Unit 5: Accident Investigation Report Analysis

5. Accident Investigation Report Analysis

5.6 An Investigation into Root Causes of Accident – Ship Stability

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

Reference Number

C0013582

Description

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. 

Key Root Causes

ISM non-conformity (the cargo plan was incorrect and the captain and ship mate did not know how to do the stability calculations. The crew was fatigued - The work days were not complied - Inappropriate policy manual, inappropriate procedures; Inappropriate work environment inadequate risk assessment).  


Management fault (Inadequate Knowledge; Inadequate competence/skills; Lack of motivation or complacency - Inadequate leadership; Inadequate supervision; problems with safety culture. 


Manning issue (working hours not logged (fatigue).

Casualties

2 Injured and 2 fatalities

Action-Recommendation

The captain to undergo training in stability calculations and company to address policy/procedures deficiencies.

Would it happen again

Maybe unless ship’s stability is ensured. And safety such as working hours/fatigue are addressed.

 

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.