INVESTIGATION

CASE 10
The Lessons
1. It had become common practice for the
tugs in the port to be moved when their
berths were required by other vessels.
While it was possible for manned tugs to
move unmanned tugs, as occurred in this
accident, other options were available.
These included fully crewing and moving
each tug individually, or using a crew to
provide deckhands to handle the ropes on
an ‘unmanned’ tug so it could be moved
by a manned tug. In the event, the crews
chose to adopt a method that took them
the least time but exposed them to the
greatest risk as it required them to make
the most transfers between vessels to
unsecure and secure the mooring ropes.
2. Although tugs were frequently relocated
within the port, the operation had not
been the subject of a formal assessment,
and the tug operating company had not
issued specific instructions on how the task
should be accomplished.
3. The job of moving unmanned tugs had
become routine over time. The company
had safe systems of work in place for
mooring operations and for barge
handling; both of these safe systems of
work contained risk assessments and
control measures that could have easily
been applied to the task of moving an
unmanned tug. A ‘Tool-Box Talk’ should
be conducted before any hazardous task is
attempted, even when the perceived task is
deemed routine; this will allow all of those
involved in the task to be briefed, hazards
identified and an agreed safe procedure
adopted prior to commencing the task.
4. No one witnessed this accident. As such
it was not possible to determine exactly
how the engineer ended up between the
two tugs. It is most likely that he slipped,
tripped or fell as he attempted to pass
a mooring rope between the two tugs
before they were alongside each other. No
attempt should be made to pass between
two vessels until they are firmly alongside
each other, have stopped moving, and
permission has been given by the master to
cross.
MAIB Safety Digest 1/2017
23