Unsuitable mooring arrangement leads to fatality

The incident

Ship A arrived at the anchorage to load grain cargo from the anchored bulk carrier, ship B. The mooring arrangement between the two ships consisted of three headlines, three stern lines, two springs forward and aft. All the lines belonged to ship A. Both the ships had similar freeboards when cargo operations began.

With loading about 80% complete, ship B’s deck was about 8 m higher than Ship A’s. The forward crane operator on Ship B advised his duty officer that Ship A needed to be moved forward. Ship A’s C/O and an AB manned the aft mooring station while the 3/O and Bosun manned the forward station.

As the Bosun slackened the forward springs, the AB began to haul in on one of the aft springs. The moment it came under tension, the mooring line slipped out of its shipside open roller fairlead. It struck the C/O on head and he fell unconscious to the deck. He was unresponsive with no visible injuries but he was breathing and had pulse.

The 2/O of Ship A administered first aid to the C/O, gave him oxygen and monitored blood pressure and pulse. Almost two hours later, the C/O was transferred ashore in a tugboat. He was declared dead on arrival.

Consequences

• Fatality
• Delays
• Loss of reputation of the company

Causes

• Failure to follow procedures:

- Improper risk assessment – The RA did not consider the steep angle of mooring lines due to difference in freeboards of two ships, which resulted in ship staff using one open fairlead to pass two lines during warping.

- Lack of risk awareness - The C/O of Ship A positioned himself in a danger zone immediately adjacent to the tensioned aft spring during the warping operation.

- Mooring procedures not followed – Ship staff used a single open fairlead to pass two lines.

• Lack of planning / resource allocation - There was insufficient planning for both the mooring and the warping. Considering the short distance to be moved, the Master decided not to call the regular mooring crew who were resting at the time for this warping. He decided to carry out this operation only with the C/O and those on watch for cargo operations. There were only two persons each at the forward and aft mooring stations.
• Unfamiliarity with the operation - The crew was unfamiliar with STS bulk cargo operations.
• Fatigue – The C/O was working the whole day and was called to conduct this warping operation. He had insufficient rest and was tired at the time of the operation.
• Lack of assertiveness - Even though the AB assisting the C/O had little opportunity, he could have challenged the C/O’s decision to stand in the danger zone.
• Delay - Despite the crew’s efforts and the assistance of the tug, it took more than two hours for the casualty to be seen by a medical professional, possibly due to lack of co-ordination between different parties.

Lessons learnt

• Carry out a thorough risk assessment by considering all probable hazards and discuss same with all personnel involved before carrying out any task
• Always assign a sufficient number of crew for critical tasks such as a warping / mooring operation. Assigning insufficient number of persons makes the operation unsafe for persons carrying out the operation
• Never lead two lines through the same fairlead, this restricts the space available for each line
• The ship staff including the support / junior staff must use STOP WORK card the moment they notice a hazardous situation
• Promulgate this incident with lessons learnt to all ships for discussion with ship staff

Source: UK MAIB