Whilst unmooring, the forward breast lines were lowered by ships staff for release at the hook by the shore linesmen. The officer in charge (OIC), assuming that the ropes had been released, gave the signal to the winchman to heave the ropes home. The winch operator commenced heaving. The OIC realized, simultaneously with advice relayed via the pilot and master, that one of the mooring ropes had not released. He signalled to the winch operator to stop heaving, and to slacken the rope. The rope was then released by the linesmen and the unmooring operations continued. The pilot issued an incident report which was followed up by the company.
Extracts from the Company Report:
The company conducted a thorough investigation and analysis of the incident, focussed upon human factors rather than blame. The salient points are as follows;
- Mooring operations are covered by company’s Safety Management System, including work control manuals with specific reference to mooring. Procedures refer to appropriate industry publications, cover familiarization/ training, job hazard analysis and proper operation/ maintenance of equipment.
- The mooring team consisted of the OIC and four ratings. All personnel were experienced, considered fully competent for the mooring operation, and had completed familiarization training prior to taking up any mooring duties. They were familiar with the terminal, and the communication practices between the linesmen and the mooring stations.
- Prior to departure a tool box talk was given to all mooring party members and reported to the bridge. Similarly, the unmooring plan was agreed between master and pilot, then communicated to all.
- Communications were supervised by the bridge. Standard practice is that the OIC communicates directly with the shore linesmen and vice versa using visual signals. There is no bridge intervention unless further clarification or guidance is required.
- The linesmen unhook the lines once slacked by the vessel. The OIC and the winch operator stand close to each other, so that effective verbal communication can be maintained. During critical verification times, the OIC stands in a location which ensures that both the shore and ship’s teams can be Following confirmation of release from the hooks, (by visual signal, which is acknowledged), the vessel heaves up the lines using the winches, initially at slow speed.
- This was effectively implemented whilst releasing the headlines. With the breast lines however, and at the critical point of release, the OIC was not standing at the proper location, and was not able to verify that all lines were released. Instead an assumption was made that the lines had been released, based upon the elapsed time from the last visual contact with the Although unintentional, this was a violation of standard practice. A further error was that the winch was operated at high speed, in contravention of standard practice. It was not clear why the winch operator acted that way.
- No contributory causes of the error have been identified. Fatigue was determined not to be a factor
- A review of the unmooring Job Hazard Analysis shows that there is no direct reference to the need to communicate with shore staff to prevent this kind of incident. (Procedural improvement indicated).
- The OIC had become involved in the releasing/retrieval of the mooring ropes and had momentarily assisted the crew instead of overseeing the operation. (Lack of situation awareness).
- The lines of communication, for handling the breast lines, were insufficient as the OIC had not received a signal from the linesmen ashore to verify that all was clear and the mooring rope tails had been released from the hooks. Additionally, this had not been acknowledged, and the OIC was not in a position to determine that shore linesmen were in a position of safety away from the hooks. (Lack of proper communication and improper position for the operation).
- A human behavioural issue was identified in the unintentional risk taken by using time elapsed to infer critical information related to mooring operation. (Performance of a practice without risk appreciation).
- Finally, the fact that the winch was operated at high speed at the initial stage of heaving up implies inadequate supervision. (Improper operation of equipment and lack of proper supervision).
- The near miss analysis to be discussed with the terminal operator to improve existing mooring practices.
- Just Culture process was applied with regard to the OIC, and will include a training session.
- A Fleet Circular issued, sharing the lessons learnt and requesting a mooring operation evaluation review to be discussed on board and shared across the The review to include a mooring operation hazard analysis to ensure the lessons learnt from this near miss are incorporated, for use in future toolbox talks.
- The lessons learned are to be included in Fleet Training Officer material for on-board training.
The Maritime Advisory Board emphasised that the person in charge should not get involved in handling ropes and should always maintain a full oversight of the operation. The company’s effort to investigate the human factors is refreshing – it is only by doing this that root causes will be properly addressed, as opposed to simply saying “Did not comply with the SMS!”.
Useful references – OCIMF Effective mooring, and the Nautical Institute Mooring and Anchoring Ships Volumes 1&2.