The contributing factors to the incident were; 

• Faults in the ship’s engine directional control systems were not identified prior to the incident. 
• Only persons qualified at the level of ship’s master, Master class 4, receive training procedures in docking processes (mooring processes).
• The deck supervisor had received induction and buddy system training for the role as deck supervisor, but had not received specific training in mooring processes.
• Skippers in control of vessels cannot manage the mooring processes, and must ensure deck crew understand the proposed docking procedures.
• Mooring lines need to be laid out on the deck to prevent the rope uncoiling in a manner that poses a hazard to the deck-hand.

The employer must ensure plant, systems and information and training is provided to enable employees to perform tasks in such a manner that they are not exposed to hazards by:

• Deck-hands who are required to handle mooring lines when berthing a vessel are to be provided with competency training in safe mooring procedures.
• Ensure mooring lines are flaked out to run smoothly through the bollards to prevent being caught in the rope coils.

• Task training provided in the vessel skipper’s master’s certificate
• National Training performance criteria of the TDM (Transport & Distribution. Maritime).

Further information can be obtained from WorkSafe’s website or by contacting customer service on 1300 307 877 or email safety@demirs.wa.gov.au