MARINE SAFETY INVESTIGATION REPORT

Investigation into the fatality on board the

Maltese registered container vessel

CMA CGM Pegasus

in the port of Dalian, China

on 24 August 2013

201308/024

MARINE SAFETY INVESTIGATION REPORT NO. 20/2014

FINAL

Marine Safety Investigation Unit

ii

Investigations into marine casualties are conducted under the provisions of the Merchant

Shipping (Accident and Incident Safety Investigation) Regulations, 2011 and therefore in

accordance with Regulation XI-I/6 of the International Convention for the Safety of Life at

Sea (SOLAS), and Directive 2009/18/EC of the European Parliament and of the Council of 23

April 2009, establishing the fundamental principles governing the investigation of accidents

in the maritime transport sector and amending Council Directive 1999/35/EC and Directive

2002/59/EC of the European Parliament and of the Council.

This safety investigation report is not written, in terms of content and style, with litigation in

mind and pursuant to Regulation 13(7) of the Merchant Shipping (Accident and Incident

Safety Investigation) Regulations, 2011, shall be inadmissible in any judicial proceedings

whose purpose or one of whose purposes is to attribute or apportion liability or blame, unless,

under prescribed conditions, a Court determines otherwise.

The objective of this safety investigation report is precautionary and seeks to avoid a repeat

occurrence through an understanding of the events of 24 August 2013. Its sole purpose is

confined to the promulgation of safety lessons and therefore may be misleading if used for

other purposes.

The findings of the safety investigation are not binding on any party and the conclusions

reached and recommendations made shall in no case create a presumption of liability

(criminal and/or civil) or blame. It should be therefore noted that the content of this safety

investigation report does not constitute legal advice in any way and should not be construed

as such.

© Copyright TM, 2014.

This document/publication (excluding the logos) may be re-used free of charge in any format

or medium for education purposes. It may be only re-used accurately and not in a misleading

context. The material must be acknowledged as TM copyright.

The document/publication shall be cited and properly referenced. Where the MSIU would

have identified any third party copyright, permission must be obtained from the copyright

holders concerned.

MARINE SAFETY INVESTIGATION UNIT

Malta Transport Centre

Marsa MRS 1917

Malta

iii

CONTENTS

LIST OF REFERENCES AND SOURCES OF INFORMATION .......................................... iv

GLOSSARY OF TERMS AND ABBREVIATIONS ................................................................v

SUMMARY ............................................................................................................................. vi

1 FACTUAL INFORMATION .............................................................................................1 1.1 Vessel, Voyage and Marine Casualty Particulars .......................................................1 1.2 The Vessel ..................................................................................................................2 1.3 Narrative .....................................................................................................................2 1.4 The Mooring Crew .....................................................................................................5 1.5 The Mooring Equipment ............................................................................................6 1.6 Mooring Practices .......................................................................................................8 1.7 Safety Management and Crew Training ...................................................................12

2 ANALYSIS .......................................................................................................................14 2.1 Aim ...........................................................................................................................14 2.2 Fatigue ......................................................................................................................14 2.3 Cause of the Accident ...............................................................................................14 2.4 Experience of the Mooring Team .............................................................................14 2.5 Design of the Mooring Equipment ...........................................................................15 2.6 Mooring Practices .....................................................................................................15 2.7 Teamwork and Informational Support .....................................................................17

3 CONCLUSIONS ...............................................................................................................19 3.1 Immediate Safety Factor ...........................................................................................19 3.2 Latent Conditions and other Safety Factors .............................................................19 3.3 Other Findings ..........................................................................................................20

4 ACTIONS TAKEN ...........................................................................................................20 4.1 Safety Actions Taken During the Course of the Safety Investigation ......................20

iv

LIST OF REFERENCES AND SOURCES OF INFORMATION

Crew members and managers MV CMA CGM Pegasus.

Oil Companies International Marine Forum [OCIMF]. 2008. Mooring Equipment

Guidelines MEG3 (3rd

Ed.). Livingston: Witherby Seamanship International.

International Standard Organization. (2012). ISO 3730:2012(E): Shipbuilding and

marine structures-mooring winches. Geneva: Author.

Marine and Coastguard Agency [MCA]. 2011. Code of safe working practices for

merchant seamen (Consolidated Ed.). Norwich. The Stationary Office.

v

GLOSSARY OF TERMS AND ABBREVIATIONS

°C Degrees Celsius

AB Able seaman

BV Bureau Veritas

CCTV Closed circuit television

DPA Designated person ashore

GT Gross tonnes

kW Kilowatts

LT Local time

M Metres

MSIU Marine Safety Investigation Unit

OS Ordinary seaman

PPE Personal protective equipment

RA Risk assessment

RPM Revolutions per minute

SMS Safety management system

TEU Twenty-foot equivalent units

vi

SUMMARY

On 24 August 2013, at about 1853, an able seaman (AB) was struck by a mooring

rope during unberthing operations on board the Maltese registered container vessel

CGM CMA Pegasus. The AB suffered a serious injury to the back of his head and

was taken to a nearby hospital. He succumbed to his injury later during the night due

to excessive bleeding.

The safety investigation was unable to determine as to how the mooring rope jumped

off the roller guide and caused the accident. However, a number of safety factors

were identified, including incorrect procedures, inadequate supervision and

inadequate risk management during the mooring operations. The safety investigation

also concluded that the ergonomics at the forward mooring station had contributed to

the accident.

Taking into consideration the safety actions taken by the CMA Ships, no

recommendations have been made by the Marine Safety Investigation Unit (MSIU).

1

1 FACTUAL INFORMATION

1.1 Vessel, Voyage and Marine Casualty Particulars

Name CMA CGM Pegasus

Flag Malta

Classification Society Bureau Veritas

IMO Number 9399210

Type Container

Registered Owner Alize 1956

Managers CMA Ships

Construction Steel (Double bottom)

Length overall 363.61 m

Registered Length 351.29 m

Gross Tonnage 131332

Minimum Safe Manning 17

Authorised Cargo Containers

Port of Departure Tanjin, China

Port of Arrival Dalian, China

Type of Voyage Coastal

Cargo Information 7227 TEUs

Manning 29

Date and Time 24 August 2013 at 1853 (LT)

Type of Marine Casualty Very Serious Marine Casualty

Place on Board Forecastle Deck

Injuries/Fatalities One fatality

Damage/Environmental Impact None

Ship Operation Normal Service – Alongside/Moored

Voyage Segment Departure

External & Internal Environment Clear weather, twilight, good visibility, light airs

from the South-East. Air temperature was

recorded at 28°C.

Persons on Board 29

2

1.2 The Vessel

CMA CGM Pegasus is a 131,332 gt, fully cellular container ship, owned by

Alize 1956 and managed by CMA Ships, Marseille. The vessel was built by Hyundai

Heavy Industries in Ulsan, Republic of Korea in 2010 and is classed by Bureau

Veritas (BV).

The vessel has a length overall of 363.61 m, a moulded breadth of 45.60 m and a

moulded depth of 29.74 m. The vessel has a summer draught of 15.50 m and a

summer deadweight of 131,268 tonnes. CMA CGM Pegasus has a displacement of

171,371 tonnes and can carry 11,388 TEUs.

Propulsive power is provided by a 12-cylinder MAN-B&W 12K98ME-C, two-stroke,

single acting slow speed diesel engine, producing 72,079 kW at 104 rpm. This drives

a fixed pitch propeller to give a service speed of about 24.50 knots.

CMA CGM Pegasus is operated on the French Asia Line service. A round trip would

take about two to three months. Prior to 24 August 2013, the vessel had called at

Dalian on 02 June 2013. In the 99 days prior to the accident, i.e. between 19 May

2013 and 24 August 2013, the vessel had called at 23 ports. At the time of the

accident, the vessel was loaded with 7,227 TEUs and she was on her West-bound leg

of the service with the next scheduled port of call being Busan, Republic of Korea.

1.3 Narrative

On 24 August 2013, the vessel completed its cargo operations at 18001. Soon

afterwards, assigned crew members proceeded to their respective departure stations on

the bridge, forecastle deck and poop deck. The pilot boarded at about 1850.

Soon after the pilot embarked, the master ordered the fore and aft stations to reduce

the mooring lines to two spring lines and two headlines or two sternlines. At about

1852, the master ordered the fore and aft mooring parties to release two head and two

stern lines. Accordingly, the mooring crew on the forecastle deck lowered the two

outboard headlines on winches ‘M3’ and ‘W1’ (Figure 1). In order to stow the

1 Unless otherwise stated, all times are local.

3

mooring rope on the respective storage drums, the AB positioned himself at winch

‘W1’, and the ordinary seaman (OS) at winch ‘M3’. The third mate stood on the port

side stand. The bosun operated the winches from the port side control stand (Figure

1).

Figure 1: Mooring layout and position of the crew members on the forecastle deck

Although the two outboard headlines were released from the shore bollard, the

mooring ropes did not fall free into the water. Apparently, the mooring ropes were

trapped under the stern lines of MSC Savona, which was berthed ahead of

CMA CGM Pegasus. MSC Savona’s two stern lines were on the same shore bollard

(Figure 1). The bosun then tried to free the trapped headlines by hauling them and in

doing so the mooring rope at ‘W1’ jumped off the pedestal roller and hit the AB on

his chest. The AB fell backwards towards the forepeak store hatch cover and hit his

head against the steel structure of the forepeak store hatch cover. The impact of the

4

AB

OS

M3

B

AB’s Helmet

AB’s shoe

M1

B

M2

B

W1

B

W2

B

Pedestal roller

Mooring rope

AB’s shoe

mooring rope was so severe that the AB was thrown about five metres and his helmet

and shoes flew over 14 metres away (Figures 2 and 3).

Figure 2: Positions of the AB and the OS at the winches

Figure 3: The AB’s position after the accident

5

As a result of the impact, the AB suffered serious injury at the back of his head and

bled heavily. The third mate alerted the master of the accident. The injured AB was

given first aid and eventually rushed to a nearby hospital with the assistance of the

stevedores. Notwithstanding the treatment in hospital, the AB succumbed to his

injuries later during the night. The hospital reported ‘Traumatic Hemorrhagic Shock’

as the direct cause of his death.

1.4 The Mooring Crew

The Master issued a ‘Watch Plan’ every month, which determined the specific crew

members required to man the mooring stations. The ‘Watch Plan’ required four

persons at the forward mooring station, and five at the aft station, including the

officer-in-charge. The safety investigation verified that on 24 August, the mooring

crew at the forward station was in accordance with the ‘Watch Plan’ issued by the

master.

The Minimum Safe Manning Certificate issued by the flag State Administration

required the vessel to be operated by four deck officers including the master, the chief

mate, two navigational officers and six deck ratings. At the time of the accident, the

vessel was manned by six deck officers including the master, seven deck ratings and a

deck cadet.

The third mate was a Croatian national and 26 years old. He had joined the vessel in

July 2013 after completing a five month contract on board a sister vessel with the

same Company. He was attending the forward mooring stations for the second time;

the first time being when the vessel had come alongside during that morning.

The bosun, a 49 year old Filipino national, had served with the Company for over

seven years, and had always attended forward mooring stations. He was familiar with

the operation of the winches. He joined the Company in November 2007 and since

then had completed four contracts of approximately nine months each as a bosun.

Prior to joining the Company, he had served about 36 months as a Bosun and 18

months as an AB on other ships.

6

The OS, also a Filipino national, was 29 years old and this was his first contract with

the Company. He had joined the vessel in June 2013 and normally attended the

forward mooring stations.

The AB was a 35 years old Filipino national and had served for 21 months as an OS

before joining the Company in 2008. His pre-joining medical report indicated that he

was in good health. After joining the Company, he worked for about 16 months as an

OS on a number of ships, before being promoted to AB. Before joining CMA CGM

Pegasus, he had served for 14 months as an AB. The AB was assigned the 0000-0400

watch on the bridge, and between 1200-1600 on the deck. Between 0430 and 0600,

he was engaged in the berthing operation. He had rested between 0600 and 1200, and

in the preceding seven days prior to the accident, the AB had rested for 102 hours.

The working language on board was English. All the crew members communicated

well in this language.

1.5 The Mooring Equipment

The vessel was equipped with four electric mooring winches (numbered M1 to M4)

and two windlass (numbered W1 and W2) on the forecastle deck. Each mooring

winch and the windlass contained a split drum2 for the mooring rope. A 78 mm

polyamide mooring rope was mounted on each of the mooring drums with a

maximum breaking load of 120 tonnes. At most ports, the crew used only the six

winch mounted mooring ropes.

While all the mooring lines led directly from the winch to the fairlead at the stern, on

the forecastle deck, the headline at W1 and both the back springs at W2 and M4

required the use of pedestal rollers before being led through the fairlead. The

remaining three headlines led directly from the winch to the fairlead (Figures 1 and 2).

This mooring layout was in accordance to the vessel’s approved mooring arrangement

plan.

2 The split drum is composed of a tension section and a rope storage section. It has the advantage of

maintaining a constant brake holding capacity and heaving force. Annex A of ISO Standard 3730,

also recommends that synthetic ropes under tension should not be wound on a drum in more than

one layer or a shorter life span will result. This can normally only be achieved by using split drums.

7

The pedestal roller for the winch drum at W1 (and M4) was approximately two meters

from the respective winches (Figures 4 & 5). This position of the pedestal roller gave

a fleeting angle3 of 7.9° between the roller and the tension drum when the vessel was

port side alongside, and the mooring rope was used as a headline.

The fleeting angle at the pedestal roller when the mooring rope was looped around the

roller was approximately 13.3°, and 20.5° when not looped (Figures 4 and 5).

Figures 4 (top) and 5 (bottom): Fleet angles at the pedestal roller for mooring winch W1

3 The angle between the mooring line and a plane perpendicular to the axis of the winch drum.

Pedestal Roller (Rope

looped)

Storage Drum

Tension Drum

8

On the forecastle deck, the control stand for the winches was provided on each side,

i.e. port and starboard. Therefore, it was possible to operate the winches from either

side of the forecastle (See Figure 1). The maintenance records of mooring equipment

indicated no overdue maintenance. The mooring rollers were found to be well

lubricated and rotated freely. The forecastle deck was well illuminated for mooring

operations at night.

1.6 Mooring Practices

Within the safety management system, the Company had provided the vessel with

procedures on safety of mooring operations. They were:

i) Bridge-090- Ship manoeuvring duties;

ii) Cargo-100-Mooring, and

iii) Cargo-801-Use of the mooring winches and safety on mooring stations.

The Company had also identified mooring operations to be hazardous operations and

provided a generic risk assessment (RA) on mooring operations. This RA identified

‘Improper Mooring Arrangement’, ‘Bad Practices’ and ‘Mooring Line Breakage’ as

hazardous events, which could cause fatalities. The following mitigation measures

contained in various documents were recommended:

Familiarisation- Individual familiarisation of the mooring equipment

Maintenance procedure- Maintenance of the mooring equipment

SMS Bridge-090- Allocation of mooring duties and instructions

No-go areas on manoeuvring stations –keeping clear of high risk areas

Personal protective equipment (PPE) – use of correct PPE on mooring stations

DPA letter (section 1.7) following instructions and guidance in this letter

Pre-departure briefing- to be carried out by the master/officer on the mooring

station.

No additional hazards were identified by the vessel. In fact, the ship’s specific RA in

use was similar to the generic RA provided by the Company.

9

The Company also provided guidance to the crew on use of appropriate PPE. At the

mooring stations, crew members were required to wear a safety helmet, safety shoes,

safety gloves and a high visibility reflective vest. At the time of the accident, the

crew members were reported to be wearing the appropriate PPE and were also

carrying walkie talkies.

During un-berthing operations, it was a practice to put the entire mooring rope on the

storage drum (Figure 6).

Figure: 6: The storage drum and the tension drum with the pedestal roller aligned to the tension

drum

While hauling the mooring ropes, one crew member was positioned at each winch to

stow the mooring rope only on the storage drum. The tension side of the drum was

left empty when departing from a port. Since it was difficult for one person to stow

the mooring rope on the storage drum, at times the crew used a small rope to pull the

mooring rope towards the storage drum (Figures 7 and 8).

Storage Drum Tension Drum

10

Figures 7 and 8: Stowing the rope on the storage drum

During mooring operations, the bosun always operated the winches using the controls

on the side towards the quay. This meant that when the vessel was alongside to the

port side, the crew handling the mooring ropes at winches W1 and M3 would not be

in the direct line of sight of the winch operator (Figures 9 and 10).

Figure 9: View from the port side winch control stand (W1 and M3 are not visible)

W2

B

M4

M2

11

M3

W1

AB

OS

Third mate’s stand

Starboard side winch

control stand

M1

W1

M2

AB

OS

Figure 10: View from the starboard side winch control stand

From his stand, the third mate had a somewhat restricted view of the forward mooring

equipment and the crew members assigned to their respective positions (Figure 11).

Figure 11: View from the third mate’s stand on the forecastle

M3

12

1.7 Safety Management and Crew Training

The master carried out monthly safety committee meetings with all, except the on-

duty crew members. Evidence indicated that no mooring operation related issues

were raised by the crew during such meetings.

The Company also provided guidance by means of DPA Letter 10-028 on safety at

mooring stations. This guidance included the importance of PPE, communication,

snap-back danger zones, and various examples of good and bad mooring practices

(Figure 12).

Figure 12: Extract from DPA Letter 10-028

The vessel was provided with Videotel video on demand. However, during the course

of this safety investigation, the videos on mooring training could not be played.

Moreover, at the time of the on site investigation, the MSIU was not be presented with

records to indicate that the crew had undergone training on mooring operations4. The

visit on the forecastle during the course of the safety investigation revealed that the

snap back zones were found to be incorrectly and inadequately marked (Figures 13

and 14).

4 During the consultation phase of the safety investigation, the Company submitted that the on board

library had four sessions of videos related to mooring operations. The Company indicated that

according to training records, the third mate had completed two sessions out of four (in 2011 and

2013) and the AB had completed one session out of four (in 2013).

13

Figure 13: Inadequate and incorrect snap-back zone markings

Figure 14: Recommended snap-back zone markings

(Adopted from Marine and Coastguard Agency [MCA], 2011).

14

2 ANALYSIS

2.1 Aim

The purpose of a marine safety investigation is to determine the circumstances and

safety factors of the accident as a basis for making recommendations, to prevent

further marine casualties or incidents from occurring in the future.

2.2 Fatigue

On the day of the accident, the vessel berthed at 0554 and operated cargo until 1800.

The AB’s hours of rest indicated that he had received adequate rest before attending

the mooring stations. An alcohol test carried out on the remaining crew members

after the accident returned a negative result and therefore fatigue and/or alcohol

related issues were not considered to be a contributory cause to this accident.

2.3 Cause of the Accident

Although there were three other crew members present on the forward mooring

station, not one of them actually witnessed the AB being struck by the mooring rope.

The safety investigation simulated, recorded and analysed a number of possibilities in

an effort to replicate the mooring rope jumping off the roller, but it was unable to

achieve the desired results.

According to the crew members, they always looped the mooring rope around the

roller (Figure 12) and they never experienced a mooring rope jumping off the pedestal

roller. Although it remained unclear as to how the mooring rope jumped off the

roller, the safety investigation did not exclude the possibility that the AB may had

taken off the loop, and when the Bosun heaved on the stuck mooring rope, the shock

load (as the mooring rope took up weight) was transmitted up along the mooring rope,

causing it to jump off the roller.

2.4 Experience of the Mooring Team

Mooring operations were a fairly routine task for the crew. However, the third mate

was supervising the forward station for the first time. His previous experience of five

months on board the sister vessel may have not given him sufficient knowledge in

15

identifying the risks associated with jammed mooring ropes. There was no evidence

to suggest that the third mate had undergone familiarisation with the typical

arrangements of the mooring fittings on the forecastle deck by a senior deck officer.

There was also conflicting evidence of whether the bosun was instructed to heave up

the mooring rope or whether he did it on his own accord. In either case, neither did

the bosun nor the third mate warn the other crew members that weight was about to

come up on a slack mooring rope.

The vessel was not fitted with a CCTV on the forecastle deck for the master to

monitor the mooring / unmooring operations from the bridge. Since the forward

mooring deck is not visible from the bridge, the master would have been unable to

monitor the activities and therefore had to rely on the officer-in-charge of the mooring

party to execute safe and best practices during the mooring / unmooring operations.

2.5 Design of the Mooring Equipment

Pedestal rollers are installed when it is not possible to have direct leads from the

winch drum to the fairlead. It is a known fact that should a mooring rope leading

around a pedestal roller breaks, it will fly back in a wide angle. It is for this reason

that the use of a pedestal roller is generally discouraged when securing the mooring

line. However, in this case, the design and mooring layout on the forecastle deck

gave a limited choice to the crew members.

A fleeting angle of between 13.3° and 20.5° indicated that the pedestal roller was not

ideally located for mooring operations. Clearly, with a large fleeting angle in the

order of 20.5°, it was difficult for the lone crew member to stow the rope correctly on

the storage drum. This hazard was not identified by the crew members and

consequently not discussed during the vessel’s safety committee meetings.

2.6 Mooring Practices

The practice of stowing the used length of the mooring rope only on the storage drum

upon unmooring was unnecessary; the mooring rope could have been heaved on either

the tension or the storage drum upon unmooring.

16

Operating the winches from the port side winch control stand prevented a direct line

sight between the operator and the crew handling the mooring ropes on the winches.

Had the operator used the starboard side winch control for operating the winches M3

and W1, he would have been able to observe the two rope handlers5. However, when

operating winches W2 and M4, the operator would have to use the control on the port

side in order to observe the rope handlers.

The bosun did not warn the AB and the OS when the mooring rope became taut. This

could have been done by using his VHF radio to communicate with the crew.

Nonetheless, the potential for mooring ropes to unexpectedly come under load during

berthing and unberthing operations is not uncommon, and this risk was not entirely

appreciated by the mooring party.

For the vessel’s headlines to be trapped under the stern lines of the other vessel, it is

likely that the vessel’s mooring ropes were not tight, when MSC Savona berthed. It is

a normal practice for the crew to tighten the moorings in such situations. If the

mooring ropes were taut when MSC Savona berthed, it is unlikely that the vessel’s

headlines would have been trapped.

During the course of the safety investigation, the crew members were found to be

wearing the appropriate PPE, and safety helmets were fitted with chin straps. There

was no evidence to suggest that additional PPE could have prevented the accident. A

chin strap is normally not designed to provide addition helmet retention during a fall

or impact. Similarly, a Type I safety helmet6, which is generally supplied on board

vessels, is designed to provide crown protection but no protection from lateral

impacts.

Although the snap-back zones had been incorrectly marked, the safety investigation

determined that these did not contribute directly to the accident. However, should the

crew members rely on these marked zones, they might be lulled into a false sense of

security and may actually find themselves exposed to hazards by the very same things

5 Vide Figure 10.

6 Type I safety helmets provide limited impact and penetration protection to the top of the head.

These helmets are not designed to protect against lateral blows from the front, side, or rear. These

helmets, however, should be effective against small tools, bolts, rivets, sparks and similar hazards;

however, some conditions can exceed the helmet’s capacity to protect against serious injury or

death.

17

that is intended to warn them against the hazards related to mooring and unmooring

operations.

2.7 Teamwork and Informational Support

Team work is central to most settings, including any task on board. However, as

indicated above, the AB was unaware that the mooring rope was coming taut. To this

effect, the AB did not benefit from the support of other crew members. Evidence did

not indicate that the AB was warned by any other crew member to position himself

just ahead of winch W1. Moreover, the master on the bridge was unable to visually

see the crew members operating on the forecastle. Informational support, i.e. advice

from other crew members on the potential hazards of staying in that position, was

therefore not available.

The lack of informational support impinged on the judgments which the AB made (to

stay in a ‘vulnerable’ position) without recognising that a potential problem may have

existed. Thus, the issue was not necessarily limited to one of compliance with the

Company’s procedures, but also with operational (local) management in trying to

anticipate (potentially) developing safety issues.

Another benefit of informational support (and related team work) is the ability to

make proactive decisions on whether the conditions are safe and operations need to be

curtailed before the defined limit of danger is breached. This would have also been

enhanced by team work, increasing the possibility / ability to see something

anomalous and foresee how the situation may potentially run out of hand. The

identification of cues is not only related to technical skills. Experience and skills

brought by other crew members like the bosun would have been crucial in the

identification of cues. However, this possibility was severely compromised given that

the matter was never identified and discussed on board during specific risk assessment

exercises.

18

THE FOLLOWING CONCLUSIONS AND SAFETY

ACTIONS SHALL IN NO CASE CREATE A

PRESUMPTION OF BLAME OR LIABILITY.

NEITHER ARE THEY BINDING OR LISTED IN ANY

ORDER OF PRIORITY.

19

3 CONCLUSIONS

Findings and safety factors are not listed in any order of priority.

3.1 Immediate Safety Factor

.1 Although it remained unclear how the mooring rope came off the pedestal

roller, it is likely that incorrect layout of the mooring rope may have caused its

jumping off from the roller.

.2 The bosun was not in a position to observe the mooring rope handlers at the

winch since he was looking over the rails.

.3 Neither the third mate nor the bosun warned the crew when the mooring rope

was about to became taut.

.4 Informational support i.e. advice from other crew members on the potential

hazards of staying in that position, was not available to the AB.

3.2 Latent Conditions and other Safety Factors

.1 The location of the winch controls prevented a direct line of sight between the

operator and the mooring rope handlers.

.2 With the large fleeting angle at the pedestal roller, it was rather difficult for

one person to handle the mooring rope while hauling.

.3 It was unnecessary to stow the entire mooring rope on the storage drum

immediately upon hauling the mooring ropes.

.4 The officer-in-charge of the mooring operation had limited experience to

identify the risks associated with unmooring a vessel.

20

3.3 Other Findings

.1 The on board safety meetings did not identify the additional specific risks

associated with incorrect mooring practices and the layout of the mooring

fittings on the forecastle deck.

.2 The crew adapted incorrect procedures to stow the mooring rope only on the

storage drum.

.3 Due to limited berthing space at most container terminals, it was a regular

practice to use the same mooring bollards for mooring ropes from vessels at

adjacent berths, causing potential entrapment and damage to the mooring lines.

4 ACTIONS TAKEN

4.1 Safety Actions Taken During the Course of the Safety Investigation

Following the accident,

1. the Company’s Safety, Security & Environment Department has reviewed its

mooring procedures. New procedures have been introduced and enforced

since December 2013 as follows:

Bridge 090: Mooring Stations Procedures, which contains and explains

the main principles of mooring operations;

Bridge 091: Mooring Stations Checklist, which has to be completed

before each operation and reported to the bridge team; and

Bridge 092: Mooring Stations Booklet, which includes familiarisation

training and instructions, knowledge of good practices, and guidelines

for painting snap back zones.

2. The Company has also carried out a thorough review of its mooring risk

assessment as a result of this accident.

3. The Company’s procedures for familiarisation have been reviewed, including

changes in the familiarisation processes:

21

when embarking and the crew member is not familiar with equipment

and ship’s working environment;

before the ship leaves the port and the crew member is not familiar

with emergency related alarms and duties;

before taking the first navigational watch or within 72 hours for other

crew members (ship knowledge, fire fighting, life saving appliances,

Security, Environment and MLC 2006);

deck, engineering officers checklists which must be completed within

72 hours of joining the vessel and deck crew training and instruction

checklist, which must be completed before taking the first watch;

evaluation and training request to give indications on how to evaluate

the knowledge of the crew and identify training needs.

4. The Company has also addressed the mooring equipment fitted on board its

ships. All vessels in excess of 11000 TEUs are now equipped with

Bexconeema 180 m (one eye) ropes7.

5. Moreover, a new design of the mooring stations has been adopted, following

the analysis of this accident. The new design will feature in the Company’s

new buildings, which will be delivered in the next two years or so.

7 A high modulus polyethylene fibre rope. One of the main advantages of the rope is that it reduces

snap back risk.