Unit 5: Accident Investigation Report Analysis

5. Accident Investigation Report Analysis

5.7 An Investigation into Root Causes of Accident - Explosion

Table 20: Micro Presentation of a Review of an Accident – Review 7

Reference Number

C0012731

Description

Temperature of Styrene Monomer not monitored, and Temperature alarm not set. The vessel was vetted by a CDI inspector in USA. One of the questions included in the CDI questionnaire was: Are officers aware of the documentation and handling requirements for cargoes and inhibitors, and if the cargo carried is required to be inhibited, is the required information available? No deficiencies were recorded, and the vetting report noted the vessel to be in compliance with IBC and company procedures and observed the cargo handling and monitoring equipment in good condition overall.

Key Root Causes

ISM non-conformity (Inadequate risk assessment - Instructions and guidance were clear that inhibited cargoes should not be stowed adjacent to heated cargoes but no problems noted before and crew had been carrying these cargoes for some time without problem. 

Management fault: (non-compliance with instructions for inhibited cargoes – ineffective communication - Language could have been an issue, Russian officers and Filipino crew).

Casualties

1 injury on one vessel and one on the other one and, 15 shore workers/officials were also reported to have been injured.

Action-Recommendation

The internal audit report noted that the SMS was well implemented, the senior officers were diligent, and that the tanker was very well maintained. Two non-conformities and 11 observations were recorded. The non-conformities concerned the absence of records of atmospheric checks when tank cleaning, and the recording of working hours. The observations were related to minor errors and omissions in documentation 

Would it happen again

Yes, as despite the Inspector asking the right question and considering the underlying problem the accident happened. Also, the vessel was considered to be in compliance of IBS and company procedures.

 

Title: An Investigation into Root Causes of Accident - Explosion

Accident Investigation Review 7 - Explosion

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

Temperature of Styrene Monomer not monitored and Temperature alarm not set. The vessel was vetted by a CDI inspector in USA. One of the questions included in the CDI questionnaire was: Are officers aware of the documentation and handling requirements for cargoes and inhibitors, and if the cargo carried is required to be inhibited, is the required information available? No deficiencies were recorded, and the vetting report noted the vessel to be in compliance with IBC and company procedures and observed the cargo handling and monitoring equipment in good condition overall.  As a result, this accident ended up as an explosion causing 2 injuries and 15 shore workers/officials injured. 

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

According to the investigation, the internal audit reports noted that the SMS was well implemented, the senior officers were diligent, and that the tanker was very well maintained. However 2 non-conformities concerned the absence of records of atmospheric check when tank cleaning was in process and the recording of working hours. 

5. Observations

 The investigators' report identifies two main errors that contributed to the incident. Firstly, there was a failure to adhere to clear instructions against stowing inhibited cargoes next to heated cargoes, although there were no previous issues with this practice. Secondly, potential communication challenges arose due to language differences between officers and crew members. 

6. Comments

The accident investigation focused on an explosion caused by a failure to monitor the temperature of Styrene Monomer and set temperature alarms. Despite the vessel being in compliance with IBC and company procedures, the accident resulted in injuries to crew members and shore workers. The investigation revealed non-conformities related to atmospheric checks during tank cleaning and working hour recordings. The report emphasizes the need to address SMS procedures and highlights two contributing factors: failure to follow instructions on stowing inhibited cargoes near heated cargoes and potential communication challenges. It is worth mentioning that the accident could happen again since the inspectors asked the right questions and the vessel was considered to be in compliance of IBS and company procedures.