Improper Mooring Arrangement Led to Chief Mate’s Death: What Went Wrong & Safety Lessons

Introduction

Mooring may seem routine to many but mistakes during mooring operations can kill. In a tragic case aboard the bulker Teal Bay, the chief mate died after being struck by a snapping, tensioned mooring line. The cause? An improper mooring arrangement, lack of risk assessment, reduced crew, and unfamiliarity with the setup.

In this article, we’ll break down exactly what happened, analyze the technical and human errors, and surface concrete safety lessons. No jargon, just clarity. Useful for students, officers, and anyone in maritime operations.

What Happened: Incident Overview

Setting the Scene

The vessel Teal Bay arrived at Kavkaz, Russia, to load grain via a transloading operation from a nearby ship (Kavkaz V) and barges. It was moored alongside Kavkaz V to facilitate cargo transfer.  

This ship-to-ship arrangement was new to the crew; they had never done it with a vessel of Kavkaz V’s size.  

The mooring setup used:

• 3 head lines
• 3 stern lines
• 2 bow spring lines
• 2 stern spring lines (i.e. forward spring from stern) 
  

As loading progressed, Teal Bay’s hull sank deeper in the water (freeboard reduced) and the deck dropped lower relative to Kavkaz V. That change caused some mooring lines to take an upward lead (making them slope upward toward the higher deck).  

The Fatal Moment

Around 22:20, loading was nearly complete. The Kavkaz V’s crew wanted Teal Bay to shift forward slightly so a crane could reach another hold area. The Master of Teal Bay chose to “warp ahead” (i.e. move the ship slightly using mooring lines) rather than do a full mooring operation (which would require waking up more crew). 

Because they didn’t want to disturb off-watch crew, only minimal personnel were used: the Chief Mate was sent to the stern, the Third Mate to the bow, each assisted by one Able Seaman (AB).  

At about 22:35, the AB on the stern spring line applied tension (winch). Meanwhile, the crew on the bow slackened the forward springs. Because one line ran through an open roller fairlead, and the line was under an upward lead (because of height difference), it popped out of the fairlead. The line shot upward as it went under tension and struck the Chief Mate in the head. He collapsed unconscious.  

Efforts were made to provide first aid, including oxygen. The ship notified authorities and tried to evacuate him using a tug. But permission issues delayed boarding the tug; later efforts with a helicopter failed (none were available). Eventually, the tug boarded him, but he died en route or soon after, as a result of a brain hemorrhage from blunt force trauma.  

Autopsy confirmed the cause: head injury, brain hemorrhage.  

What Went Wrong: Faults & Failures

In dissecting the incident, several critical failures stand out. Let’s examine them in layers: human, technical, organizational.

1. Improper Mooring Arrangement & Upward Lead

Because the ship had settled lower and was shifting during loading, some mooring lines ended up having vertical or upward leads rather than staying nearly horizontal. That upward slope created the risk that a line under tension could lift out of an open fairlead.  

The fact that the line was routed through an open roller fairlead (vs. closed or universal type) contributed to it popping out when under tension. In that vertical condition, the line found a path to escape the fairlead.  

If they had used a closed fairlead or universal fairlead in areas with upward leads, this risk would have been reduced.  

2. Lack of Risk Assessment & Planning

No proper task-specific risk assessment was done before the warping movement. The crew did not analyze that the upward lead, open fairlead, or height differential presented a hazard.  

Because the master treated the shift as a “small move,” he bypassed a full mooring operation (which would normally involve waking all deck crew, setting all lines, inspections). That decision removed layers of protection.  

3. Short-Handed Operation / Inadequate Crew

Instead of bringing forth the full deck team, only a minimal number of personnel were used. The Chief Mate was assigned dual duty: overseeing the stern operation and supervising the evolution. With fewer crew, margins for error shrink.  

Had the full team been deployed, the Chief Mate likely would not have had to be at the stern in a dangerous spot.  

4. Crew Unfamiliarity with This Mooring Setup

The crew had little experience with ship-to-ship loading operations of this type or with mooring alongside another large ship in such a layout. They lacked familiarity with mooring behavior under these changing freeboard/height conditions.  

That unfamiliarity may have prevented them from foreseeing that an upward lead plus open fairlead was unsafe. 

5. Delay & Issues in Medical Evacuation

After the injury, first aid was provided, and notification made to rescue coordination. However, evacuation was delayed: a tug arrived but refused to board until port permission was obtained. No helicopter was available. These procedural and logistic delays in time-critical head injury reduced survival chances.  

While one cannot conclusively say faster evacuation would have saved him, the report notes that extra time in medevac reduced his chances.  

Safety Lessons & Preventive Measures

This tragic event offers several lessons that should be internalized by ship operations, training, and safety culture.

Use Appropriate Fairleads

• Replace open roller fairleads with closed or universal fairleads especially in areas where lines may have upward or vertical leads. Closed fairleads resist a line “popping out” under tension. 
• Routings of mooring lines must be carefully planned with awareness of vertical offsets.
  

Always Conduct Risk Assessment & Toolbox Talk

• Before any evolution (especially those deviating from normal), do a task-specific risk assessment. Identify hazards: upward leads, difference in deck heights, slack lines, fairlead types.
• Conduct a toolbox talk (pre-job briefing) among all involved to point out known hazards and controls.
• Never skip safety steps because a task is “small” or seems simple.
  

Maintain Proper Crew Levels & Roles

• For any mooring or warping evolution, deploy adequate personnel. Don’t under-man save time or effort.
• Assign roles clearly; ensure the person managing the line is not placed in a snap-back zone or dangerous spot (e.g., standing next to an open fairlead in upward lead).
• When fatigue or convenience pressures push to minimize crew, resist it—safety must override speed.
  

Training & Familiarity

• Crew should be trained on different mooring configurations, especially unusual ones like ship-to-ship or when freeboards shift significantly.
• Simulated drills for “unfamiliar mooring setups” help build mental models for what might go wrong.
• Familiarize with dynamics of lines under changing deck heights and loads.
  

Emergency Preparedness

• Ensure medevac protocols are clear and tested: tug boarding procedures, port permissions, helicopter backup, stretcher readiness.
• First aid training, prompt oxygen, communication to MRCC (Maritime Rescue Coordination Centre), and readiness to evacuate quickly are vital.
• Identify delays or bureaucratic bottlenecks in mediation, and plan ahead (liaising with port authority in advance).
  

Also Read: Top DNS Colleges in India: Best Merchant Navy Diploma in Nautical Science Institutes

Organizational & Management Policies

• Ship managers should enforce policies to remove open fairleads fleet-wide in high-risk positions.
• Encourage a stop-the-job culture: if personnel see danger, they can refuse or pause until mitigations are in place.
• Safety audits should check mooring arrangements, crew levels, fairlead types, route planning.
• Investigations should feed back into training, procedures, and hardware changes.
  

Broader Context & Similar Incidents

This case is not unique; mooring and rope failures remain a significant hazard at sea and in port.

• A general cargo vessel case described by Safety4Sea had a crew member struck by a line during warping; lack of risk assessment and snap-back zones were cited. 
• Britannia P&I’s “BSAFE Incident Case Study 20” describes a fatal head injury from a mooring line that sprang loose from a fairlead during a warping operation.
• IMCA/MAIB report: a deck officer was killed when a mooring rope parted in high winds and the flying bight struck him. The importance of snap-back zones and arrestors is stressed.
• A Marine Insight article documents a fatal accident during mooring when a crew member failed to move clear of the snap-back zone, violating guidance.
  

These show common threads: tensioned ropes, snap-back zones, failure to anticipate vertical leads, minimal crew, and procedural gaps.

What You Should Do Onboard (Practical Guide)

Putting all lessons into actionable steps:

Pre-evolution assessment

• Before any movement, walk through the plan: which lines will move, their leads, potential vertical offsets.
• Identify which fairleads will be in use; ensure they are safe (closed if needed).
• Decide crew strength needed. Don’t shortcut.
• Include “What if” contingencies (line fails, sudden strain change, shifting alignment).

Toolbox talk & role assignment

• Brief crew about hazards: upward lead, snap-back zones, line under tension.
• Assign roles clearly (who operates winch, who monitors slack, who secures lines).
• Designate a safety observer to monitor zones and call “stop” if danger arises.

During execution

• Energy in lines changes fast—stay alert.
• Avoid placing personnel in snap-back zones.
• Ensure fairleads are correct and lines are routed safely.
• Move incrementally; do small adjustments rather than big sudden pulls.

If something seems unsafe—stop

• Don’t proceed if lines shift unexpectedly or conditions change.
• Pause, re-assess, reconfigure, then continue.

Emergency readiness

• Ensure first aid kit, oxygen, communication link with MRCC and port, ambulance/tug/medevac readiness.
• Keep stretcher, lighting, and safe path ready.
• After any impact, act quickly: secure other lines, isolate danger, inform authorities immediately.

Post-incident review

• If things go wrong, don’t sweep under the rug. Investigate, learn, update procedures and training.
• Share lessons across the fleet or company.

Conclusion

This tragic death of a Chief Mate triggered by improper mooring is a stark reminder that even routine tasks carry risk when corners are cut. The chain of failures was clear: vertical line leads, an open fairlead, minimal crew, absence of risk assessment, and delay in evacuation.

But the lessons are within reach: proper planning, correct hardware (fairleads), full crew deployment, risk assessment, training, and readiness to stop when things deviate. If the maritime community can internalize these lessons, lives can be saved.

If you like, I can make a one-page safety poster / infographic summarizing this case (for your studies or for onboard). Do you want me to design that for you?