Report on the investigation of a fatal accident during mooring operations on board the bulk carrier Mona Manx/Отчет о расследовании несчастного случая со смертельным исходом во время швартовных работ на борту сухогруза Mona Manx

Издание на английском языке
The book is dedicated to the investigation of a fatal incident that occurred during mooring aboard the bulk carrier Mona Manx. It describes in detail the circumstances of the accident, analyzes the causes and factors that contributed to the accident, and discusses measures that could prevent similar incidents in the future. The focus is on maritime safety issues, the importance of following procedures and standards, and the need for crew training. The book emphasizes that the purpose of the investigation is not only to find out the causes of the tragedy, but also to improve the safety of maritime operations in general in order to avoid a repeat of such cases.

Contents
Glossary of abbreviations and acronyms
Synopsis
Section 1 - Factual information
1.1 Particulars of Mona Manx and accident
1.2 Background
1.3 Narrative
1.3.1 Post-accident response
1.4 Environmental
1.5 Mona Manx
1.5.1 General
1.5.2 Aft mooring deck arrangement
1.5.3 Mooring line entrapment and release
1.5.4 Safety management
1.5.5 Crew
1.6 Puerto Ventanas
1.6.1 Port and pilotage
1.6.2 Berth arrangement
1.6.3 Port operational guidance
1.6.4 Port guidance for the master
1.7 Guidance on mooring operations
1.7.1 Code of Safe Working Practices for Merchant Seafarers
1.7.2 Effective mooring
1.8 Previous mooring deck accidents
1.8.1 Teal Bay
1.8.2 Zarga
1.8.3 Ocean Gold
1.8.4 Probo Bear
1.8.5 Retainer
Section 2 - Analysis
2.1 Aim
2.2 Overview
2.3 The accident
2.3.1 The mooring line strike
2.3.2 The entrapment and release of the spring line
2.3.3 The manoeuvre
2.3.4 Emergency response
2.4 Risk management
2.4.1 Mooring operations
2.4.2 Risk assessments and mitigation
2.5 Communications
Section 3 - Conclusions
3.1 Safety issues directly contributing to the accident that have been addressed or resulted in recommendations
3.2 Other safety issues directly contributing to the accident
3.3 Other safety issues not directly contributing to the accident
Section 4 - Action taken
4.1 Actions taken by other organisations
Section 5 - Recommendations
Figures
Figure 1: Puerto Ventanas site location
Figure 2: Representation, showing tugs holding Mona Manx alongside
Figure 3: Position of the aft deck mooring party at 0833:42
Figure 4: Position of the aft deck mooring party at 0836
Figure 5: Position of the 2/O at 0836:11
Figure 6: Representation, showing the position of the 2/O at the ship’s rail
Figure 7: Aft spring line recoiling upwards at 0836:31
Figure 8: Mona Manx's aft mooring deck (view to port forward)
Figure 9: Fenders at Puerto Ventanas Site 3
Figure 10: Representation of entrapment of aft spring line between Mona Manx's hull and the second fender
Figure 11: View of aft mooring deck from Mona Manx's port bridge wing