Investigators have called for a review of safety systems on Singapore-flagged ships after a crew member was seriously injured.
The Rio De La Plata container ship was preparing to leave the Port of Timaru in November 2020 and three crew members had started unmooring at the front when one of them got caught in a rope.
The rope handler was dragged into the mooring winch, causing serious injuries to their hand and face.
An investigation by the Transport Accident Investigation Commission found the ship's safety system wasn't followed, equipment should have been installed better and planning was insufficient.
The ship's safety plan identified mooring operations as a risk.
A standard mitigation was to have a forward mooring party of four crew operating two winches.
The investigation found the mooring party was a crew member down.
"The supervisor was also operating the winch, and each rope handler had to both handle the rope with one hand and signal to the supervisor/ winch operator with the other," the commission said in its investigation report.
"With some safety-focused thinking, they could have changed the unmooring plan to use just one winch at a time, enabling one worker to concentrate on handling the rope and another to monitor the rope handler and communicate safely with the winch operator."
It found it was likely the crew member stepped too close to the mooring winch while completely engaged in communication with the winch operator and handling the rope, reducing their awareness of their own safety.
"Unmooring operations are just as dangerous as mooring operations and crew must ensure that there are always sufficient personnel available to carry out the operation safely," the commission said.
"Equipment on board ships must be installed and operated as intended by the manufacturer. Any deviation from the manufacturer's recommendation can increase the risk of serious injury."
Last month, the commission recommended the Maritime and Port Authority of Singapore investigate and potentially review its audit processes to see if they could be further developed to identify weaknesses in the safety management system and whether further practical improvements could be made.
The Maritime and Port Authority of Singapore responded last week, saying it had launched a preliminary inquiry.
"We have reviewed the company's investigation report and are satisfied with its corrective / preventive actions to prevent a recurrence," the authority said.
It said this case would be published in a regular e-bulletin to the maritime industry to highlight the hazards associated with mooring operations.
It had also shared the case with its flag state control department to strengthen checks of mooring operations as part of the control and monitoring programme for Singapore-flagged ships.