Authorities have called for new safety measures on one of the Aran Islands after a man and woman fell into the sea while disembarking a ferry.
The woman, who hurt her back, and the man, who could not swim, ended up in the water at Inis Oirr pier after a gangway came loose on Bank Holiday Monday in June last year.
The Marine Casualty Investigation Board (MCIB) found ropes used to fasten the stern of the ferry to the quayside had not been properly tied on.
It also warned that the crew of the MV Rose of Aran, owned by Liscannor Ferry Company, were not trained or prepared for rescuing someone from the harbour.
"The recovery of the casualties would not have occurred without people on the shore entering the water and assisting them to shore," the MCIB said.
A life ring was thrown in for the man and he was helped to shore over rocks while a man climbed down from the pier and got into the water to help the woman up a ladder.
The man and woman were taken back to Doolin later in the day by ferry.
The MCIB ordered the ferry company to ensure boats were safely and securely moored before gangways were deployed and passengers allowed to use them.
It also called for new policies to monitor the safety of passengers embarking and disembarking.
Galway County Council has been told to come up with a safety management system for all operations on Inis Oirr pier.
The MCIB said a bystander tied the stern rope from the ferry to a bollard on the quayside as it berthed but it was not checked before the 96 passengers began to disembark.
The investigators criticised the practice of large numbers of people crowding on to the pier to get ferries off the island in busy periods - about 500 people were quayside when the accident happened.
They also warned about vehicles using the pier and cargo being unloaded and said that during one inspection a life ring was obscured by bags of stones.
The MCBI said there had been a lack of detailed risk assessment for mooring at Inis Oirr in different tides, a lack of policing of operations, safety organisation and management in the harbour.
It said this was "not conducive to the safe berthing of vessels and transit of passengers to and from the pier".