Lack of communication between members of a Steam Packet crew who weren't following company procedures was the main reason for the collapse of the gangway at Heysham in March.
That's according to a damning report into the incident by the United Kingdom's Marine Accident Investigation Branch, which also highlights the poor state of the structure.
The gangway collapsed as passengers were going onboard, resulted in eight people needing to be rescued from a section of it, although not the part which actually collapsed.
Fire officers said at the time that was incredibly fortunate.
Edward Oldham takes a closer look at the report (text, below, from attached audio file):
The gangway moved when propellers were engaged, when the e starboard engine was still running.
The report says this happened because of a breakdown in communication between crew on the bridge and in the engine room as they carried out tests before leaving port.
It was assumed the starboard engine was off when it wasn't, as someone else started the propellers.
But, according to the Steam Packet's bridge departure checklist, all passengers and vehicles should be onboard and gangways and ramps disconnected before the engines are started.
Also, the report says those in charge of the Ben-my-Chree's autotension winches were not fully familiar with how to use them effectively, meaning they didn't restrain the vessel when it surged forward.
And finally the state of the gangway is criticised.
The report says the port's owners Peel Ports, one of Island-based billionaire John Whittaker's companies, had not inspected or maintained the gangway to ensure it was fit for purpose.
Neither had it been bolted down on its foundation on port-side.
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