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

6.9 An Investigation into Root Causes of Accident – Mooring operation

Reference Number

C0012821

Description

The vessel while at a floating Berth during an emergency mooring operation at the aft mooring station, the outgoing length of a double breast line “jumped over” a roller fairlead and severely injured the vessel’s Third Officer on his legs. The vessel’s Chief Officer was also injured on his left hand in his attempt to assist the Third Officer. First aid was provided. Third Officer’s both lower legs were subsequently amputated. The Chief Officer suffered three broken fingers in his left hand.

Key Root Causes

ISM non-conformity (Inadequate risk assessment – Lack of training in mooring operations as per SMS requirements). 


Management fault (Inappropriate implementation of SMS: failure to follow the safety best practices for mooring operations (e.g., non-implementation of the guidelines in “Effective Mooring” publication). Unsafe decision to transfer the outgoing length of the aft double breast line to an adjacent roller fairlead by hand, when the vessel was moving in and out from the berth. Ignoring hazards and being inattentive to risks such as shifting a line when the line is under strain, standing on a line or in a closed bight of line).

Casualties

2 injuries, one crew's legs amputated.

Action-Recommendation

For the Management Company to provide training in mooring operations as per SMS requirements and include realistic hazards and consequence - Proper implementation of the emergency checklists, as per SMS requirements - Mooring plans to be prepared and retained as evidence of the mooring arrangement/agreement with the port’s authorities, as required by SMS. The management to consider the typical minimum mooring requirements for cape size (e.g., 4 headlines and 4 stern lines) provided by the industry and the SMS to be revised accordingly.

Would it happen again

No, if risk assessed effectively and training in mooring operation given. 

Title: An Investigation into Root Causes of Accident – Mooring operation

Accident Investigation Review 19 - Mooring Operation 

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

The vessel while at a floating Berth during an emergency mooring operation at the aft mooring station, the outgoing length of a double breast line “jumped over” a roller fairlead and severely injured the vessel’s Third Officer on his legs. The vessel’s Chief Officer was also injured on his left hand in his attempt to assist the Third Officer. First aid was provided. Third Officer’s both lower legs were subsequently amputated. The Chief Officer suffered three broken fingers on his left hand.

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 highly recommended for Management Company to provide training in mooring operations as well as the proper implementation of the emergency checklists as per SMS requirements and include realistic hazards and consequence. As it is required by SMS the mooring plans must be prepared and retained as evidence of the mooring arrangement/agreement with the port’s authorities. The management is considering the typical minimum mooring requirements for cape size provided by the industry and the SMS to be revised accordingly. 

5. Observations

The investigation report highlights a critical mistake rooted in the inappropriate implementation of the Safety Management System (SMS), notably neglecting safety best practices for mooring operations outlined in the "Effective Mooring" publication. Inadequate risk assessment and lack of supervision compounded the situation. A hazardous decision was made to manually transfer the aft double breast line to an adjacent roller fairlead while the vessel was manoeuvring in and out of the berth. Hazards were overlooked, and risks associated with shifting a strained line, standing on a line, or being in a closed bight of line were disregarded. 

6. Comments

The investigation report underscores a grave accident during an emergency mooring operation, revealing failures in SMS implementation and risk assessment. The findings stress the need for comprehensive training, strict adherence to emergency checklists, and proper mooring plans. The incident's roots lie in neglecting safety protocols and oversight, leading to severe injuries. Rectifying these deficiencies and aligning practices with industry standards are crucial to preventing similar accidents, prioritizing crew safety and effective mooring operations. The accident could have been avoided if risk assessed was effective and training in mooring operation was given.