OPTIMISM Training Platform

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.