OPTIMISM Training Platform

Reference Number	GDMR3
Description	A ship with a history of having problems with automated systems developed faults with a data control device leading to a blackout and failure of one of the propulsion engines.
Key Root Causes	ISM non-conformity (Inadequate procedures and lack of action to take note of earlier problems and inadequate manning) - Inadequate system design - Issues with preventive maintenance - Inadequate risk-assessment - Inadequate policy/procedures - insufficient resources –  Management fault (commercial pressures - poor decision-making).
Casualties	None and spillage of fuel into the sea
Action-Recommendation	In appropriate safety management system and procedures and inadequate manning. To review the existing procedures to include management of failure in the ship machinery systems and indicate responsibilities, communication and additional measures to be taken in such cases.
Would it happen again	Maybe, due to complexities of automated systems but preventive maintenance could reduce the risk of such accidents.

Title: An Investigation into Root Causes of Accident - Collision

Accident Investigation Review 13 - Collision

1. Introduction 

In this accident investigation was carried out by a qualified accident investigator employed by a leading 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 a systematic 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

A ship with a history of having problems with automated systems developed faults with a data control device leading to a blackout and failure of one of the propulsion engines.

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

It is recommended to include management of failures in the ship machinery systems in the existing procedures. Subsequently specify responsibilities, necessary communications, and additional measures to be taken in such cases. 

5. Observations 

The investigators' report highlights a series of errors and recklessness that contributed to the incident. Inadequate procedures and a lack of response to earlier problems, combined with insufficient manning, underscore the deficiencies. The system design, preventive maintenance, and leadership was also inadequate. Furthermore, there were issues with risk assessment, policy and procedures, as well as insufficient resources, commercial pressures, and poor decision-making. These factors collectively led to the incident.

6. Comments

The accident investigation report attributes the collision to human error and recklessness. Additionally, it underscores the need for enhanced safety measures and effective implementation of the ISM Code and a effective risk assessment by the management. The incident involving automated system failures and blackout highlights the importance of including management of machinery system failures in procedures. Due to the complexities of automated system it is difficult to certainly mitigate the risk, but preventive maintenance as well as addressing responsibilities, communication, and additional measures during such events can significantly prevent reoccurrences.