A vessel was departing from port when crew found it necessary to remove the mooring lines from the shoreside bollards with no safe un-boarding/boarding arrangements in place – instead clambering over the side (CCTV capture shown below). A standard unmooring process (using shore-based support) had been discussed with the team involved during the pre-task briefing/toolbox talk.
What went wrong?
Immediately before starting the unmooring operation, the port authorities informed the vessel that the ‘shoreside linesmen’ were not available. As a further consequence, the mooring lines were not recovered quickly enough, resulting in an entanglement into a stern thruster.
What were the causes?
- Failure to follow company operating procedures and internal HSSE rules;
- Ineffective assessment of risks before starting work;
- Failure to effectively recognise and manage the safety risks associated with the change to the planned activity (failure to manage change);
- No-one stopped the job (stop work authority).
What actions were taken?
- The fouled mooring line was removed/cleared from the thruster;
- Reinforcement and raising awareness of:
- existing company rules on safety including the obligation of all employees to ‘speak up/step in’ if they see an unsafe act and/or condition
- the importance of dynamic risk assessment and management of change (MoC)
- the relevant sections of Code of Safe Working Practices for Merchant Seafarers (COSWP)
- fleet level risk assessment and management procedures
- fleet level vessel mooring/unmooring procedures;
- There was a visit by senior management and discussion with the team involved.
What lessons were learned?
- Vessel crew should not act as linesmen for their own vessel;
- Contingency plans should be developed in advance for this type of routine activity;
- Changes to any activity should be effectively risk assessed and managed using the MoC process.