Unit 5: Accident Investigation Report Analysis

5. Accident Investigation Report Analysis

5.3 An Investigation into Root Causes of Accident - Collision

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

IMO Number

9036430 / RZ-HK3

Description

Shortly before noon, the bulk carrier collided with a moored tugs port, 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. Goliath sustained minor damage to its bow while the tugs were both subsequently declared a constructive total loss.

Key Root Causes

ISM nonconformity (Inadequate SMS - Inadequate crew training to ensure BRM requirements are met in full)


Management fault (Master and 2nd Chief did not have any BRM training. 

Casualties

None

Action-Recommendation

To provide training on BRM to all deck officers and supporting crew. All deck officers serving on board, on both duty rosters should be provided with bridge resource management (BRM) training ashore. A new dynamic navigation audit was instituted to allow for regular audits focused on the effective implementation of BRM on board. The crew training schedule for ships across the fleet to be updated to reflect the safety management system’s requirement for BRM training. The technical modifications to be made to VecTwin joystick system panels to incorporate a positive visual indication that the correct steering mode had been selected at the steering console. The checklist for the transfer of controls was also to be updated to include this additional check.  The amendments be made to ship’s safety management system procedures for navigation, passage planning, watch keeping, master/pilot exchange and the bridge arrival and departure checklists. The amendments include a requirement for watch handovers during pilotage to be planned and agreed upon by the master in advance and for safe areas to be identified for such handovers to take place.

Would it happen again

No if the Master and 2nd Officer trained on BRM.

 

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.