A number of working practices on a passenger ferry on which a 19-year-old deckhand died in a mooring rope accident were "unseamanlike", an official report has said.
There was a "lack of suitable oversight" of the unmooring operation being carried out on the River Thames Woolwich Ferry, Ernest Bevin, on the day Ben Woollacott died, said the Marine Accident Investigation Branch (MAIB) report.
Mr Woollacott was dragged overboard by a mooring rope while releasing lines securing the ferry to a mooring buoy. He suffered head injuries and did not regain consciousness after he was rescued from the water in the accident on the Thames in south-east London on the morning of August 3 last year.
The report said it was most likely that Mr Woollacott, a sixth-generation Thames waterman, was dragged violently against the side of the Ernest Bevin by the mooring rope which had become entangled in the vessel's propeller and was being wound in at a speed in excess of 20mph.
He suffered severe facial injuries and was almost certainly unconscious when he entered the water. He subsequently drowned, despite his lifejacket bringing him to the surface and the quick actions of his colleagues.
The report said: "A number of unseamanlike working practices were evident on board."
It added: "It would have been very difficult for Benjamin to adopt working practices that were at variance to those followed by his more experienced and mature colleagues."
The MAIB continued: "The unmooring operation was a routine task but it had not been captured by the company's safety management system.
"Consequently no risk assessment for the operation had been conducted to assess and mitigate the hazards faced by the crew, and the very real hazard posed by the rotating propeller blades during the task had not been formally recognised. This situation was compounded by a lack of suitable oversight at the time of the accident."
The report said an internal investigation and a broad review of its safety management system had been conducted by the ferry operator, Serco Limited Marine Services, which resulted in a number of control measures being taken to prevent a similar accident in the future.