Unit 6: Additional Micro Analysis of Accident Reports – Reviews 11 to 20

6.1 An Investigation into Root Causes of Accident – Collision in Narrow Channel

Reference Number

C0010024

Description

The vessel collided in restricted visibility with a refrigerated cargo. The bridge team on each ship were aware of the other ship’s presence in the channel, but both misjudged their own and the other ship’s position. When the actual situation was acknowledged on both ships, it was too late to manoeuvre to avoid the collision.

Key Root Causes

ISM non-conformity (Inadequate risk assessment).


Management fault (Incorrect Perception/knowledge - Poor team operation/decision making).


A safety margin that was based on whether the ships were positioned 50-100 meters to each side of the channel. The factors contributing to the collision: restricted visibility, navigating in a narrow channel, the north-easterly current, a pilot boat being alongside the two vessels making a large course alteration. Individually these factors did not constitute a recognizable significant risk, but in conjunction they created a small margin between success and failure. .

Casualties

None

Action-Recommendation

Action taken: Master attended additional BRM training; a fleet wide navigation safety campaign discussions on the collision and measures to prevent similar collisions in the future. I t also conducted a review of ship board risk assessments as well as ship management’s navigation procedures for sailing in similar situations which included a pre-appointment briefing program for on signing officers.

Would it happen again

No but navigating in a narrow channel with adverse currents and poor visibility is a high risk which could have been avoided with more in-depth training.

 

Title: An Investigation into Root Causes of Accident – Collision in Narrow Channel

Accident Investigation Review 11 - Collision in Narrow Channel

1. Introduction 

The accident investigation was carried out by a qualified accident investigator employed by an Accident Investigation Agency. 

This 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 vessel collided in restricted visibility with a refrigerated cargo. The bridge team on each ships was aware of the other ship’s presence in the channel, but both misjudged their own and the other ship’s position. When the actual situation was acknowledged on both ships, it was too late to maneuver to avoid the collision.

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. This accident was caused by human error. Therefore, additional BRM trainings were conducted for the master. Additionally, a fleet-wide navigation safety campaign has been implemented. Shipboard risk assessment and ship management’s navigation in similar situation have been reviewed as well. 

5. Observations 

The investigators' report reveals a significant error in the inadequate risk assessment process, along with a notable mistake involving incorrect perception and knowledge. Poor team operation and decision-making further compounded the situation. The collision incident was influenced by several factors, including restricted visibility, navigating in a narrow channel, the north-easterly current, and a pilot boat being alongside the two vessels during a large course alteration. Although individually these factors may not have been recognized as significant risks, their combined effect created a narrow margin between success and failure, ultimately leading to the collision. 

6. Comments

The accident investigation report attributes the collision to human error and underscores the importance of effective risk assessment, teamwork, and decision-making. The company's response included additional BRM training, a fleet-wide safety campaign, and reviews of shipboard risk assessments. The report stresses that chances of collisions are high while navigating in a narrow channel with adverse currents and poor visibility. However, comprehensive training can aid to mitigate this challenge.