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o Before arrival, the master conducted a meeting to brief officers on the mooring plan and the constraints at the port. The vessel, an 85,000-tonne bulk carrier, is provided with 16 mooring lines on mooring drums. As it was, the vessel was not accommodated along her full length of 287rn at the berth; her aft section was to overhang the end of the berth by about 20m. The plan was to berth the vessel 6-3-3 forward and aft. This mooring could be achieved by doubling the existing ropes and the mooring plan agreed with the pilot. The lead of all mooring lines was relatively short as the vessel was not berthed with her full length alongside the berth. The master protested to the agents and charterers immediately after berthing about the inadequacy of moorings and the unsafe conditions for rigging the gangway. Sometime after berthing it was observed that the vessel's bow had come off the berth by about l m. The third mate and an ordinary seaman (OS) proceeded to the forecastle deck and the second mate and one able seaman proceeded aft. To bring the bow alongside, the third mate heaved on the starboard breast line and second mate slackened the stern lines. The third mate proceeded to heave up a head line and the OS was asked to heave up the star-board breast line. Within 10-15 seconds of the OS being asked to heave up the starboard breast line a loud sound of parting rope was heard. The third mate immediately came to the starboard side where he observed the OS, prone and bleeding, between the mooring winch and the control stand. The broken mooring rope was a 70mm diameter polypropylene monofilament 8-strand plaited rope that on visual examination, was found to be in a generally good condition. The rope had parted at a point about 14m from the eye. As a result of being hit on the head by the parted breast line the OS was declared dead at the hospital that same evening. Contributing factors o The OS, although holding a šualification as an Efficient Deck Hand (EDH) and havingbeen given awareness training for the mooring ešuipment on this vessel, had only recently been promoted to OS from steward. He had little experience of tending to the moorings of a large vessel in such difficult environmental circumstances. o The plan of mooring ešuipment at forecastle deck shows that the breast line is passed through the pedestal roller fitted aft of the mooring winch on deck. In this arrangement the winch operator's position is in the snap back zone of the breast line. o It is likely that the OS did not realise that he was standing in the snap-back zone for the rope he was hauling as the snap-back markings were no longer clearly marked on deck, o The head line that the third officer was hauling was approximately twice the length of the line that the OS was working, already pretensioned during initial efforts to bring the ship back alongside. Although the ropes were of similar materials it is likely that the shorter length of rope acting as the breast line began taking on a breaking load, while the forward head line was still taking up the elasticity of the rope. o The lead of all mooring lines was relatively short, reducing the length of wharf available. The vessel was also unable to heave on her stern lines and bow lines simultaneously to keep the vessel alongside, as the overhang would have resulted in the stern moving in and the bow moving out. o Coordination betweenthe terminal, pilots and the vessel was poorly managed and did not provide for safe berthing of the vessel. The issues with inadequate mooring arrangements, safe access and egress, and the commercial pressures of starting cargo operations all stretched senior management onboard. This resulted in confusion, incomplete preparation and inadešuate shore-to-ship coordination. This failure also carried over to the following evening when another rope failed at the next high flood tide. This time the rope was not being attended to. o Given the size of the ship, reduced wharfage, and tidal currents, the most appropriate action would have been to have a tug standing by during the manoeuvres. Actions taken o The snap-back zones have been re-established and now include the pedestal fairlead position. All fairlead rollers at the forecastle deck have been derusted and painted to smooth the surface. o Crew educated on the snap-back zones at forward and aft mooring stations. o A campaign on mooring safety has been carried out in the company fleet. Every vessel in the fleet reviewed their mooring arrangement and prepared a risk assessment for mooring as per fitted mooring arrangement and in normal weather conditions. The countermeasures to these hazards were also identified. The šuality and quantity of mooring ropes rešuired for each vessel must be identified and documented. REPORT NUMBER 201372 Loss of anchor o A few hours after leaving port the weather conditions deteriorated and the master reduced speed, taking all necessary precautions for navigation in bad weather. Sometime later the weather improved and the master had the crew check the forecastle for any damage, the lashing, and anchor stowage. All was found in order. The same day, the chief officer went forward on safety rounds and both anchors were once again found in the proper stowage position and secured. Later that day the weather turned bad again until the late morning of the next day. At that time, the starboard side anchor was found missing, while the chain, including the swivel and the end link, was still onboard. What went wrong A tongue type stopper is fitted in such a way that the horizontal link of the chain rests on the tongue, thus taking the weight of the anchor and anchor chain, when the anchor is fully housed. It is believed that the anchor, although lashed and secured with a turnbuckle, was not fully resting on the chain stopper. This is supported by the fact that the anchor had earlier been found loose and the turnbuckle was retightened. If the anchor was fully housed and properly resting on the stopper, the lashing would not have been found loose. Therefore the anchor, hanging slightly, was subject to heavy movements due to bad weather. This caused the pin of the D-shackle to be lost, resulting in the loss of anchor. After the incident, corrective action was taken such that the anchor chain was properly resting on the stopper when the anchor was in the fully stowed position. Also, the locking pin on the D-shackle has been welded to avoid accidental release. MARS editor's note: While it is indeed important to have the o anchor chain snug to the stopper, all other gear such as the turn-buckles should also be snugged up so as to hold the anchor fast against the anchor pocket. REPORT NUMBER 201370 Passengers lacked information A small coastal vessel,on a scheduled route carrying passengers and cargo to several isolated settlements, was proceeding at night towards a port stop of the route. A series of events in the wheelhouse conspired to cause the vessel to sideswipe an outlying island near the port. Within a very short time the vessel was listing heavily to starboard due to water ingress in several tanks. The impact and the listing to starboard roused most passengers and crew; some of the crew began instructing berthed passengers on the lower decks to go to the main saloon. People had difficulty moving in the crowded corridors and climbing the stairs with the vessel in its listed condition. Passenger-care crew members, having received no information from the bridge or having sought clarification, were unable to answer passenger šuestions regarding the situation. Engine room crew attempted to call the bridge, but got no response. Within minutes, passengers were assembling on the observatory deck. Some berthed passengers wore life-jackets; others, still uninformed of the nature of the emergency, arrived without their lifejackets - some in pyjamas and bare feet. Distribution of lifejackets was done by crew and passengers from the deck storage box just outside the main saloon. Lacking clear directions from the crew, only some passengers donned their lifejackets, while some children were given adult-sized lifejackets. The vessel remained afloat and was able to dock. It was then discovered that two passen-gers - one of whom had reduced mobility - had remained in their cabin on a lower deck. Passengers then disembarked and the crew searched the vessel for any remaining passengers. Company practice was to provide a safety briefing to pas-sengers who embarked at the initial departure port, on the various lifesaving appliances, including life rafts and lifejackets, as well as their stowage and location. These passengers were told that, in the event of an emergency, they were to assemble in the uppermost central saloon. They also received a demonstration of the general alarm. In this occurrence, 41 passengers embarked at the initial departure port and received the briefing; on the other hand, 219 other passengers, who embarked at later ports, did not receive the briefing. Some of the findings related to passenger briefings and emergency communication brought o light by the investigation were: o The failure to notify those on board of an emergency situation delayed emergency response and increased the risk of counterproductive behaviour. o Passengers who are not given safety briefings are deprived of key Information, putting them at increased risk in the event of an emergency. MARS editor's note: Al-though this event occurred in 2007 on a small coastal liner, the lack of adešuate passenger brief-ings is of concern to the entire passenger-carrying industry. Recently, it was reported to MARS that, on a major English Channel crossing service, passenger safety briefings were totally absent. Safety is beginning to slip. Must we wait for another Herald of Free Enterprise to occur before returning to what should already be an established best practice?