Unit 5: Accident Investigation Report Analysis

5. Accident Investigation Report Analysis

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

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

Reference Number

C0013490

Description

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 was not recovered.

Key Root Causes

ISM non-conformity (Inadequate risk-assessment - Lack of knowledge - Not compliant with ISM procedures).

Casualties

1 fatality

Action-Recommendation

Company’s SMS procedures were updated:

- to include the requirement for when the work on the ship’s deck should be terminated in event of adverse weather conditions and 

- to include the requirement 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 PPE in the case it is required to access the deck in adverse weather conditions when deemed necessary for the safety of crew and/or ship

- To ensure that all crew members are familiar with these procedures, a campaign will be run on the precautions and hazards of working on deck in adverse weather conditions and ensuring compliance with ISM procedures.

- to share the Company’s investigation report along with the lessons learned from the incident with all ships within the fleet.
- to ensure the heavy weather warnings and bulletins are closely monitored and timely actions are taken to terminate any ongoing task during heavy weather.

- to review the Company's heavy weather procedure to include:
- Allowable safe weather limits and guidance for the master to terminate tasks which unnecessarily expose the crew to heavy weather.
- to carry out a thorough risk assessment and using appropriate PPE in case it is required to access the deck in heavy weather when deemed necessary for the safety of crew and ship.
- to ensure the crew is trained and familiar with the requirements of the Company's heavy weather procedures once established and how to implement it.

Would it happen again

No.

 

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.