Unit 5: Accident Investigation Report Analysis

5. Accident Investigation Report Analysis

The primary focus of this section is to present a comprehensive overview of the Accident investigation report review process and findings, structured under the headings of Introduction, Background, Methodology, Investigation, Findings, Observations, and Comments. This structured approach allows for a systematic exploration of each accident, facilitating a thorough understanding of the complexities involved.

The Reviews presented herein are grounded in rigorous methodologies. A comprehensive approach is undertaken, involving thorough accident investigation reports and meticulous data collection. 

This accident investigation report reviews containing the first batch of 20 accident's details, take into consideration details presented in the accident investigation reports focusing on root cause of accidents and any other contributing factors. 

The twenty accident investigation reports conclude with some observations drawing attention to noteworthy insights garnered from each investigation. It emphasizes recurring patterns, identifies systemic issues, and presents lessons learned from each case. This section aims to offer a holistic view of the overarching themes emerging from these accidents.

The conclusion, labelled "Comments," provides a platform for critical analysis and reflection. It encourages discussion on potential improvements to safety management systems, audit practices, and regulatory oversight.

5.1 An investigation into ISM Audit and PSC MoU Inspection and the subsequent accident

Table 15: Micro Presentation of a Review of an Accident – Review 1

Title: An investigation into ISM Audit and PSC MoU Inspection and the subsequent accident

Accident Investigation Review 1 - Ship Stability

1. Introduction 

In this investigation the Audit carried out by an ISM qualified Auditor employed by a leading Recognized Organization (RO) is reviewed in light of a subsequent PSC MoU inspection followed by a catastrophic accident. The focus of the earlier assessment (ISM Audit) was to evaluate the effectiveness of the company’s ISM safety management system. 

The investigation aimed to evaluate the effectiveness, or effective implementation, of the ISM Code with the ultimate goal of enhancing safety and marine environment protection. 

2. Background

The International Safety Management (ISM) Code, adopted by the International Maritime Organization (IMO), establishes a framework for safe operation and management of ships and the prevention of pollution. Shipping companies are required to implement and maintain effective safety management systems that comply with the ISM Code. The ISM auditor was responsible for assessing the extent to which shipping companies adhere to these The Code requirements and ensuring compliance with the ISM Code.

3. Methodology

The verification by RO Auditor involved a comprehensive review of documentation, interviews with key personnel, and on-site inspections of the vessel. The Auditor employed a systematic approach to evaluate the verification and certification practices against the requirements set forth in the ISM Code.  C4FF reviewed the information available primarily from accident investigation report with a view to find out the main root causes of the accident more rigorously.

4. Investigation

C4FF Accident 1 (90611306) - A container ship was capsized due to a lack of stability because the crew failed to weigh the containers, which is a must for this type of vessel. The weights specified in BAPLIE and the corresponding weights in Bills of Lading were not the same. There were two injuries which could have been much worse.

Findings

4.1 Verification/Audit Practice

The verification/audit took place in accordance with the recognized organization (RO) practice. The Auditor examined the safety management system manual containing policies, procedures, and records/documents to assess the extent of compliance with the ISM Code. The review identified instances where documentation lacked clarity, specificity or failed to address specific safety and environmental concerns adequately but did not recommend withdrawal or suspension of the SMC or DOC. 

4.2 Certification Practices

The auditor assessed the validity and adequacy of companies SMS and examined the SMC and DOC issued. The company had the required certificates and argued well against some of the concerns raised by the Auditor, which allowed the ship to continue its planned passages.

4.3 Accident investigation

Based on the actions recommended by Investigators, there was a lack of policy/procedures for weighing the container and lack of supervision.  There was evidence of bridge officers being inexperienced, overloaded, and fatigued. There could have been commercial pressures, and the accident could have been due to complacency. Other root causes were inappropriate manning, ineffective communication, and poor team operation.

Inadequate Knowledge, training, and competence: The investigation revealed discrepancies in training records, suggesting that some crew members lacked appropriate training and qualifications for their assigned duties. The officers were not trained in loading and the loading of containers considering the type of vessel they were working on. This finding raised concerns regarding the shipping company’s commitment to continuous professional development and ensuring a competent workforce.

Further review of the accident by C4FF identifies a series of 'Mistakes' as contributing to the accident not only the documented policy and procedures were inadequate, but this accident could have been due to 'Recklessness' as the crew should have known that the containers had to be weighed. The accident could have been avoided if the containers were weighed, loaded correctly and double checked.

4.4 PSC MoU Inspection

The MOU inspection took place in April 2011, some 3.5 years after the ISM audit by the RO.  The following deficiencies were found:

• Crew fatigue, rest and work periods were not met - Error

• Labels with safety signs - Error

• Personal firefighting equipment - Error

• Rescue radio equipment - Error

• The ship complied with the minimum number of crew members, but not with their qualifications - Error

• The minimum crew certificate in the section on special requirements and conditions. 

It was noted “The grades and number of personnel listed above reflect the minimum number of persons necessary for the safety of navigation and operation. Additional personnel as may be considered necessary for cargo handling and control, maintenance or watch keeping and as needed for required rest periods are the responsibility of the owner and the master”

5. Observations

This investigation highlights the crucial role of ISM qualified auditor plays in verifying the ISM Code practice within the company. By identifying non-conformities/deficiencies and areas for improvement, the auditor contributed to the overall enhancement of safety and marine environment protection in the shipping industry. Implementing the recommended improvements while may have helped the company align its practice with ISM requirements and ensured adequate levels of safety and compliance, the clear evident from the PSC MoU inspection shows that either the ISM audit was ineffective which considering the quality and reputation of the RO which carried out the audit is unlikely or that the length of the SMC and DOC validity period is too long without additional an oversight. While it can be argued that commercial pressure could have played a role in the accident it is clear that the key root cause was inadequate knowledge/skill/competence of the crew members in charge of loading and unloading the containers.

6. Findings: 

• Of the interest to the company

Based on the findings of the audit, it has been identified several deficiencies in the company’s SMS practice: a) Documentation, ensuring clarity, specificity, and alignment with the ISM Code requirements. b) Competence, ensuring all crew members possess the necessary qualifications for their assigned roles. c) The quality of internal ISM audit, ensuring identified deficiencies are rectified. d) Protecting the crew and ship, enduring commercial pressure does not compromise the safety of the crew and the ship. 

• Of interest to the IMO

PSC MoU inspection draws serious concerns about ISM Code effectiveness in this investigation. Whilst the vessel had valid SMC and DOC, the PSC inspectors found serious deficiencies/ISM non-conformities. This is a clear case of questioning the period of SMC and DOC validity and subsequent processes of verifying actions including preventive measures agreed to address deficiencies/concerns and their implementation.

5.2 An Investigation into Root Causes of Accident – Entering Enclosed Spaces

Table 16: Micro Presentation of a Review of an Accident – Review 2

Title: An Investigation into Root Causes of Accident – Entering Enclosed Spaces

Accident Investigation Review 2 - Enclosed Spaces

1. Introduction 

In this accident investigation was carried out by a qualified accident investigator employed by a leading Accident Investigation Agency. 

The investigation aimed to demonstrate the difficulties to establish the root causes of accidents. 

2. Background

The International Safety Management (ISM) Code, adopted by the International Maritime Organization (IMO), establishes a framework for safe operation and management of ships and the prevention of pollution. Shipping companies are required to implement and maintain effective safety management systems that comply with the ISM Code. The accident investigators were responsible for proposing remedies to ensure the accident does not happen again and in the process identify any other contributing root causes.

3. Methodology

The investigation by the accident Investigators involved a comprehensive review of accident using any documents forwarded to them to carry out the investigation according to the Agency rules and practice. The Investigators employed a systematic approach to evaluate the accident and its root causes against the requirements set forth by the Agency.  C4FF reviewed the information available primarily from accident investigation report with a view to find out if ISM can be more effectively implemented or its effectiveness improved.

4. Investigation

C4FF Accident 2 (9244386) - While chief officer (C/O) was checking the cleanliness of the empty tanks prior to loading cargo at the next destination port, he discovered dampness and residue remaining inside one of the tanks and decided to remove them with support from the bosun and two ordinary seamen (OS), A and B without having conducted gas freeing or checking oxygen and gas levels beforehand and without carrying a portable detector or wearing personal protective equipment (PPE). The OS A felt drowsy and dizzy and noticed OS B lying on the floor at the bottom of the tank. Bosun was informed and the incident was reported to C/O. Later, OS B recovered but the C/O did not.

Findings

4.1 Investigation Practice

The Investigation took place in accordance with the Accident Investigation Agency procedures and practice. The Investigators examined various aspect of the accident and SMS Manual containing policies, procedures, and records/documents as well as non-Quality Assurance and Control deficiencies to ensure their findings would stop this accident from happening again. 

4.2 Accident investigator’s Report

The investigation report identified instances where Shipping company must constantly provide training programs for crew members so that they do not let their experience, practices, and work efficiency concerns override the need to be safe in confined spaces. The shipping companies, too, need to maintain strict guidance and supervision through internal audits.

5. Observations 

A review of the investigators report show that there was a non-compliance viz., entering enclosed spaces without having conducted gas freeing or checking oxygen and gas levels beforehand and without carrying a portable detector or wearing personal protective equipment (PPE) – There was an inappropriate policy manual, inappropriate procedures, inadequate supervision, problems with safety culture and inadequate leadership of operational tasks, including a lack of correction of unsafe practices. Furthermore, there was evidence of inadequate risk assessment, inadequate team composition, inadequate leadership, inadequate Knowledge, inadequate competence/skills and incorrect perception.

6. Comments

It is difficult to imagine that all these deficiencies were the result of a mistake. How would it be obvious to an observer that there was a means available for checking oxygen and gas levels and were the crew trained on freeing gas and using a portable detector, and the latter properly maintained and the crew were trained on using it correctly and in accordance with the Manufacturer’s instructions. The same can be stated about the PPEs.

5.3 An Investigation into Root Causes of Accident - Collision

Table 17: Micro Presentation of a Review of an Accident – Review 3

Title: An Investigation into Root Causes of Accident - Collision

Accident Investigation Review 3 - Collision

1. Introduction 

In this accident investigation was carried out by a qualified accident investigator employed by an Accident Investigation Agency. 

The investigation aimed to demonstrate the difficulties to establish the root causes of accidents. 

2. Background

The International Safety Management (ISM) Code, adopted by the International Maritime Organization (IMO), establishes a framework for safe operation and management of ships and the prevention of pollution. Shipping companies are required to implement and maintain effective safety management systems that comply with the ISM Code. The accident investigators were responsible for proposing remedies to ensure the accident does not happen again and in the process identify any other contributing root causes.

3. Methodology

The investigation by the accident Investigators involved a review of accident using any documents forwarded to them to carry out the investigation according to the Agency rules and practice. The Investigators evaluated the accident and its root causes against the requirements set forth by the Agency.  C4FF reviewed the information available primarily from accident investigation report with a view to find out if ISM can be more effectively implemented or its effectiveness improved.

4. Investigation

Shortly before noon, the bulk carrier collided with the moored tugs. The tugs, which were unmanned at the time, sustained significant damage and subsequently sank. Authorities ashore initiated pollution control and oil spill recovery measures and the ensuing loss of fuel and other oils from the tugs were largely contained. The vessel sustained minor damage to its bow while the tugs were both subsequently declared a constructive total loss.

Findings

4.1 Investigation Practice

The Investigation took place in accordance with the Accident Investigation Agency procedures and practice. The Investigators examined various aspect of the accident and SMS Manual containing policies, procedures, and records/documents as well as non-Quality Assurance and Control deficiencies to ensure their findings would stop this accident from happening again. 

4.2 Accident investigator’s Report

In light of the investigation report findings, it has been recognized that BRM training is crucial and has been mandated for all deck officers and supporting crew on board regardless of duty roster to undergo the training ashore. To monitor and evaluate the effective implementation of BRM on board, new dynamic navigations audit has been introduced. This audit will focus specifically on assessing how well BRM practices are being incorporated into the ship’s operations. In order to ensure compliance with the safety management system’s requirements, the crew training schedules for all ships in the fleets must be updated to include BRM training. Technical modifications are needed for the VECTwin joystick system panels to show the selected steering mode, improving navigation awareness. The transfer control checklist will be enhanced, and SMS procedures will be updated to promote effective BRM implementation. This includes changes in passage planning, watchkeeping, master/pilot exchange, and bridge arrival/departure checklists. During pilotage, watch handovers will be pre-planned, ensuring safe transitions between bridge team members in designated safe areas.

5. Observations

A review of the investigators report highlights significant deficiencies in the safety management system, particularly concerning the lack of BRM training for the Master and 2nd Chief. Addressing these issues is of utmost importance to ensure the safety of the crew, passengers, and vessels, and to promote a proactive safety culture throughout the fleet. Proper corrective actions must be taken immediately to rectify these inadequacies and prevent potential accidents or incidents in the future.

The accident investigation, carried out by a qualified investigator, aimed to identify the root causes of the vessel. It emphasized the importance of implementing the ISM Code and maintaining effective SMS. Findings highlighted the need for BRM training for deck officers and crew to ensure safe navigation. The report proposed measures such as dynamic navigations audits, technical modifications, and amendments to SMS procedures to enhance safety. Addressing deficiencies in the SMS was emphasized, particularly the lack of BRM training for certain crew members. Significance of proactive safety measures were stressed to prevent potential accidents in the future.

5.4 An Investigation into Root Causes of Accident – Freefall Lifeboat

Table 18: Micro Presentation of a Review of an Accident – Review 4

Title: An Investigation into Root Causes of Accident – Freefall Lifeboat

Accident Investigation Review 4 - Freefall Lifeboat

1. Introduction 

In this accident investigation was carried out by a qualified accident investigator employed by an Accident Investigation Agency. 

The investigation aimed to demonstrate the difficulties to establish the root causes of accidents. 

2. Background

The International Safety Management (ISM) Code, adopted by the International Maritime Organization (IMO), establishes a framework for safe operation and management of ships and the prevention of pollution. Shipping companies are required to implement and maintain effective safety management systems that comply with the ISM Code. The accident investigators were responsible for proposing remedies to ensure the accident does not happen again and in the process identify any other contributing root causes.

3. Methodology

The investigation by the accident Investigators involved a review of accident using any documents forwarded to them to carry out the investigation according to the Agency rules and practice. The Investigators employed an approach to evaluate the accident and its root causes against the requirements set forth by the Agency.  C4FF reviewed the information available primarily from accident investigation report with a view to find out if ISM can be more effectively implemented or its effectiveness improved.

4. Investigation

The crew on the bulk carrier were carrying out a free-fall lifeboat drill at Port when the wire rope slings holding the lifeboat failed and it fell approximately 14 m to the water. There were 2 crew members in the lifeboat at the time. Both crew members were seriously injured and were transferred to hospital. 

Findings

4.1 Investigation Practice

The Investigation took place in accordance with the Accident Investigation Agency procedures and practice. The Investigators examined various aspect of the accident and SMS Manual containing policies, procedures, and records/documents as well as non-Quality Assurance and Control deficiencies to ensure their findings would stop this accident from happening again. 

4.2 Accident investigator’s Report

Recommendations have been produced by the accident investigator to have trainings for the crew on carrying out free-fall life boat operations. According to the report the failed sling assembly and the failed lifting brackets have been replaced with a newly manufactured, load tested, and certified sling assembly and the vessels. Lifeboat sling assembly was also included in the ship’s wires and ropes inspection log. An SMS circular was utilized for the vessels in which includes an extra safety meeting to be carried out with all crew participating to avoid recurrence.  Fully trained personnel are utilized to regularly carry out inspections and maintenance of lifeboats and associated equipment in adherence with approved practices. Lifeboat drills are conducted in accordance with applicable International Convention for the Safety of Life at Sea (SOLAS) regulations. All equipment is easily accessible and durable in rough conditions. All tests for safety and life-saving equipment are conducted to IMO guidelines. Unscheduled internal audits of the vessel have been carried out.

5. Observations 

The investigators' report on lifeboat safety compliance has raised significant concerns regarding the maintenance and operational practices on board. The report identified an error in the maintenance of lifeboats, emphasizing the critical importance of having qualified personnel carry out these tasks in strict adherence to approved practices. Additionally, the report highlights the need to apply health and safety requirements to lifeboat drills, which must be conducted in accordance with the Safety of Life at Sea (SOLAS) regulations. Furthermore there was evidence of specific mistake concerning inadequate knowledge of lowering lifeboats. 

6. Comments

Accident investigation on the bulk carrier highlighted the importance of effective implementation of the ISM Code for safe ship operations. Deficiencies in lifeboat maintenance and operational practices were identified, emphasizing the need for qualified personnel and adherence to approved procedures. Health and safety requirements for lifeboat drills, in accordance with SOLAS regulations, were emphasized to prevent accidents. The investigation underscored the challenges in determining root causes and recommended continuous improvement and crew training to enhance ISM Code effectiveness.

5.5 An Investigation into Root Causes of Accident – Man Over Board

Table 19. Micro Presentation of a Review of an Accident – Review 5

Title: An Investigation into Root Causes of Accident – Man Over Board

Accident Investigation Review 5 - MOB

1. Introduction 

In this accident investigation was carried out by a qualified accident investigator employed by an Accident Investigation Agency. 

The investigation aimed to demonstrate the difficulties to establish the root causes of accidents. 

2. Background

The International Safety Management (ISM) Code, adopted by the International Maritime Organization (IMO), establishes a framework for safe operation and management of ships and the prevention of pollution. Shipping companies are required to implement and maintain effective safety management systems that comply with the ISM Code. The accident investigators were responsible for proposing remedies to ensure the accident does not happen again and in the process identify any other contributing root causes.

3. Methodology

The investigation by the accident Investigators involved a comprehensive review of accident using any documents forwarded to them to carry out the investigation according to the Agency rules and practice. The Investigators employed an approach to evaluate the accident and its root causes against the requirements set forth by the Agency.  C4FF reviewed the information available primarily from accident investigation report with a view to find out if ISM can be more effectively implemented or its effectiveness improved.

4. Investigation

The ship bosun and second officer were repairing a leak on the deck’s fire main. Having completed the task took a break. Shortly thereafter, work on deck was suspended due to deteriorating weather conditions. But despite this, after the break, the bosun and second officer went back on deck to collect tools when a heavy wave struck the deck and washed the bosun overboard. Bosun has not recovered.

Findings

4.1 Investigation Practice

The Investigation took place in accordance with the Accident Investigation Agency procedures and practice. The Investigators examined various aspect of the accident and SMS Manual containing policies, procedures, and records/documents as well as non-Quality Assurance and Control deficiencies to ensure their findings would stop this accident from happening again. 

4.2 Accident investigator’s Report

The company has taken the necessary actions, including, updating company’s SMS procedure to ensure the requirements for instances where the work on the ship’s deck should be terminated due to adverse weather conditions and to carry out a risk assessment for work to be carried out on the ship’s deck in adverse weather conditions, including the use of appropriate PPE when the access to the ship’s deck is inevitable. A campaign will be run on the precautions and hazards to ensure crew members are familiar with the heavy weather procedures. It is also recommended to monitor heavy weather warnings closely and take time actions to terminate works on deck in 

5. Observations 

The investigators' report highlights critical deficiencies onboard, including inadequate risk assessment, lack of knowledge, and non-compliance with ISM procedures. These issues underscore the urgent need to address safety protocols, improve knowledge and competence, and ensure adherence to established procedures ensuring compliance with ISM procedures.  

6. Comments

This accident investigation aimed to identify the root causes of the incident involving a ship bosun washed overboard. The investigation revealed deficiencies in risk assessment, knowledge, and compliance with ISM procedures. To prevent similar accidents, the company updated safety procedures and emphasized crew awareness of heavy weather protocols. Adherence to safety measures and ISM procedures is crucial to prevent such incidents in the ship.

5.6 An Investigation into Root Causes of Accident – Ship Stability

Table 19: Micro Presentation of a Review of an Accident – Review 6

Title: An Investigation into Root Causes of Accident – Ship Stability 

Accident Investigation Review 6 - Ship Stability Man Over Board

1. Introduction 

In this accident investigation was carried out by a qualified accident investigator employed by an Accident Investigation Agency. 

The investigation aimed to demonstrate the difficulties to establish the root causes of accidents. 

2. Background

The International Safety Management (ISM) Code, adopted by the International Maritime Organization (IMO), establishes a framework for safe operation and management of ships and the prevention of pollution. Shipping companies are required to implement and maintain effective safety management systems that comply with the ISM Code. The accident investigators were responsible for proposing remedies to ensure the accident does not happen again and in the process identify any other contributing root causes.

3. Methodology

The investigation by the accident Investigators involved a comprehensive review of accident using any documents forwarded to them to carry out the investigation according to the Agency rules and practice. The Investigators employed an approach to evaluate the accident and its root causes against the requirements set forth by the Agency.  C4FF reviewed the information available primarily from accident investigation report with a view to find out if ISM can be more effectively implemented or its effectiveness improved.

4. Investigation

Accident C0013582: When the ship was carrying out operations cargo, after the port crane loaded the last container listed on the deck in the loading plan, the ship began to list to starboard without stopping, so the company's personnel stevedore and the crew members who were on board went to the dock or jumped into the water. 

Findings

4.1 Investigation Practice

The Investigation took place in accordance with the Accident Investigation Agency procedures and practice. The Investigators examined various aspect of the accident and SMS Manual containing policies, procedures, and records/documents as well as non-Quality Assurance and Control deficiencies to ensure their findings would stop this accident from happening again. 

4.2 Accident investigator’s Report

One of the main issues in this case was the lack of knowledge of the Captain in stability calculation. Therefore, he has to undergo training in stability calculation. Moreover, the company needs to take the necessary actions regarding policy/procedures deficiencies. 

5. Observation 

The investigators' report reveals numerous shortcomings: an incorrect cargo plan, lack of stability calculation knowledge, crew fatigue, inappropriate policy manual, procedures, and work environment, inadequate knowledge and competence, lack of motivation, inadequate risk assessment, leadership, and supervision, and problems with safety culture. 

6. Comments

The accident investigation in this report seems to have followed the required procedures and practices. It identified several factors contributing to the incident, including the lack of knowledge of the captain in stability calculation and deficiencies in company policies and procedures. The findings suggest that training the captain in stability calculation and addressing policy/procedure deficiencies are essential steps to prevent similar accidents. Failure to address the identified issues could lead to a reoccurrence of a similar incident in the future.

5.7 An Investigation into Root Causes of Accident - Explosion

Table 20: Micro Presentation of a Review of an Accident – Review 7

Title: An Investigation into Root Causes of Accident - Explosion

Accident Investigation Review 7 - Explosion

1. Introduction 

In this accident investigation was carried out by a qualified accident investigator employed by an Accident Investigation Agency. 

The investigation aimed to demonstrate the difficulties to establish the root causes of accidents. 

2. Background

The International Safety Management (ISM) Code, adopted by the International Maritime Organization (IMO), establishes a framework for safe operation and management of ships and the prevention of pollution. Shipping companies are required to implement and maintain effective safety management systems that comply with the ISM Code. The accident investigators were responsible for proposing remedies to ensure the accident does not happen again and in the process identify any other contributing root causes.

3. Methodology

The investigation by the accident Investigators involved a comprehensive review of accident using any documents forwarded to them to carry out the investigation according to the Agency rules and practice. The Investigators employed an approach to evaluate the accident and its root causes against the requirements set forth by the Agency.  C4FF reviewed the information available primarily from accident investigation report with a view to find out if ISM can be more effectively implemented or its effectiveness improved.

4. Investigation

Temperature of Styrene Monomer not monitored and Temperature alarm not set. The vessel was vetted by a CDI inspector in USA. One of the questions included in the CDI questionnaire was: Are officers aware of the documentation and handling requirements for cargoes and inhibitors, and if the cargo carried is required to be inhibited, is the required information available? No deficiencies were recorded, and the vetting report noted the vessel to be in compliance with IBC and company procedures and observed the cargo handling and monitoring equipment in good condition overall.  As a result, this accident ended up as an explosion causing 2 injuries and 15 shore workers/officials injured. 

Findings

4.1 Investigation Practice

The Investigation took place in accordance with the Accident Investigation Agency procedures and practice. The Investigators examined various aspect of the accident and SMS Manual containing policies, procedures, and records/documents as well as non-Quality Assurance and Control deficiencies to ensure their findings would stop this accident from happening again. 

4.2 Accident investigator’s Report

According to the investigation, the internal audit reports noted that the SMS was well implemented, the senior officers were diligent, and that the tanker was very well maintained. However 2 non-conformities concerned the absence of records of atmospheric check when tank cleaning was in process and the recording of working hours. 

5. Observations

 The investigators' report identifies two main errors that contributed to the incident. Firstly, there was a failure to adhere to clear instructions against stowing inhibited cargoes next to heated cargoes, although there were no previous issues with this practice. Secondly, potential communication challenges arose due to language differences between officers and crew members. 

6. Comments

The accident investigation focused on an explosion caused by a failure to monitor the temperature of Styrene Monomer and set temperature alarms. Despite the vessel being in compliance with IBC and company procedures, the accident resulted in injuries to crew members and shore workers. The investigation revealed non-conformities related to atmospheric checks during tank cleaning and working hour recordings. The report emphasizes the need to address SMS procedures and highlights two contributing factors: failure to follow instructions on stowing inhibited cargoes near heated cargoes and potential communication challenges. It is worth mentioning that the accident could happen again since the inspectors asked the right questions and the vessel was considered to be in compliance of IBS and company procedures.

5.8 An Investigation into Root Causes of Accident – Enclosed Spaces

Table 21: Micro Presentation of a Review of an Accident – Review 8

Title: An Investigation into Root Causes of Accident – Enclosed Spaces

Accident Investigation Review 8 - Enclosed Spaces

1. Introduction 

In this accident investigation was carried out by a qualified accident investigator employed by an Accident Investigation Agency. 

The investigation aimed to demonstrate the difficulties to establish the root causes of accidents. 

2. Background

The International Safety Management (ISM) Code, adopted by the International Maritime Organization (IMO), establishes a framework for safe operation and management of ships and the prevention of pollution. Shipping companies are required to implement and maintain effective safety management systems that comply with the ISM Code. The accident investigators were responsible for proposing remedies to ensure the accident does not happen again and in the process identify any other contributing root causes.

3. Methodology

The investigation by the accident Investigators involved a comprehensive review of accident using any documents forwarded to them to carry out the investigation according to the Agency rules and practice. The Investigators employed an approach to evaluate the accident and its root causes against the requirements set forth by the Agency.  C4FF reviewed the information available primarily from accident investigation report with a view to find out if ISM can be more effectively implemented or its effectiveness improved.

4. Investigation

Recklessness by the ship management and Mistake by the two Stevedores who did not follow the shipboard enclosed space entry procedures and entered a cargo hold without authorization from ship officers - The access hatch only maintained marking “Restricted Area Authorized”, which did not fully meet the requirement of the Code.

Findings

4.1 Investigation Practice

The Investigation took place in accordance with the Accident Investigation Agency procedures and practice. The Investigators examined various aspect of the accident and SMS Manual containing policies, procedures, and records/documents as well as non-Quality Assurance and Control deficiencies to ensure their findings would stop this accident from happening again. 

4.2 Accident investigator’s Report

It is the required to have the ship crew to be trained on procedures and requirements for entering enclosed space and seek permission to entry such spaces. Markings for restricted areas should be in line with requirements of the ISM code to prevent reoccurrence of the incident in the future.

5. Observations

The investigators' report uncovers a critical Error involving the non-compliance of the Code of Safe Working Practices for Merchant Seafarers. Specifically, the report highlights that the entrances to unattended dangerous spaces on the ship, such as the enclosed cargo hold loaded with logs, were not properly locked or secured against unauthorized entry as required. Additionally, the necessary markings designating these entrances as dangerous spaces were missing. 

6. Comments

The accident investigation report reveals a serious safety lapse in the compliance with the Code of Safe Working Practices for Merchant Seafarers. The failure to properly lock or secure entrances to dangerous spaces, such as the enclosed cargo hold, and the absence of required markings were key factors in the tragic incident. It emphasizes the importance of comprehensive training for ship crew on procedures and requirements for entering enclosed spaces and the necessity of adhering to ISM code regulations. Implementing the recommended safety measures is crucial to prevent similar accidents in the future and ensure the well-being of the crew onboard ships.

5.9 An Investigation into Root Causes of Accident – Fall from Height

Table 22: Micro Presentation of a Review of an Accident – Review 9

Title: An Investigation into Root Causes of Accident – Fall from Height

Accident Investigation Review 9 – Case Study 9 Fall from Height

1. Introduction 

In this accident investigation was carried out by a qualified accident investigator employed by an Accident Investigation Agency. 

The investigation aimed to demonstrate the difficulties to establish the root causes of accidents. 

2. Background

The International Safety Management (ISM) Code, adopted by the International Maritime Organization (IMO), establishes a framework for safe operation and management of ships and the prevention of pollution. Shipping companies are required to implement and maintain effective safety management systems that comply with the ISM Code. The accident investigators were responsible for proposing remedies to ensure the accident does not happen again and in the process identify any other contributing root causes.

3. Methodology

The investigation by the accident Investigators involved a comprehensive review of accident using any documents forwarded to them to carry out the investigation according to the Agency rules and practice. The Investigators employed an approach to evaluate the accident and its root causes against the requirements set forth by the Agency.  C4FF reviewed the information available primarily from accident investigation report with a view to find out if ISM can be more effectively implemented or its effectiveness improved.

4. Investigation

In the accident, AB1 might have no sufficient time or have the skill to control the tag line and keep the tag line clear from himself. It was likely that AB1 might fail to release the tag line in time or suddenly be tangled by the tag line when the latter was abruptly tensioned by the fast-slewing crane without any warning which is clear sign of Recklessness.

Findings

4.1 Investigation Practice

The Investigation took place in accordance with the Accident Investigation Agency procedures and practice. The Investigators examined various aspect of the accident and SMS Manual containing policies, procedures, and records/documents as well as non-Quality Assurance and Control deficiencies to ensure their findings would stop this accident from happening again. 

4.2 Accident investigator’s Report

The risk assessment and planning of the lifting operations must be addressed in order to be perfectly aligned with the Code of Safe Working Practices. 

5. Observations 

The investigators' report reveals a critical error in the lifting operation, primarily stemming from the lack of effective communication among the lifting team members. Additionally, on-site supervision was inadequate, and the training on lifting operation and safety awareness for the lifting team was insufficient. 

6. Comments

The accident investigation report points out the importance of effective communication, proper risk assessment, and adequate training in lifting operations to prevent similar incidents. Addressing these issues and aligning with the Code of Safe Working Practices is crucial to ensure safety and prevent accidents during lifting operations.

5.10 An Investigation into Root Causes of Accident - Grounding

Title: An Investigation into Root Causes of Accident - Grounding

Accident Investigation Review 10 Grounding

1. Introduction 

In this accident investigation was carried out by a qualified accident investigator employed by an Accident Investigation Agency. 

The investigation aimed to demonstrate the difficulties of establishing the root causes of accidents. 

2. Background

The International Safety Management (ISM) Code, adopted by the International Maritime Organization (IMO), establishes a framework for safe operation and management of ships and the prevention of pollution. Shipping companies are required to implement and maintain effective safety management systems that comply with the ISM Code. The accident investigators were responsible for proposing remedies to ensure the accident does not happen again and in the process identify any other contributing root causes.

3. Methodology

The investigation by the accident Investigators involved a comprehensive review of accidents using any documents forwarded to them to carry out the investigation according to the Agency rules and practice. The Investigators employed an approach to evaluate the accident and its root causes against the requirements set forth by the Agency.  C4FF reviewed the information available primarily from accident investigation report with a view to finding out if ISM can be more effectively implemented or its effectiveness improved.

4. Investigation

Under harbor pilot guidance, the bulk carrier experienced an electrical blackout resulting in loss of propulsion and steering control. As a result, the ship exited the channel and ran aground. The ship was recovered into the channel with the aid of tugs, before being taken out of the channel, to anchor, for further investigation.

Findings

4.1 Investigation Practice

The Investigation took place in accordance with the Accident Investigation Agency procedures and practice. The Investigators examined various aspect of the accident and SMS Manual containing policies, procedures, and records/documents as well as non-Quality Assurance and Control deficiencies to ensure their findings would stop this accident from happening again. 

4.2 Accident investigator’s Report

The company has taken the necessary actions, including program of continual improvement of its safety management and operating systems, and staff education and training processes which involved the whole fleet. As a result, SMS was updated as well as actions directed at identification, operation, maintenance and spare parts management relating to critical plant or machinery.  

5. Observations 

The investigators' report highlights critical deficiencies onboard, including inadequate risk assessment, lack of knowledge, and non-compliance with ISM procedures. These issues underscore the urgent need to address safety protocols, improve knowledge and competence, and ensure adherence to established procedures ensuring compliance with ISM procedures.  

6. Comments

The investigators' report highlights significant errors that contributed to the grounding incident. Firstly, inappropriate policy and procedures for monitoring procurement led to the failure to obtain a critical component, the fan belt, for the emergency generator. Additionally, there was an inadequate risk assessment, as the consequences of not having the fan belt available were not properly addressed. These deficiencies in procurement and risk assessment procedures significantly impacted the vessel's ability to respond effectively to a blackout and resulted in the unfortunate grounding incident.