Marine Accidents Case Study

Determining causes and circumstances of marine accidents in order to raise the quality of seafaring

Though marine accidents are universally known to be responsible for bringing international conventions into place, the Directorate General of Shipping (DGS), Government of India, also finds these as useful inputs for improving management systems, enhance quality and for making efficient quality management system to be effective. In this regard the new Director General of DGS, Gautam Chatterjee pointed out that case studies on marine accidents could turn out to be useful if it is participative and bring about a more realistic approach to ship operations.

Highlighting some case studies relating to certain prominent accidents (and casualty circulars issued on the subjects by the directorate) Capt Harish Khatri, Dy. D.G. (Technical) DGS gave blow by blow account of each of the nine incidents that occurred in the last  26 months and explained the causes leading to the mishaps and the findings. He took pains to point out in each case “What happened?” “How it happened?” “Why it happened?” and the “Lesson to be learnt”.    

Interestingly the details can also be accessed in the DGS’ website under circulars: 01/2011 which relates to Collision between two Container Vessels on the Hoogly River; 02/2011 with regard to Explosion in Engine Room; 03/2011 detailing Casualty related matter – Reports on marine casualties and incidents. Also 01/2012 about Sinking of a bulk carrier 20 nautical miles off the Mumbai coast; 02/2012 - Sinking of mechanized sailing vessel off the coast of Oman; 03/2012 – Sinking of mechanized sailing vessel; 04/2012 – Collision between two Motor Tankers; and 06/2012 with regard to Fire in Engine room. Finally, he gave details with regard to an accident relating to Fire in Containers which is elucidated in the accident circular of 01/2013.       

Capt Khatri enunciated that the intention was not to propagate a blame culture but to strictly encourage ship manning agents, ship owners, seafarers, training institutes and other related companies of the shipping industry to cultivate a proactive and constructive approach and to raise the quality bar.

From the industry side Capt Ashis K. Dass, Manager Training of Mitusi O.S.K. Lines Maritime (India) Pvt. Ltd., who spoke on “Cause, Analysis & Preventive Measures of Incidents” presented details of studies carried out by his company on three cases of collisions that happened recently as a result of restricted visibility and other shortcomings.

Capt Dass mentioned that in all three incidents of collisions it was found that the master was available on the bridge during the coastal passage. However, the bridge team was not ‘aware of the concerned target’. There was hardly any discussion between each of the bridge team members and close quarter recordings. In fact, all equipment on board the ship was found to be good working condition. The main engines were not used to avoid the collision (which should have been done in all the three cases). All three accidents happened because of communication failure.  

The findings revealed that complacency was the keyword that led to the accidents in all the three cases. There was failure to utilize the available date (such as not paying attention to alarms going off, etc.). The risk assessment by the Bridge team members (BTM) was ineffective and above all the investigations indicated there being a clear case of non-compliance of the International Regulations for Preventing Collisions at Sea 1972 (COLREG) by the BTM. The three mandatory preventive measures considered important including assessment, identification and implementation were found to have been ignored.

Is it pressure of work or concerns about the family or other domestic worries that vessels are often found to be hugging the coast and BTM are try to catch the network on their cell phones, or engaging in paper work other than navigation? The sailing staff should remember not to allow distraction from other activity other than navigational business.

Capt Sudipto Dasgupta of Anglo Eastern Maritime Training Center presented a navigational case study about one of the vessel managed by Anglo Eastern which collided with the pier in port of Antwerp. The ship was a bulk carrier build in 1996 in Jiangnan shipyard and was a 34,167 DWT narrow vessel of length 200 meters. When trying to turn to starboard off berth 100, the maneuver went wrong and the vessel made contact with the berth on the port side in a way of the fore peak tank, No 1 cargo hold causing a breach and No. 1 port wing tank (upper) getting damaged. The vessel started taking in water in the forepeak tank as well as No.1 cargo hold which was in loaded condition. Had the vessel been in deeper waters and without any assistance from port services to pump out the water, the consequences could have been disastrous. However, there were no casualties or pollution as a result of this incident.

Investigations concluded that though resources were available they were not properly utilized. The forward tug was pulling from a position at about 3 points on the starboard bow. The effect of the tug pulling from this position would have resulted in an increase in the speed of the vessel and would not have been particularly effective in turning the vessel’s bow to starboard.

For the forward tug to have been more effective, the tug should have pulled at right angles to the vessel’s head on the starboard side. Similarly, the aft tug would have been more effective if she would have been ordered to pull at right angles to the vessel’s head on the port side instead of moving along with the vessel in the same direction. In the whole maneuver the pilot showed poor judgment by moving the loaded vessel at high speed (in excess of 4.2 knots) in waters with restricted sea room. The pilot did not communicate his change of plans to the master. The conversation between the pilot and the tugs was in Dutch and hence the master was not in the loop.

At the time of the incident, master and third officer were on the bridge, chief officer was on the forward stations and second officer was on aft stations. All during the maneuver there was no indication or discussion about this in the conversation with the master. The pilot did not discuss the passage with the master. Had the constant radius turn (CRT) been planned both the master as well as the pilot would have been in better control of the situation.

Here the challenge was of speed. Had the 3 mate just told the master that the speed is in excess would it not have saved the situation?

The DGS’s role to contribute to safety at sea by determining the causes and circumstances of marine accidents and working with others to reduce the likelihood of such accidents recurring in the future is indeed commendable. It is noteworthy that accident investigations are conducted solely in the interest of future safety. Such action could well go a long way in drawing more talent to seafaring.

The Company of Master Mariners of India (CMMI) played host as they always do in assisting the DGS in organizing the event and bringing together all the leading lights of the maritime industry, heads of the shipmanagers, shipping companies, manning agents the maritime training academies and others. Keeping in line with their objectives CMMI continues to champion the cause of maritime industry in general and seafarers in particular. They are ever ready to assist the government and the Directorate of Shipping when the need arises.

When requested by Capt. L. K. Panda, the Nautical Advisor to the Government of India during the seminar to help in conducting more such events and help in other activities of the DGS, Capt Philip Mathews, Secretary General of CMMI readily agreed.

Capt Mathews informed that the committee members will be demitting office as their term was getting over. However, some of the members could continue in the new team. The audience gave a rousing applause to the outgoing committee.

Citing 'A Case Study of Marine Accident Investigation and Analysis with Focus on Human Error '
@article{ OGGHBK_2011_v30n1_137} ,title={A Case Study of Marine Accident Investigation and Analysis with Focus on Human Error} ,volume={1} , url={http://dx.doi.org/10.5143/JESK.2011.30.1.137}, DOI={10.5143/JESK.2011.30.1.137} , number= {1} , journal={Journal of the Ergonomics Society of Korea} , publisher={The Ergonomics Society of Korea} , author={Hong-Tae, Kim and Seong, Na and Wook-Hyun, Ha} , year={2011} , month={Feb}
TY - JOUR
T2 - Journal of the Ergonomics Society of Korea
AU - Hong-Tae, Kim
AU - Seong, Na
AU - Wook-Hyun, Ha
SN - 2093-8462
TI - A Case Study of Marine Accident Investigation and Analysis with Focus on Human Error
VL - 30
PB - The Ergonomics Society of Korea
DO - 10.5143/JESK.2011.30.1.137
PY - 2011
UR - http://dx.doi.org/10.5143/JESK.2011.30.1.137
ER -
Hong-Tae, K. , Seong, N. , & Wook-Hyun, H. ( 2011). A Case Study of Marine Accident Investigation and Analysis with Focus on Human Error. Journal of the Ergonomics Society of Korea, 30 (1) The Ergonomics Society of Korea. doi:10.5143/JESK.2011.30.1.137
Hong-Tae, K , Seong, N , & Wook-Hyun, H 2011, A Case Study of Marine Accident Investigation and Analysis with Focus on Human Error, Journal of the Ergonomics Society of Korea, vol. 1, no. 1, Retrieved from http://dx.doi.org/10.5143/JESK.2011.30.1.137
[1] K Hong-Tae , N Seong , and H Wook-Hyun , “A Case Study of Marine Accident Investigation and Analysis with Focus on Human Error”, Journal of the Ergonomics Society of Korea, vol. 1, no. 1, Feb 2011.
Hong-Tae, Kim and   , Seong, Na and   , Wook-Hyun, Ha and   , “A Case Study of Marine Accident Investigation and Analysis with Focus on Human Error” Journal of the Ergonomics Society of Korea, 1. 1 2011:
Hong-Tae, K , Seong, N , Wook-Hyun, H A Case Study of Marine Accident Investigation and Analysis with Focus on Human Error. Journal of the Ergonomics Society of Korea [Internet]. 2011. Feb ; 1 (1) Available from http://dx.doi.org/10.5143/JESK.2011.30.1.137
Hong-Tae, Kim , Seong, Na , and Wook-Hyun, Ha , “A Case Study of Marine Accident Investigation and Analysis with Focus on Human Error.” Journal of the Ergonomics Society of Korea 1 no.1 () Feb, 2011): http://dx.doi.org/10.5143/JESK.2011.30.1.137

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