Dec 9

Lessons from Tragedy: Preventing Mooring Line Accidents – The Mona Manx Incident

Lessons from Tragedy: Preventing Mooring Line Accidents – The Mona Manx Incident

This post analyses the incident, explores safety measures to prevent similar accidents, and challenges readers with thought-provoking questions to enhance their understanding of maritime safety protocols.

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Read the Report and Answer the Questions

What happened during the mooring operation of the bulk carrier Mona Manx?

On August 26, 2021, the second officer of the Isle of Man registered bulk carrier Mona Manx was fatally injured during a berthing operation at Puerto Ventanas, Chile.
He was struck by a recoiling mooring line that had become entrapped between the vessel and a fender on the berth. The line suddenly released as the vessel manoeuvred astern under its own power.

Why was the second officer standing in the danger zone of the mooring line?

It is highly probable that the second officer moved to the danger zone to obtain an improved view of the mooring line as the vessel manoeuvered astern along the berth. His initial position on the aft mooring deck did not allow him to monitor the spring line and fenders effectively.

Was the Mona Manx manoeuvring in accordance with the port’s procedures?

No, the Mona Manx was manoeuvring astern under its own power, which was in contravention of the port’s procedures. The terminal’s mooring procedure specifically stated that no ship running manoeuvres should be conducted at the site.

Were the risks associated with the mooring operation properly assessed and mitigated?

No, the risks associated with the specific maneuver, including line entrapment and vertical recoil, were not adequately assessed or mitigated. The vessel's SMS did not require a toolbox talk for this manoeuvre, and the port's risk assessments did not include the hazard of mooring lines becoming entrapped.

Was the master of the Mona Manx aware of the port's procedures regarding the use of engines alongside?

It is probable that the master was unaware of the port’s requirement prohibiting the use of engines for maneuvering alongside. This information was not included in the documentation provided to the master before arrival. Additionally, the pilot was also seemingly unaware of this procedure.

Did the Code of Safe Working Practices for Merchant Seafarers provide sufficient guidance on the risks of mooring operations?

The COSWP did address snap-back zones but did not provide sufficient detail on the risks of vertical recoiling lines or line entrapment. This accident highlights the need for improved guidance on these specific hazards.

Could communication issues have contributed to the accident?

Yes, it is possible that congested radio communication between the mooring stations and the bridge reduced the crew's ability to safely conduct the berthing operation. The reliance on a single VHF channel for all communication may have led to missed instructions or warnings.

What actions have been taken to prevent similar accidents in the future?

The Maritime and Coastguard Agency has updated the COSWP to include guidance on the risks of line entrapment and vertical recoil. Union Marine Management Services, the ship's management company, has also taken steps to improve crew training and awareness. Puerto Ventanas S.A. has held toolbox talks with its shore staff and is recommended to review and update the information provided to masters and pilots before port calls.
Summary

Date: November 2024

Source: Marine Accident Investigation Branch (MAIB) Report 18/2024

Subject: Investigation of fatal accident during mooring operations on board the bulk carrier Mona Manx at Puerto Ventanas, Chile, on 26 August 2021

https://www.gov.uk/maib-reports/mooring-deck-accident-on-bulk-carrier-mona-manx-with-loss-of-1-life

Synopsis:
The second officer of the Isle of Man registered bulk carrier Mona Manx was fatally struck by a recoiling mooring line while the vessel was berthing at Puerto Ventanas, Chile.

The line, an aft spring line, had become entrapped, likely on a fender, and then suddenly released as the vessel manoeuvred astern under its own power, causing it to recoil upwards.

Key Findings:
  • The second officer was standing in the danger zone of the tensioned mooring line when it released. It's likely he moved to this position to gain a better view of the line during the manoeuvre.
  • Mona Manx was manoeuvred astern using its own engine, violating the port's procedures which specifically prohibited “ship running manoeuvres” at the site.
  • The Code of Safe Working Practices for Merchant Seafarers (COSWP) did not address the specific hazards of line entrapment and vertical recoil.
  • The Master/Pilot Exchange (MPX) did not include all available information about safely berthing Mona Manx, such as the port's prohibition on using engines while alongside.
  • No toolbox talk or risk assessment was conducted for the manoeuvre of moving the vessel astern with mooring lines deployed, failing to identify and mitigate the hazard of line recoil.
  • Congested radio communication may have hampered the crew's ability to safely conduct the berthing operation.

Contributing Factors:
Line Entrapment: The design of the berth fenders, combined with the need to slacken the spring line during the manoeuvre, created a situation where the line could easily become trapped.

Use of Engines: Moving the vessel astern under its own power while alongside created a dynamic environment that increased the risk of line tension and sudden release.

Inadequate Risk Management: Both the vessel's SMS and the port's risk assessments failed to address the hazards of line entrapment and vertical recoil. The COSWP, while mentioning snapback zones, did not specifically cover these risks.

Communication Issues: Congestion on the single VHF radio channel used by the crew may have contributed to ineffective communication and supervision during the mooring operation.

Quotes from the Source:
Port's mooring procedure: "(…) No ship running manoeuvres are to be considered at this site."

COSWP on mooring operations: "When moorings lines are under strain, all personnel in the vicinity should remain in positions of safety, i.e. avoid the snap-back zones... seafarers should always be aware of other areas of potential danger – the whole mooring deck may be considered a danger zone."

OCIMF Effective Mooring guidance: "Where possible, ask the bridge team to monitor you and to make sure that your position is not at risk from possible snap-back... not to stand close to the line’s path. You will be at risk of serious injury or death because you won’t be able to react in time."

Actions Taken:
The Maritime and Coastguard Agency amended the COSWP to include guidance on the vertical component of recoiling lines and the risks associated with line entrapment.
Union Marine Management Services Pte. Ltd has taken several actions, including fleet-wide sharing of the incident, reinforcement of toolbox talks and buddy culture, and review and update of SMS procedures regarding engine use alongside and mooring line entrapment.
Puerto Ventanas S.A. conducted toolbox talks with shore staff to disseminate safety lessons from the accident.

Conclusion:
The tragic death of the second officer on Mona Manx highlights the crucial need to thoroughly assess and mitigate the often overlooked risks associated with mooring line entrapment and vertical recoil. Clear communication, adherence to port procedures, and comprehensive risk management are paramount in ensuring safe mooring operations.