A mooring bollard on a River Thames ferry service killed a passenger when it came loose less than a month after being repaired, according to a report.
The stainless steel bollard came loose from the Star Clipper on 2 May 2004 at St Katharine's Pier in London and hit a woman waiting to board.
It had been repaired on 9 April, according to a report by the Marine Accident Investigation Branch (MAIB).
The report said the repair work "failed catastrophically".
After working loose from the vessel the bollard catapulted over a 1.1 metre-high safety fence.
The woman was waiting with her husband and about 30 other people when she was hit.
She was given first aid by other passengers and by the crew of a harbour services launch but died later in hospital.
The investigation into the incident found that the mooring bollard fitted on the Star Clipper was not part of the original build specification.
The MAIB said the one that failed on 2 May "had evolved empirically through a series of modifications in reaction to earlier, less catastrophic, failures".
It said the Maritime and Coastguard Agency had not been informed of the failures and was not consulted on subsequent modifications.
The MAIB recommended that procedures were tightened to ensure that similar incidents did not occur.