Galway County Council has been told to implement enhanced safety measures on Inis Oírr pier, after a gangway came loose from a passenger ferry, causing two people to enter the water.
The Marine Casualty Investigation Board has completed a report into the incident which happened last June.
The MV Rose of Aran had docked at Inis Oírr pier, when a gangway came loose from the pier.
A man and a woman fell into the sea but were rescued by a number of bystanders. They did not sustain serious injuries.
In a 52-page report into the incident, published today, the MCIB says the incident was caused by the vessel drifting off berth, causing the gangway to dip towards the water.
The two passengers were trapped between the vessel and the pier when they fell into the sea.
The boat, which is operated by the Liscannor Ferry Company, had sailed from Doolin to Inis Oírr on the morning in question.
Over 500 people were on the pier at the time, due to a Bank Holiday weekend, which attracted many visitors to the island.
The report identified a lack of management in terms of crowd control at the pier as well as cargo and vehicles causing congestion.
It says that Galway County Council should implement a safety management system for all operations on the pier.