Accident report finds fatal mooring incident on Nisyros ‘could have been avoided’

The Government of Gibraltar has published an accident investigation report into the fatality on board the Gibraltar-registered motor tanker Nisyros during bunkering operations in British Gibraltar Territorial Waters on May 20, 2025.

The report found the accident could have been avoided and made a number of recommendations aimed at improving safety, including bolstering Gibraltar’s capability to provide emergency medical assistance at sea.

On the afternoon of the incident, the ship’s Filipino pumpman was fatally injured whilst operating the port forward mooring winch while heaving in excess rope.

As no one witnessed the accident, investigators found it difficult to reach a firm conclusion as to exactly what happened.

But they found the man likely became entrapped in the mooring rope around the winch and died of multiple injuries.

The incident was initially investigated by the RGP, which found no evidence of drug or alcohol consumption, or foul play.

At the time of the accident, the pumpman was alone on the fo’c’sle, the forward part of the vessel.

Another crewman had moved to a position further down on the main deck port side in preparation to receive a heaving line.

The investigation noted that the ship’s Mooring System Management Manual stipulated there should always be a minimum of two experienced persons at each mooring station throughout the operation, in addition to the officer in charge of the mooring station, whose role is to supervise and keep an overview of the operation.

On this occasion, no officer was undertaking this role.

It found too that due to the repetitive nature of the work in a busy bunkering port, the crew may have become complacent.

The report said it was also 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, the seafarer 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.

“This tragic accident could have been avoided had the correct number of seafarers been stationed at the forward mooring station and that the correct procedures for mooring operations been followed,” said Neil Atkinson, the Marine Accident Investigation Compliance Officer.

“Furthermore, it is imperative that safety devices are not disabled or tampered with.”

MT Nisyros’s management company, MM Marine Inc, has carried out its own internal investigation and has reviewed the relevant Safety Management System and Mooring System Management Plan and procedures.

Safety flashes and safety alerts have been issued to all fleet vessels, and fleet personnel have been instructed to complete additional training on mooring risk assessments and management and safe mooring practices.

Safe mooring practices will be audited across the fleet to ensure compliance and manning levels have also been reviewed, taking into account available cabin space on each vessel and resulting in an increase in crew complement.

The report made safety recommendations aimed at increasing crew awareness of guidance on mooring operations and emphasised the importance of adherence to the vessel’s operating procedures.

Among its other recommendations was improving Gibraltar’s ability to respond to a medical emergency at sea.

When the Nisyros’ captain sought medical assistance after the accident, he was told the quickest option was to berth his vessel in port.

“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,” the report said.

“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.”

It recommended that the Gibraltar Ambulance Service, together with the GHA and the GPA, review the port’s emergency response capabilities for emergency services to attend vessels at anchor, in order to develop “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 report added.

“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 full report, including all recommendations, is available via the Office of the Marine Accident Investigation Compliance Officer’s website.

Investigations under the Gibraltar Merchant Shipping (Accident Reporting and Investigation) Regulation 2012 are not concerned with apportioning blame or determining civil or criminal liabilities.

Their purpose is to reduce the risk of future casualties and incidents and to lessen their serious consequences, including loss of life, loss of ships and pollution of the marine environment.