Several safety failings led to the death of a dredge worker in Fife, an investigation by the Marine Accident Investigation Branch (MAIB) has found.
Brian Smith, 72, was crushed between the Cherry Sand vessel and the quayside wall while disembarking at Rosyth Port on February 28 last year.
The MAIB found the method used for self-mooring the boat was “inherently hazardous”.
Mr Smith, the master of the boat, missed the quay while trying to step on to the quayside before the boat was fully docked.
The report of the investigation notes he was warned by another crew member not to attempt to leave the boat as it was too early.
Wearing a life jacket, the crew were able to recover him but his injuries were too severe and he could not be revived.
The MAIB said due to the hazardous nature for self-mooring the Cherry Sand, crew members routinely stepped ashore or on board before the vessel was tight alongside.
It found another failing was linesmen not being used and that no measures were taken to avoid having to place a crew member ashore while the vessel was unmoored.
An audit by UK Dredging did not identify any safety issues that were below the expected level.
The MAIB has recommended the Maritime and Coastguard Agency updates the code of safe working practices to include guidance for safe self-mooring and the circumstances when it is permissible for crew to carry out self-mooring operations.
Associated British Ports has been recommended to review its audit programme to ensure a common approach to safety and adherence to operational procedures across the UK Dredging fleet.