Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2498
Initial Report
During routine mooring operations, while a crew member was in the process of heaving up the ground line, it appeared to be short. An attempt was made to use a messenger line, connect it to the ground line, and secure the ground line sufficiently on deck using the capstan before transferring it to the bollard. During the heaving operation, the crew member in charge at the mooring station repeatedly requested shore personnel to provide a better arrangement. Whilst they were attempting to solve this issue, the crew member operating the capstan continued to heave in the line until, unfortunately, the messenger line parted, causing the ground line to strike the crew member who was near the capstan at the time.
CHIRP Comment
CHIRP has contacted the reporter to find out how the injured crew member fared, and thankfully, they have recovered, but it was very fortunate that the injury was not more serious.
All the signs indicated that the ground line was too short, and while negotiating for a better arrangement, the operation continued, resulting in the messenger being over-tensioned and parting.
The Advisory Board commented that marina ground lines are often found in poor condition, increasing the risks to the crew during their use. Marinas should take greater responsibility for their condition and increase the frequency of their inspections and maintenance.
A risk assessment related to mooring in port should include ground lines as part of that assessment. The fact that the line was still being heaved on board despite concerns over its suitability was an excellent case for a “stop-work authority” to be enacted.
Key Issues relating to this report
Local Practices (Deviation) – The use of a short ground line and messenger workaround indicates a normalised departure from the standard procedure—a workaround that became routine under operational pressure.
Situational Awareness – There was a failure to maintain an accurate awareness of line tension and the risk of the ground line parting while negotiating with the shore.
Communication – Although concerns were raised, there was no effective closed-loop communication between the person in charge and the capstan operator.
Alerting – Repeated requests by the mooring station went unheeded, indicating a breakdown in the system of alerting and assertive challenge.
Teamwork – Lack of a shared mental model and coordination between shore personnel, the mooring leader, and the capstan operator.
Pressure – implicit in the fact that they continued the operations, potentially from schedule or routine expectations, and this overrode safety concerns.
Key Takeaways
Seafarers – If it doesn’t feel safe, stop.
Don’t continue unsafe work—stop and speak up clearly. Know the risks, don’t normalise shortcuts, and act on warning signs.
Managers – Unsafe workarounds reveal unsafe systems.
Workarounds mean something’s wrong. Fix procedures, empower crews to halt unsafe tasks, and learn from close calls.
Regulators – Deviations are symptoms, not root causes.
Focus on systems, not just actions. Promote human factors reporting and ensure procedures align with real-world demands.