OPTIMISM Training Platform

Reference Number	GDMR6
Description	With the clam open, there was a failure in the propulsion system that caused the gate to strike against the quay and the bulb of the ship against one of its pillars, causing minor damage to the Quay.
Key Root Causes	ISM non-conformity (Inappropriate policy/procedures - Machine interface, automation issues, maintenance and equipment malfunctions.  Crew related/Management fault (The accident occurred due to a malfunction of the propulsion control system accompanied by human error in the execution of the propulsion control transfer procedure from the bridge to the engine room, and in the subsequent return of control to the bridge.
Casualties	None
Action-Recommendation	To examine the propulsion control system between the Bridge and the Engine room and ensure additional training in the execution of such control transfers.
Would it happen again	Maybe not, if automation issues effectively resolved and propulsion control procedure from the Bridge to engine room and vice versa.

Title: An Investigation into Root Causes of Accident Collison with Quay

Accident Investigation Review 16 - Collision with Quay

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

With the clam open, there was a failure in the propulsion system that caused the gate to strike against the quay and the bulb of the ship against one of its pillars, causing minor damage to the Quay. 

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

Propulsion control system between the Bridge and the Engine room needs to be examined. To ensure similar accident won’t reoccur, additional training in the execution of such control must be conducted.

5. Observations 

The accident stemmed from a propulsion control system malfunction compounded by human errors during the execution of propulsion control transfer procedures between the bridge and the engine room. These errors were followed by inappropriate policy and procedures and inadequate supervision. Machine interface, automation issues, maintenance, and equipment malfunctions also played a role. Rectifying these issues is essential to prevent similar accidents by ensuring robust procedures, enhanced supervision, improved human-machine interaction, and more effective maintenance protocols.

6. Comments

The accident investigation report highlights a propulsion system failure that led to a collision with the quay. The findings emphasize the importance of examining the propulsion control system and providing additional training for its execution. The incident reveals a combination of technical and human factors, including improper procedures, inadequate supervision, and automation issues.