A married ship's officer was killed when a trailer struck him on a ferry ramp at Bootle Docks operated by a drug-taking driver.
A probe has been completed into the tragedy which happened last summer when the 33-year-old victim was fatally hurt.
The man at the wheel of a port tractor unit tested positive for cannabis, but a government investigation ruled that did not contribute to the accident, at Brocklebank Dock, in Sefton.
The driver was arrested by police, and while he was initially quizzed for causing death by careless driving, he was eventually prosecuted for drug driving, and ordered to pay £175 and serve a three year ban.
A report from the Marine Accident Investigation Branch (MAIB) pointed out how the driver had a 2017 conviction for driving while under the influence of drugs.
And the MAIB did comment: "Recreational cannabis use can impair judgement and performance.
"Random testing had not been carried out by the port operator."
Bartosz Wronski suffered fatal injuries, on May 15, 2019, and was later described as "held in high regard by other officers and crew."
The husband had worked for Seatruck Progress - a freight vessel registered in the Isle of Man - for seven years, which ran routes between Liverpool and Dublin.
He was Polish, and a "third officer", who worked opposite the second officer in 12-hour watches that started at midday and midnight respectively.
At the time of the accident, Mr Wronski was facing down the ramp and talking on his mobile telephone when he was struck.
He was unaware of the trailer approaching from behind and the tractor unit’s driver was not expecting any pedestrians to be on the stern ramp, and could not see the third officer due to the trailer blocking his view ahead.
Andrew Pettigrew, 32, who was driving the tractor unit, was arrested the day after the collision which led to a charge for the lesser offence of drug driving.
The Brighton-le-Sands man admitted the offence, was ordered to pay £85 to the Crown Prosecution Service, £90 to fund victim services and was banned from the road for three years.
In an account of the tragedy, the MAIB report said: "When the tractor driver, whose semi-trailer struck the 3/O[third officer], saw the 3/O entangled between his semi-trailer’s right-hand rear wheels he immediately applied the brakes and stopped the semi-trailer.
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"The tractor driver then jumped from his cab and yelled out that he had not seen the casualty and had not been speeding.
"The chief engineer, sitting in a car on the quay, heard the shouting and on looking round saw an orange boiler suit between the trailer’s rear tyres.
"He immediately alerted the emergency services and then moved to carry out a primary first-aid survey of the 3/O.
"The chief engineer was unable to detect a pulse, and when the paramedics arrived on scene at 19.35 they also assessed the 3/O[third officer] and declared him deceased."
The government-run Marine Accident Investigation Branch said the "use of mobile telephones and other communications media is an increasing source of distraction on working decks and in other hazardous work spaces on board ships, for which formal guidance is currently lacking."
It was the second work-related death in five months to have occurred on board ferries operated by Seatruck Ferries Ltd and berthed in Liverpool.
Recommendations have been made to Seatruck Ferries Ltd aimed at "improving the effectiveness of its procedures, and improving the safety culture of its crews."
Other guidance was issued to the Maritime and Coastguard Agency, and the Isle of Man Ship Registry to raise the awareness of the potential hazards of mobile telephone use.
Andrew Moll, Chief Inspector of Marine Accidents, said: "This tragic accident has highlighted two significant safety issues.
"The first, is the hazard of using a mobile phone when on duty or in a working environment.
"Users can too easily become distracted from the tasks they are doing and lose awareness of what is happening around them.
"This accident occurred on the loading ramp of a ro-ro ferry, however, the use of mobile phones in other hazardous work spaces and on the bridge of ships is becoming a serious concern.
"Secondly, this accident again highlights the importance of separating moving vehicles and pedestrians on the ramps and vehicle decks of ro-ro ferries.
"Moving vehicles are a constant hazard during loading and discharge, and if physical separation cannot be achieved then robust procedural controls must be put in place to prevent people from being injured or killed."
