OPTIMISM Training Platform

Reference Number	C0013465
Description	After disembarking the pilot and given the Ready for engines1, the ship suffered a fault from the electrical plant and the control of the engine and rudder on the bridge and later the ship was stranded in a sandy shoal area. The systems for the generation and distribution of electrical energy, and the control of the propulsion and government of the vessel were poorly managed, in view of the set of technical failures revealed during the accident.
Key Root Causes	ISM non-conformity (Inappropriate policy manual - Inappropriate procedures - Inadequate risk assessment  Management fault (Inadequate supervision; Problems with safety culture - Poor team operation; Working towards different goals; Incorrect perception).
Casualties	None
Action-Recommendation	An inappropriate policy manual and procedures, inadequate supervision, and problems within the safety culture are evident. Additionally, there are issues related to inadequate risk assessment, poor team operation, divergent goals, and incorrect perception.
Would it happen again	Yes, if propulsion system not managed effectively.

Title: An Investigation into Root Causes of Accident - Grounding

Accident Investigation Review 20 - Grounding

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

After disembarking the pilot and given the Ready for engines1, the ship suffered a fault from the electrical plant and the control of the engine and rudder on the bridge and later the ship was stranded in a sandy shoal area. The systems for the generation and distribution of electrical energy, and the control of the propulsion and government of the vessel were poorly managed, in view of the set of technical failures revealed during the accident.

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 for the shipping company to prioritize several key areas for safety enhancement. First, a comprehensive review and improvement of the maintenance procedures for the ship's electrical plant is crucial, including regular inspections and training for crew members. Also, implementing redundancy and backup systems for critical components can minimize the impact of technical failures. Crew training and competency should be regularly reinforced, particularly focusing on electrical plant operations and emergency responses.

5. Observations 

The investigators' report reveals a critical error stemming from multiple sources. An inappropriate policy manual and procedures, inadequate supervision, and problems within the safety culture are evident. Additionally, there are issues related to inadequate risk assessment, poor team operation, divergent goals, and incorrect perception. Addressing these shortcomings is imperative to establish a robust safety framework, enhance team collaboration, align goals, and ensure accurate risk assessment to prevent similar incidents in the future.

6. Comments

The investigation underscores a significant accident resulting from technical failures and inadequate management of the ship's systems. The recommendations emphasize the importance of enhancing maintenance procedures, crew training, and implementing backup systems. The report highlights a series of deficiencies in policy, procedures, supervision, and safety culture. Addressing these gaps is vital to prevent future incidents and foster a safer maritime environment through improved systems management, crew competence, and effective risk assessment.