under its own power.
Investigation findings
The second officer was struck because he was standing in the danger zone of the tensioned mooring line when it released. The investigation highlighted the following contributing factors:
- The second officer likely moved into the danger zone to get a better view of the mooring line during the vessel’s maneuvering.
- The vessel was maneuvered astern under its own power, contravening the port’s procedures.
- The Code of Safe Working Practices for Merchant Seafarers (COSWP) did not adequately address risks associated with mooring line entrapment and vertical recoil.
- Critical information for safe berthing was not fully discussed during the master/pilot exchange (MPX).
- The astern maneuver with deployed mooring lines was neither part of a toolbox talk nor risk-assessed, and the hazard of mooring line recoil was not mitigated.
- Congested radio communication might have hindered the crew’s ability to safely conduct the berthing operation.
Safety issues directly contributing to the accident that have been addressed or resulted in recommendations
- Mona Manx’s 2/O was fatally injured when he was struck on the head by the aft spring line, which became trapped, tensioned, and released when the bulk carrier manoeuvred astern along the berth under its own power.
- It is highly probable that the 2/O moved forward to the side deck and ducked underneath the accommodation ladder to improve his view of the aft spring line, and this placed him in the danger zone of the tensioned mooring line.
- Mona Manx was manoeuvred astern under its own power in contravention of the port’s procedures.
- Mona Manx’s manoeuvre astern with mooring lines deployed was neither the subject of a toolbox talk nor risk assessed by the vessel’s crew or port operator and hazards associated with mooring line recoil were not mitigated.
- The port’s berthing procedures were neither provided to Mona Manx’s master or pilot nor discussed during the MPX, thereby reducing the effectiveness of the MPX to assist a safe berthing operation.
Other safety issues directly contributing to the accident
- The risks associated with mooring lines detailed in the COSWP did not include the hazards associated with vertical recoiling lines or line entrapment.
- It is possible that congested radio communication reduced the ability of Mona Manx’s crew at the mooring stations and on the bridge to safely conduct the berthing operation.
Other safety issues not directly contributing to the accident
- Despite a rapid emergency response, the severity of the 2/O’s injuries were unsurvivable and he was declared deceased at the scene.
Action taken
Actions taken by other organisations
The Maritime and Coastguard Agency published the COSWP 2015 edition – Amendment 7, October 2022, which included amendments to the Anchoring, Mooring and Towing Operations chapter summarised below:
- Risk assessment and control measures should consider the mooring equipment at the berth, with consideration given to the snagging of lines on shoreside fixtures, such as a fender, that then come under tension and suddenly release.
- A snagged line under tension that then releases without breaking might recoil in the horizontal or vertical plane, or a combination of both. Risk assessments should consider the possibility that lines under tension suddenly releasing or the recoil of a parted line might have a vertical component.
- Personnel should steer clear of lines under tension and avoid snap-back areas and entrapped lines due to the risk of a sudden release under tension.
- There may be danger areas that have not been identified as snap-back zones.
- Risk exists in any area, including side decks, where there is the potential for lines to come under tension or snap-back.
Union Marine Management Services Pte. Ltd has:
- Shared information about this incident fleetwide and instructed every master to discuss it with all staff, briefing them again about the hazards of mooring line snap-back and to stay away from snap-back areas.
- Reiterated the importance of toolbox talks; the mooring plan discussion with all station heads before starting mooring operations; and a buddy culture (behaviour-based safety) where all staff monitor actions and stop any unsafe acts.
- Instructed that training videos on effective mooring are screened for all staff on board.
- Started a review of its port arrival checklist, which will be amended to include briefing mooring station leaders on the correct mooring deck arrangement, fittings and mooring pattern to use for various berthing scenarios.
- Added the OCIMF Effective Mooring publication to the fleet standards library for all ships.
- Reviewed and updated its SMS procedures to provide clear instructions for:
- Vessels manoeuvring alongside using their engines; and
- The risk of mooring line entrapment/release under tension during mooring operations.
- Updated its SMS procedures to include the requirement to conduct a dynamic risk assessment before starting an operation that is not covered by its generic risk assessments.
Puerto Ventanas S.A has completed a series of toolbox talks with its shore staff detailing the safety lessons learned from this accident.
