The incident 

On the afternoon of the 20 May 2025, the pumpman of the Gibraltar Registered tanker Nisyros was fatally injured whilst operating the port forward mooring winch during heaving in excess rope becoming entrapped in the mooring rope around the winch and sadly died of multiple injuries.

At the time of the accident the pumpman was alone on the fo’c’sle as the AB (Deck) had moved to a position further down on the main deck port side in preparation to receive a heaving line which would then be attached to the forward spring. As no one witnessed the accident it is difficult to reach a firm conclusion as to what exactly happened.

However, the Mooring System Management Manual stipulates that there should always be a minimum of two experienced persons at each mooring station throughout the operation, apart from the Officer in charge of the mooring station. The role of the officer is to supervise and keep an overview of the mooring operation.

On this occasion there was not an officer undertaking this role. In effect the only person on the fo’c’sle was the pumpman who was operating the Port forward mooring winch by himself, at the same time as possibly ensuring that the mooring rope was correctly feeding and winding onto the winch’s drum.

The investigation concluded that:

• The composition of the forward mooring party was not in compliance with the requirements of the mooring manual.
• Page 8 of the owner’s preliminary assessment of the incident states that, no officer was assigned to the mooring station forward in order to maintain compliance with hours of work and rest.
• The pumpman was operating the winch at the same time as ensuring that the mooring rope was possibly correctly feeding and winding on to the mooring winch’s drum.
• Due to repetitive nature of the work undertaken, the crew may have become complacent.
• It is possible that the mooring winch actuator lever had been incorrectly secured in the running position by using the safety clip or external device.
• At this time, he may have become entangled in the slack rope, in all likelihood by standing too close to the winch’s drum subsequently resulting in being dragged in feet first under the rotating drum.

Safety issues directly contributing to the accident and have resulted in recommendations

No officer was assigned to the mooring station forward in order for the officer to maintain compliance with hours of work and rest. The composition of the forward mooring party was not in compliance with the requirements of the mooring manual. There was therefore lack of supervision at the mooring station.

No specific risk assessment was available addressing the risks and hazards associated with working with mooring winches, as outlined in the OCIMF Effective Mooring guidelines.

It was established that the Master did not notify the Company that the mooring party was reduced to two seafarers instead of the three required under the Mooring System Management Plan. While this adjustment was made to maintain compliance with hours of work and rest regulations, the deviation was not brought to the Company’s attention through any of the established channels, such as Safety Committee meetings, Master’s Reviews of the SMS, or the reporting of non-conformities.

Other safety issues directly contributing to the accident

Inspection revealed that the spatial distance between the windlass operational lever and the drum was 1.90 m. Taking this into consideration, if the winch had been operated in accordance with its design function, it would have been difficult for a person located by the drum, or at the position where the deceased was found, to be within simultaneous reach of the operational lever.

It is therefore possible, that the mooring winch actuator lever had been incorrectly secured in the running position by using the safety clip or other external device.

Considering the deficiency described on the Flag State Inspection report, company internal accident investigation, and the possibility of the winch remaining engaged, it may indicate that an unsafe practice of securing the windlass in an operational mode thus allowing the operator to move away from the operational position may have on occasions taken place on the ship.

The mooring winch was in all likelihood operational at the same time as the Pumpman was possibly ensuring that the mooring rope excess slack was correctly feeding and winding on to the mooring winch’s drum. At this time, he may have become entangled in the slack rope, in all likelihood by standing too close to the winch’s drum subsequently resulting in being dragged in feet first under the rotating drum.

Due to repetitive nature of the work undertaken, the crew may have become complacent.

Other safety issues not directly contributing to the accident

The Gibraltar Ambulance Service no longer maintains the dedicated marine assets, specialist equipment, or specific training protocols required for the safe sea-based transfer of paramedics to vessels at anchor or elsewhere within British Gibraltar Territorial Waters (BGTW).

For 17 years prior to 2020, there was in place a system available to any vessel in distress within BGTW to receive prompt medical attendance and professional casualty retrieval from the Gibraltar Ambulance Service. Since 2020, operational capacity has been restricted to responding to medical emergencies on vessels that are securely berthed within the port.

Actions taken

In response to this accident, MM Marine has undertaken the following preventive measures:

• Relevant SMS and Mooring & Lines Management Plan procedures were reviewed and found to be in order.
• A Safety Flash (01/2025, attached for reference) was circulated to the fleet on the first day. An additional Safety Meeting was conducted on board all fleet vessels, during which its contents were discussed with all officers and crew, highlighting the serious consequences arising from the incident.
• A Safety Alert (01/2025, attached for reference) was circulated to the fleet on 23rd May, and the preventive measures listed therein were analysed and discussed with all officers and crew.
• Reinforcement of training through onboard drills and supervision audits.
• All fleet deck personnel have been instructed to complete OLP Training No. 0370 – Mooring Risk Assessment and Management in July 2025.
• All fleet crew have been instructed to complete OLP Training No. 0181 – Ship-to-Ship Transfer Operations in July 2025.
• As involved parties in the incident, the Master and Chief Officer of Nisyros will undergo re-training in safe mooring practices prior to their next assignment.
• Enhanced compliance checks during mooring operations are to be performed through the end of Q3 2025.
• Unannounced mooring audits will be implemented fleet wide.
• The implementation of additional safeguards against unsafe winch operation is currently under research and consideration.
• Although fleet manning complements already exceed the Minimum Safe Manning requirements set by flag states—including duplication of certain positions (e.g., two Pumpmen)—they have undertaken a review of current manning levels in conjunction with available cabin and space capacity on each vessel. This was done to further ensure the consistent presence of a supervisor at each mooring station.

As a result, and based on each vessel’s operational utilisation intensity, they have decided to implement the following adjustments:

• Qingdao-type vessels: One additional 2nd Officer and one additional OS will be assigned.
• Fujian-type vessels: One additional OS will be assigned.
• The relevant incident investigation reports will be updated with any new findings and recirculated to the fleet to enhance awareness and help prevent recurrence.
• This incident will be discussed across the fleet during upcoming HSSCMs, with a focus on bridge teams and deck personnel.
• The incident, along with the investigation results and lessons learned, will be included in the agenda of the next quarterly Management Review Meeting.
• The incident has been added to the Company’s Familiarization Agenda, to be discussed during pre-joining familiarisation and presented in the next in-house training session or open forum.
• The Office of the Marine Accident Investigation Compliance Officer released a Safety Bulletin (No:01) in June 2025 highlighting the dangers and risks associated with mooring operations.

Recommendations

The Marine Accident Investigation Compliance Officer acknowledges that the company has conducted a thorough and timely internal investigation into the accident. Their efforts to identify contributing factors and implement preventative measures demonstrates a proactive commitment to safety. The actions taken, including revisions to manning, risk assessments, training, and procedural oversight, are intended to mitigate future risks and enhance the safety of mooring operations across the fleet.

MM Marine Inc is recommended to:

• Include in the company SMS a specific risk assessment addressing the risks and hazards associated with working with mooring winches, as outlined in the OCIMF Effective Mooring guidelines and COSWP, explicitly considering the operational and safety risks posed by winches.
• Revise manning levels to ensure that a minimum of two experienced personnel is available at each mooring station throughout operations, in addition to the Officer in Charge, to ensure compliance at all times with the Mooring System Management Plan.
• Ensure that safe mooring operations are systematically included in the agenda for all ship inspections and internal audits.
• Ensure that a toolbox meeting is conducted prior to each mooring operation to review all associated risks, hazards, and the mooring plan.
• Circulate fleet-wide safety bulletins to inform crews of the fatal accident, highlight lessons learned, outline preventative measures, and raise awareness of the importance of adhering to safe operating procedures.
• Consider modifying the winch control to prevent the safety catch being used to hold the operating lever in heaving and lowering positions and to put in place suitable guarding in way of the winch drum to prevent someone from becoming trapped in the rotating drum.
• Continue to monitor and adjust their vessels manning levels based on operational requirements, to ensure compliance at all times with Regulation 2.7 of the Maritime Labour Convention, 2006.
• Issue a circular to all vessels, reinforcing and encouraging the requirement to communicate any such deviations, through the established reporting mechanisms outlined in the ISM Code. This measure will enhance crew awareness and ensure that the Company remains fully informed to evaluate associated risks and implement appropriate corrective actions.

The Gibraltar Port Authority is recommended to:

When carrying out unannounced visits to bunker vessels in port, also ensure that correct mooring procedures are being followed and mooring operations are conducted safely, in line with SMS requirements, COSWP, and OCIMF Effective Mooring guidelines and industry best practices. Such inspections help deter unsafe shortcuts and reduce the risk of complacency and normalisation of unsafe practices.

The Gibraltar Ambulance Service, in conjunction with the Gibraltar Health Authority, together with the Gibraltar Port Authority and in consultation with other interested parties is recommended to:

Review the port’s emergency response capabilities for emergency services to attend vessels at anchor with the aim of developing a sustainable and safe solution to restore an effective emergency medical response capability for all vessels within BGTW.

This will ensure that the port maintains effective emergency response capabilities to respond to incidents involving vessels at anchor. The ability to provide timely medical and rescue assistance is essential in mitigating the consequences of emergencies, safeguarding life, and ensuring the protection of the marine environment.

The Gibraltar Maritime Administration is recommended to:

Routinely audit mooring operations when carrying out annual safety surveys and whilst conducting audits under the International Safety Management Code