Unit 5: Accident Investigation Report Analysis

5. Accident Investigation Report Analysis

5.10 An Investigation into Root Causes of Accident - Grounding

Table 23: Micro Presentation of a Review of an Accident – Review 10


Reference Number

C0011070

Description

Under harbour pilot guidance, the bulk carrier experienced an electrical blackout resulting in loss of propulsion and steering control. As a result, the ship exited the channel and ran aground. The ship was recovered into the channel with the aid of tugs, before being taken out the channel, to anchor, for further investigation.

Key Root Causes

ISM non-conformity (Inappropriate policy/procedures for monitoring procurement - Inadequate risk assessment) – Management fault (Grounding occurred due to blackout and that the emergency generator was not able to run for required time, since the fan belt was not present. The belt was ordered by the crew 9 months before, but was not delivered since 9 ports visits).

Casualties

None

Action-Recommendation

The company has undertaken a fleetwide program of continual improvement of its safety management and operating systems, and staff education and training processes. This included updating SMS and actions directed at identification, operation, maintenance and spare parts management relating to critical plant and machinery.

Would it happen again

No if the fan belt chased and was fitted and communication issues ashore and aboard addressed.

Title: An Investigation into Root Causes of Accident - Grounding

Accident Investigation Review 10 Grounding

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 of establishing 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 accidents 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 finding out if ISM can be more effectively implemented or its effectiveness improved.

4. Investigation

Under harbor pilot guidance, the bulk carrier experienced an electrical blackout resulting in loss of propulsion and steering control. As a result, the ship exited the channel and ran aground. The ship was recovered into the channel with the aid of tugs, before being taken out of the channel, to anchor, for further investigation.

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 program of continual improvement of its safety management and operating systems, and staff education and training processes which involved the whole fleet. As a result, SMS was updated as well as actions directed at identification, operation, maintenance and spare parts management relating to critical plant or machinery.  

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

The investigators' report highlights significant errors that contributed to the grounding incident. Firstly, inappropriate policy and procedures for monitoring procurement led to the failure to obtain a critical component, the fan belt, for the emergency generator. Additionally, there was an inadequate risk assessment, as the consequences of not having the fan belt available were not properly addressed. These deficiencies in procurement and risk assessment procedures significantly impacted the vessel's ability to respond effectively to a blackout and resulted in the unfortunate grounding incident.