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Unit 6: Additional Micro Analysis of Accident Reports – Reviews 11 to 20

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Book: Unit 6: Additional Micro Analysis of Accident Reports – Reviews 11 to 20
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Date: Thursday, 9 April 2026, 7:15 AM

Table of contents

6.1 An Investigation into Root Causes of Accident – Collision in Narrow Channel

Reference Number

C0010024

Description

The vessel collided in restricted visibility with a refrigerated cargo. The bridge team on each ship were aware of the other ship’s presence in the channel, but both misjudged their own and the other ship’s position. When the actual situation was acknowledged on both ships, it was too late to manoeuvre to avoid the collision.

Key Root Causes

ISM non-conformity (Inadequate risk assessment).


Management fault (Incorrect Perception/knowledge - Poor team operation/decision making).


A safety margin that was based on whether the ships were positioned 50-100 meters to each side of the channel. The factors contributing to the collision: restricted visibility, navigating in a narrow channel, the north-easterly current, a pilot boat being alongside the two vessels making a large course alteration. Individually these factors did not constitute a recognizable significant risk, but in conjunction they created a small margin between success and failure. .

Casualties

None

Action-Recommendation

Action taken: Master attended additional BRM training; a fleet wide navigation safety campaign discussions on the collision and measures to prevent similar collisions in the future. I t also conducted a review of ship board risk assessments as well as ship management’s navigation procedures for sailing in similar situations which included a pre-appointment briefing program for on signing officers.

Would it happen again

No but navigating in a narrow channel with adverse currents and poor visibility is a high risk which could have been avoided with more in-depth training.

 

Title: An Investigation into Root Causes of Accident – Collision in Narrow Channel

Accident Investigation Review 11 - Collision in Narrow Channel

1. Introduction 

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

This 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 vessel collided in restricted visibility with a refrigerated cargo. The bridge team on each ships was aware of the other ship’s presence in the channel, but both misjudged their own and the other ship’s position. When the actual situation was acknowledged on both ships, it was too late to maneuver to avoid the collision.

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. This accident was caused by human error. Therefore, additional BRM trainings were conducted for the master. Additionally, a fleet-wide navigation safety campaign has been implemented. Shipboard risk assessment and ship management’s navigation in similar situation have been reviewed as well. 

5. Observations 

The investigators' report reveals a significant error in the inadequate risk assessment process, along with a notable mistake involving incorrect perception and knowledge. Poor team operation and decision-making further compounded the situation. The collision incident was influenced by several factors, including restricted visibility, navigating in a narrow channel, the north-easterly current, and a pilot boat being alongside the two vessels during a large course alteration. Although individually these factors may not have been recognized as significant risks, their combined effect created a narrow margin between success and failure, ultimately leading to the collision. 

6. Comments

The accident investigation report attributes the collision to human error and underscores the importance of effective risk assessment, teamwork, and decision-making. The company's response included additional BRM training, a fleet-wide safety campaign, and reviews of shipboard risk assessments. The report stresses that chances of collisions are high while navigating in a narrow channel with adverse currents and poor visibility. However, comprehensive training can aid to mitigate this challenge.

6.2 An Investigation into Root Causes of Accident – Enclosed Spaces

Reference Number

RZ/JU1

Description

A bulk carrier was at anchor when an ordinary seafarer collapsed in a cargo hold containing soya beans. The alarm was raised and the chief officer who entered to help also collapsed. Both the chief officer and ordinary seafarer were recovered from the hold by a team wearing breathing apparatus. Both were transferred to hospital ashore where the chief officer made a full recovery. The ordinary seafarer died as a result of exposure to lethal levels of phosphine gas.

Key Root Causes

ISM non-conformity (The cargo holds were identified as “enclosed spaces” but enclosed space procedures were not followed). It was assumed the space was safe, and PPE was not required, as the vessel was in possession of a gas free certificate hence Phosphine gas detection equipment which was onboard was not considered necessary. The vessel’s multi-gas meter used for “enclosed space” entry did not have phosphine sensors. No risk assessment form S-18 nor SM-15-01/02 Enclosed spaces (General) were completed as part of the management of risk protocols).

Management fault (Inadequate procedures and inadequate training, safety culture issues).

Casualties

I fatality and 1 injury

Action-Recommendation

Reviewed and amended procedures regarding enclosed and dangerous spaces and circulated and implemented a series of additional safety training on working in enclosed or dangerous spaces for all persons prior to joining vessels. Training on safety culture onboard. Implemented a company policy on the donning of Breathing Apparatus when entering holds where fumigant has been present.   Reviewed IMO recommendations on safe use of pesticides on ships and provided new forms for the appointment of responsible person in charge. The Flag State should also consider a review of the effectiveness of the ISM audits carried out by ROs pertaining to the adequacy of risk assessments for the safe carriage of fumigated cargoes.

Would it happen again

No if there was discussion around the assessment for potential hazards, risks or testing the spaces prior to entry. Gas free certification for the type of cargo needs reassessment.  

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

Accident Investigation Review 12 - 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

The bulk carrier was at port when an ordinary seafarer collapsed in a cargo hold containing soya beans. The alarm was raised and the chief officer who entered to help also collapsed. Both the chief officer and ordinary seafarer were recovered from the hold by a team wearing breathing apparatus. Both were transferred to hospital ashore where the chief officer made a full recovery. The ordinary seafarer died as a result of exposure to lethal levels of phosphine gas.

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

Procedures regarding enclosed and dangerous spaces have been reviewed and amended. Additional safety training on working in enclosed or dangerous spaces have been implemented for all the personnel before joining the vessel as well as a training on safety culture onboard. Moreover, company policy has been implemented on the donning of breathing apparatus when entering holds with presence of chemical pesticides. To align with the International Maritime Organization (IMO) recommendations, new forms have been provided for the appointment of the person in charge (PC). It is recommended to The Flag State to review the effectiveness of the ISM audits carried out by ROs with a focus on assessing the adequacy of risk assessments for the safe carriage of fumigated cargoes.

5. Observations 

The investigators' review uncovers a significant mistake and recklessness in handling enclosed spaces. Although the cargo holds were identified as "enclosed spaces," proper procedures were not followed. Assumptions were made about the space's safety due to the possession of a gas-free certificate, and personal protective equipment (PPE) was not considered necessary. However, the vessel lacked phosphine gas detection equipment, which was crucial for ensuring safety. Moreover, essential risk assessment protocols, such as forms S-18 and SM-15-01/02 for enclosed spaces, were not completed.

6. Comments

The accident investigation report identifies mishandling of enclosed spaces and the absence of safety precautions as the root causes of the incident. The report recommends revised procedures, enhanced safety training, and improved risk assessment protocols to prevent similar accidents as discussion around the assessment for potential hazards, risks or testing the spaces prior to entry could avoid the incident from occurring. The company has promptly taken essential actions, aligned with IMO recommendations. Further, the report highlights the need for the Flag State to review ISM audits' effectiveness, particularly in assessing risk assessments for safe cargo carriage.

6.3 An Investigation into Root Causes of Accident - Collision

Reference Number

GDMR3

Description

A ship with a history of having problems with automated systems developed faults with a data control device leading to a blackout and failure of one of the propulsion engines.

Key Root Causes

ISM non-conformity (Inadequate procedures and lack of action to take note of earlier problems and inadequate manning) - Inadequate system design - Issues with preventive maintenance - Inadequate risk-assessment - Inadequate policy/procedures - insufficient resources – 

Management fault (commercial pressures - poor decision-making).

Casualties

None and spillage of fuel into the sea

Action-Recommendation

In appropriate safety management system and procedures and inadequate manning. To review the existing procedures to include management of failure in the ship machinery systems and indicate responsibilities, communication and additional measures to be taken in such cases.

Would it happen again

Maybe, due to complexities of automated systems but preventive maintenance could reduce the risk of such accidents.

Title: An Investigation into Root Causes of Accident - Collision

Accident Investigation Review 13 - Collision

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

A ship with a history of having problems with automated systems developed faults with a data control device leading to a blackout and failure of one of the propulsion engines.

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 recommended to include management of failures in the ship machinery systems in the existing procedures. Subsequently specify responsibilities, necessary communications, and additional measures to be taken in such cases. 

5. Observations 

The investigators' report highlights a series of errors and recklessness that contributed to the incident. Inadequate procedures and a lack of response to earlier problems, combined with insufficient manning, underscore the deficiencies. The system design, preventive maintenance, and leadership was also inadequate. Furthermore, there were issues with risk assessment, policy and procedures, as well as insufficient resources, commercial pressures, and poor decision-making. These factors collectively led to the incident.

6. Comments

The accident investigation report attributes the collision to human error and recklessness. Additionally, it underscores the need for enhanced safety measures and effective implementation of the ISM Code and a effective risk assessment by the management. The incident involving automated system failures and blackout highlights the importance of including management of machinery system failures in procedures. Due to the complexities of automated system it is difficult to certainly mitigate the risk, but preventive maintenance as well as addressing responsibilities, communication, and additional measures during such events can significantly prevent reoccurrences.

6.4 An Investigation into Root Causes of Accident – Anchoring

Reference Number

GDMR4

Description

This is a hydraulic mooring anchoring incident. It occurred due to entrapment of a sailor's leg in a rope, that was being stowed using a windlass; later the leg was amputated. 

Key Root Causes

ISM non-conformity (Inadequate policy/procedures) - Poor human-machine interface Inadequate risk-assessment).

Management fault (Inadequate skill/competence - Inadequate leadership/supervision).

Casualties

1 Injury (limb amputation)

Action-Recommendation

To carry out a more effective risk-assessment and continuous training accompanied by effective operational procedures that highlights safe working practices on board the ship. The procedure should ensure the need for supervision and extra care when working with or near moving rope or chains.

Would it happen again

No, if there is a precise procedure to ensure no crew member works with or near any system with moving parts including ropes and chains unless fully trained and supervised.

Title: An Investigation into Root Causes of Accident – Anchoring 

Accident Investigation Review 14 - Anchoring

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

This is a hydraulic mooring anchoring incident. It  occurred due to entrapment of a sailor's leg in a rope, that was being stowed using a windlass; later the leg was amputated. 

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

More effective risk assessment and continuous training has to be carried out. Additionally, effective operational procedures that highlights safe working practices on the board the ship needs to be implemented. Extra care and supervision must be embedded in the procedures when working with or near moving ropes and chains.  

5. Observations 

The investigators' report underscores a critical error stemming from complacency and overconfidence, which led to non-compliance with vital safety measures. Inadequate policy and procedures, coupled with a poor human-machine interface, further exacerbated the situation. The incident also reveals shortcomings in skill and competence, inadequate leadership and supervision, and an ineffective risk assessment.

6. Comments

The accident investigation report highlights the importance of vigilant adherence to safety protocols and the ISM Code. The hydraulic mooring incident underscores the need for continuous risk assessment, robust training, and effective operational procedures. Addressing complacency and overconfidence through careful supervision and improved policies is crucial to prevent similar incidents. The report's findings reveal multiple deficiencies, emphasizing the significance of a comprehensive approach to safety management, competence building, and proper risk assessment.

6.5 An Investigation into Root Causes of Accident – Falling from Height

Reference Number

GDMR5

Description

Falling from height of less than 2.5/3.0 meters. Under the chief mate’s supervision, the crew were in the process of moving a tweendeck; the ship’s crane was used to hoist the tweendeck pontoon out of the hold so that it could be turned. The chief mate, who was standing on a fixed ladder near the hatch fell overboard and found dead.  

Key Root Causes

ISM non-conformity (Inappropriate policy manual, inappropriate procedures.  The crew did not hold a safety meeting and the working practice on board did not coincide with the procedures of the Safety Management System (SMS). The available instructions were considered ‘unworkable’ by the crew). 

Management fault (The crew did not hold a safety meeting). 

Casualties

1 fatality (Chief Mate)

Action-Recommendation

To revise instructions and learn from similar accidents. The vessel’s sister ship used a safer method and the company was aware of this but failed to minimize risk. 

Would it happen again

Maybe not, if a safety meeting was held and the CM had a harness he would not have died.

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

Accident Investigation Review 15 - Falling from Height

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 accidents 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 finding out if ISM can be more effectively implemented or its effectiveness improved.

4. Investigation

Falling from height of less than 2.5/3.0 meters. Under the chief mate’s supervision, the crew were in the process of moving a tweendeck; the ship’s crane was used to hoist the tween deck pontoon out of the hold so that it could be turned. The chief mate, who was standing on a fixed ladder near the hatch fell overboard and found dead.  

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

Instructions must be continually revised. Safety meetings should be regularly held. Appropriate PPE such as harness must be utilized in this type of task. Learn from similar accidents and methods used by other ships to mitigate the risk.  

5. Observations 

The investigators' report reveals a significant error originating from an inappropriate policy manual and inappropriate procedures. The crew's failure to conduct a safety meeting and the inconsistency between onboard working practices and the SMS procedures were key issues. The crew's perception of the available instructions as 'unworkable' made the situation worse.

6. Comments

The accident investigation report highlights a tragic incident involving a fall from a relatively low height during a tween deck movement operation. The report underscores the need for regular instruction revisions, safety meetings, and proper PPE usage, such as harnesses. Learning from past accidents and adopting effective risk mitigation methods is crucial. The findings point to inadequate policies, procedures, and crew training. The report emphasizes the importance of aligning onboard practices with SMS procedures, conducting safety meetings. Despite the crew's incompetency in not adhering to SMS procedures and available instructions, the management could have implemented strict policies to ensure that procedures and instructions are followed as they should be.

6.6 An Investigation into Root Causes of Accident Collison with Quay

Reference Number

GDMR6

Description

With the clam open, there was a failure in the propulsion system that caused the gate to strike against the quay and the bulb of the ship against one of its pillars, causing minor damage to the Quay.

Key Root Causes

ISM non-conformity (Inappropriate policy/procedures - Machine interface, automation issues, maintenance and equipment malfunctions. 

Crew related/Management fault (The accident occurred due to a malfunction of the propulsion control system accompanied by human error in the execution of the propulsion control transfer procedure from the bridge to the engine room, and in the subsequent return of control to the bridge. 

Casualties

None

Action-Recommendation

To examine the propulsion control system between the Bridge and the Engine room and ensure additional training in the execution of such control transfers.

Would it happen again

Maybe not, if automation issues effectively resolved and propulsion control procedure from the Bridge to engine room and vice versa.

Title: An Investigation into Root Causes of Accident Collison with Quay

Accident Investigation Review 16 - Collision with Quay

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

With the clam open, there was a failure in the propulsion system that caused the gate to strike against the quay and the bulb of the ship against one of its pillars, causing minor damage to the Quay. 

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

Propulsion control system between the Bridge and the Engine room needs to be examined. To ensure similar accident won’t reoccur, additional training in the execution of such control must be conducted.

5. Observations 

The accident stemmed from a propulsion control system malfunction compounded by human errors during the execution of propulsion control transfer procedures between the bridge and the engine room. These errors were followed by inappropriate policy and procedures and inadequate supervision. Machine interface, automation issues, maintenance, and equipment malfunctions also played a role. Rectifying these issues is essential to prevent similar accidents by ensuring robust procedures, enhanced supervision, improved human-machine interaction, and more effective maintenance protocols.

6. Comments

The accident investigation report highlights a propulsion system failure that led to a collision with the quay. The findings emphasize the importance of examining the propulsion control system and providing additional training for its execution. The incident reveals a combination of technical and human factors, including improper procedures, inadequate supervision, and automation issues.

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

Reference Number

C0013781

Description

When securing the drums stacks onto the poop deck in order to prepare for the severe weather conditions reported by the weather forecast an AB, OS A and OS B were facing one another to lift a toolbox; this is when OS B lost his balance and fell towards the chain railings, plunging about 18 meters onto the upper deck and later died.

Key Root Causes

ISM non-conformity (Inadequate risk -assessment - Inadequate system design - Inadequate competence/skills; 

Management fault (Inadequate team operation; Incorrect perception; Inadequate leadership).

Bad weather.

Casualties

1 Fatality

Action-Recommendation

Training on hazards of working on the deck specially when there is a bad weather.

Would it happen again

No if training is provided on risk assessment.

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

Accident Investigation Review 17 – MOB

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

When securing the drums stacks onto the poop deck in order to prepare for the severe weather conditions reported by the weather forecast an AB, OS A and OS B were facing one another to lift a toolbox; this is when OS B lost his balance and fell towards the chain railings, plunging about 18 meters onto the upper deck and later died.

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

Trainings on hazards including risk assessment focusing on bad weather should be provided to the personnel of the ship.

5. Observations 

The error arose from inadequate system design, compounded by insufficient competence, teamwork, and leadership. Incorrect perception and inadequate risk assessment further contributed, followed by challenging weather conditions. 

6. Comments

The accident investigation report highlights a tragic incident resulting from inadequate safety measures during severe weather preparations. The findings emphasize the need for hazard-specific training, particularly focused on risk assessment for adverse weather conditions. The incident underscores deficiencies in system design, competence, teamwork, and leadership. Addressing these factors through targeted training and improved safety protocols is essential to prevent similar accidents and ensure the well-being of crew members during challenging conditions.

6.8 An Investigation into Root Causes of Accident – Falling Weight

Reference Number

C0013289

Description

A CCTV footage from the shore, which captured most of the accident, showed that the Hatch Cover was lifted by the ship’s Gantry Crane, operated by the Chief Officer, which then disconnected from the crane and fell onto the closed hatch cover beneath, where two crew members were laying out supports for it. One of the two crew members, managed to escape, the other one was crushed and declared dead. The Danish Maritime Authority detained the ship. Personnel should not be permitted to work if the Gantry Crane had any malfunction according to Procedures No.36 & No.37, in the case in which it was permitted to work, a “Specific Risk Assessment”, should have been carried out and the malfunction taken into consideration.

Key Root Causes

ISM non-conformity (Inadequate risk assessment - Gantry Crane was malfunctioning – Noting that the Procedures 36 and 37 were violated as the specific risk-assessment was carried out by not considering the particular circumstances of the work to be done, specifically the hydraulic deficiency of the Gantry Crane)

Management fault (Personnel were permitted to work, i.e., the two ABs went under the Hatch Cover, in order to place the supporting wooden stanchions, despite the fact that the Gantry Crane was malfunctioning. 

Crew related (Safety Management System Procedures violation was a contributing factor to the accident).

Casualties

1 fatality

Action-Recommendation

Had procedures in place for operating the Gantry Crane as well as Gantry Crane Manufacturer’s instructions, been implemented and a Specific Risk Assessment been carried out, the accident would have been avoided. under no circumstances personnel pass beneath a load that is being lifted where the operator of the lifting equipment does not have a clear view, and an effective system of radio or other contact to be implemented.

Would it happen again

No, if procedures respected and an effective risk-assessment had taken place.

 

Title: An Investigation into Root Causes of Accident – Falling Weight

Accident Investigation Review 18 - Falling Weight

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

A CCTV footage from the shore, which captured most of the accident, showed that the Hatch Cover was lifted by the ship’s Gantry Crane, operated by the Chief Officer, which then disconnected from the crane and fell onto the closed hatch cover beneath, where two crew members were laying out supports for it. One of the two crew members, managed to escape, the other one was crushed and declared dead. The Danish Maritime Authority detained the ship. Personnel should not be permitted to work if the Gantry Crane had any malfunction according to Procedures No.36&No.37, in the case in which it was permitted to work, a “Specific Risk Assessment”, should have been carried out and the malfunction taken into consideration.

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

Conduct proper oversight to ensure adherence to procedures and the instructions provided by the Gantry Crane Manufacturer, particularly emphasizing the prohibition of personnel passing beneath a lifted load when the operator lacks a clear view. This should be accompanied by a detailed risk assessment aimed at preventing the recurrence of such accidents. Implement a robust communication system, such as radios, to facilitate effective communication.

5. Observations

 The investigation report reveals a clear violation of procedures (36 and 37) involving inadequate risk assessment, which neglected to consider specific work circumstances, notably the malfunctioning Gantry Crane's hydraulic deficiency. This allowed personnel to proceed with work under the Hatch Cover, placing wooden stanchions, despite the crane's malfunction. The lack of proper risk assessment and violation of Safety Management System Procedures both significantly contributed to the accident. 

6. Comments

The accident investigation report reveals a tragic incident involving a Gantry Crane malfunction during hatch cover operations. The findings emphasize the critical need for strict adherence to procedures, including prohibiting personnel from working beneath a lifted load without clear operator visibility. Robust oversight, detailed risk assessments, and effective communication systems are recommended to prevent similar accidents. The report underscores the significance of proper risk assessment to ensure the safety of crew members during crane operations.

6.9 An Investigation into Root Causes of Accident – Mooring operation

Reference Number

C0012821

Description

The vessel while at a floating Berth during an emergency mooring operation at the aft mooring station, the outgoing length of a double breast line “jumped over” a roller fairlead and severely injured the vessel’s Third Officer on his legs. The vessel’s Chief Officer was also injured on his left hand in his attempt to assist the Third Officer. First aid was provided. Third Officer’s both lower legs were subsequently amputated. The Chief Officer suffered three broken fingers in his left hand.

Key Root Causes

ISM non-conformity (Inadequate risk assessment – Lack of training in mooring operations as per SMS requirements). 


Management fault (Inappropriate implementation of SMS: failure to follow the safety best practices for mooring operations (e.g., non-implementation of the guidelines in “Effective Mooring” publication). Unsafe decision to transfer the outgoing length of the aft double breast line to an adjacent roller fairlead by hand, when the vessel was moving in and out from the berth. Ignoring hazards and being inattentive to risks such as shifting a line when the line is under strain, standing on a line or in a closed bight of line).

Casualties

2 injuries, one crew's legs amputated.

Action-Recommendation

For the Management Company to provide training in mooring operations as per SMS requirements and include realistic hazards and consequence - Proper implementation of the emergency checklists, as per SMS requirements - Mooring plans to be prepared and retained as evidence of the mooring arrangement/agreement with the port’s authorities, as required by SMS. The management to consider the typical minimum mooring requirements for cape size (e.g., 4 headlines and 4 stern lines) provided by the industry and the SMS to be revised accordingly.

Would it happen again

No, if risk assessed effectively and training in mooring operation given. 

Title: An Investigation into Root Causes of Accident – Mooring operation

Accident Investigation Review 19 - Mooring Operation 

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

The vessel while at a floating Berth during an emergency mooring operation at the aft mooring station, the outgoing length of a double breast line “jumped over” a roller fairlead and severely injured the vessel’s Third Officer on his legs. The vessel’s Chief Officer was also injured on his left hand in his attempt to assist the Third Officer. First aid was provided. Third Officer’s both lower legs were subsequently amputated. The Chief Officer suffered three broken fingers on his left hand.

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 highly recommended for Management Company to provide training in mooring operations as well as the proper implementation of the emergency checklists as per SMS requirements and include realistic hazards and consequence. As it is required by SMS the mooring plans must be prepared and retained as evidence of the mooring arrangement/agreement with the port’s authorities. The management is considering the typical minimum mooring requirements for cape size provided by the industry and the SMS to be revised accordingly. 

5. Observations

The investigation report highlights a critical mistake rooted in the inappropriate implementation of the Safety Management System (SMS), notably neglecting safety best practices for mooring operations outlined in the "Effective Mooring" publication. Inadequate risk assessment and lack of supervision compounded the situation. A hazardous decision was made to manually transfer the aft double breast line to an adjacent roller fairlead while the vessel was manoeuvring in and out of the berth. Hazards were overlooked, and risks associated with shifting a strained line, standing on a line, or being in a closed bight of line were disregarded. 

6. Comments

The investigation report underscores a grave accident during an emergency mooring operation, revealing failures in SMS implementation and risk assessment. The findings stress the need for comprehensive training, strict adherence to emergency checklists, and proper mooring plans. The incident's roots lie in neglecting safety protocols and oversight, leading to severe injuries. Rectifying these deficiencies and aligning practices with industry standards are crucial to preventing similar accidents, prioritizing crew safety and effective mooring operations. The accident could have been avoided if risk assessed was effective and training in mooring operation was given.

6.10 An Investigation into Root Causes of Accident - Grounding

Reference Number

C0013465

Description

After disembarking the pilot and given the Ready for engines1, the ship suffered a fault from the electrical plant and the control of the engine and rudder on the bridge and later the ship was stranded in a sandy shoal area. The systems for the generation and distribution of electrical energy, and the control of the propulsion and government of the vessel were poorly managed, in view of the set of technical failures revealed during the accident.

Key Root Causes

ISM non-conformity (Inappropriate policy manual - Inappropriate procedures - Inadequate risk assessment 

Management fault (Inadequate supervision; Problems with safety culture - Poor team operation; Working towards different goals; Incorrect perception).

Casualties

None

Action-Recommendation

An inappropriate policy manual and procedures, inadequate supervision, and problems within the safety culture are evident. Additionally, there are issues related to inadequate risk assessment, poor team operation, divergent goals, and incorrect perception. 

Would it happen again

Yes, if propulsion system not managed effectively.

Title: An Investigation into Root Causes of Accident - Grounding

Accident Investigation Review 20 - Grounding

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

After disembarking the pilot and given the Ready for engines1, the ship suffered a fault from the electrical plant and the control of the engine and rudder on the bridge and later the ship was stranded in a sandy shoal area. The systems for the generation and distribution of electrical energy, and the control of the propulsion and government of the vessel were poorly managed, in view of the set of technical failures revealed during the accident.

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 recommended for the shipping company to prioritize several key areas for safety enhancement. First, a comprehensive review and improvement of the maintenance procedures for the ship's electrical plant is crucial, including regular inspections and training for crew members. Also, implementing redundancy and backup systems for critical components can minimize the impact of technical failures. Crew training and competency should be regularly reinforced, particularly focusing on electrical plant operations and emergency responses.

5. Observations 

The investigators' report reveals a critical error stemming from multiple sources. An inappropriate policy manual and procedures, inadequate supervision, and problems within the safety culture are evident. Additionally, there are issues related to inadequate risk assessment, poor team operation, divergent goals, and incorrect perception. Addressing these shortcomings is imperative to establish a robust safety framework, enhance team collaboration, align goals, and ensure accurate risk assessment to prevent similar incidents in the future.

6. Comments

The investigation underscores a significant accident resulting from technical failures and inadequate management of the ship's systems. The recommendations emphasize the importance of enhancing maintenance procedures, crew training, and implementing backup systems. The report highlights a series of deficiencies in policy, procedures, supervision, and safety culture. Addressing these gaps is vital to prevent future incidents and foster a safer maritime environment through improved systems management, crew competence, and effective risk assessment.