OPTIMISM Training Platform

Reference Number	GDMR4
Description	This is a hydraulic mooring anchoring incident. It occurred due to entrapment of a sailor's leg in a rope, that was being stowed using a windlass; later the leg was amputated.
Key Root Causes	ISM non-conformity (Inadequate policy/procedures) - Poor human-machine interface Inadequate risk-assessment). Management fault (Inadequate skill/competence - Inadequate leadership/supervision).
Casualties	1 Injury (limb amputation)
Action-Recommendation	To carry out a more effective risk-assessment and continuous training accompanied by effective operational procedures that highlights safe working practices on board the ship. The procedure should ensure the need for supervision and extra care when working with or near moving rope or chains.
Would it happen again	No, if there is a precise procedure to ensure no crew member works with or near any system with moving parts including ropes and chains unless fully trained and supervised.

Title: An Investigation into Root Causes of Accident – Anchoring 

Accident Investigation Review 14 - Anchoring

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

This is a hydraulic mooring anchoring incident. It  occurred due to entrapment of a sailor's leg in a rope, that was being stowed using a windlass; later the leg was amputated. 

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

More effective risk assessment and continuous training has to be carried out. Additionally, effective operational procedures that highlights safe working practices on the board the ship needs to be implemented. Extra care and supervision must be embedded in the procedures when working with or near moving ropes and chains.  

5. Observations 

The investigators' report underscores a critical error stemming from complacency and overconfidence, which led to non-compliance with vital safety measures. Inadequate policy and procedures, coupled with a poor human-machine interface, further exacerbated the situation. The incident also reveals shortcomings in skill and competence, inadequate leadership and supervision, and an ineffective risk assessment.

6. Comments

The accident investigation report highlights the importance of vigilant adherence to safety protocols and the ISM Code. The hydraulic mooring incident underscores the need for continuous risk assessment, robust training, and effective operational procedures. Addressing complacency and overconfidence through careful supervision and improved policies is crucial to prevent similar incidents. The report's findings reveal multiple deficiencies, emphasizing the significance of a comprehensive approach to safety management, competence building, and proper risk assessment.