Claims at a Glance 2012

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Claims at a glanceFrequencies & Severity

2012

www.swedishclub.com

Check the conclusion

at page 9

Read the case analysis

at page 11


2/28www.swedishclub.com

Proactive . Reliable . Committed

C o n t e n t s

Executive summary 3

Opening remarks 3

Managing the manageable 3

Claims & Vessel types for P&I and H&M 4

An ever-changing world 5

Swedish Club On Line (SCOL) 5

Rules & Exceptions 5

P&I 5FD&D 6

Marine 6

Causes and remedies 7

Passage plan 7

Bridge equipment 7

Procedures 8

Risk assessment 8

Near misses 9

Safety culture 9Conclusion 9

Executive summary 10

Main areas of concern 10

Remedies 10

Interactive Root Cause Analysis 10

Method used FIVE WHYS 10

The Cherry picking process 10

Interactive Root Cause Analysis IRCA cases 11


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Executive summary

Opening remarksThis years publication will, as always,

provide eedback as to the Clubs ex-

periences in general on the claims side.We do this in order to share valuable

inormation gained through our claims

handling. As last year, the real cases re-

ported to our readers is done using the

Why method. We ask Why things

have gone wrong enough times in order

to arrive at the true level o root cause.

Apart rom these recurring eatures

o our publication we will provide you

with some interesting statistics regard-

ing claims and in particular Cargo,

Illness and Injury claims.

2011 was a year o mixed experience.

Q1 and Q2 let us with no surprises

and the hal-year results were actu-

ally better than expected. Q3 and Q4,

on the other hand, deviated negatively

rom the expected perormance. We

have dealt with complex, challenging

collisions and groundings that have

involved both P&I and H&M elements o

signicance. We have also learned the

hard way over the year how much thelocation o a casualty impacts on the

response o it. 2011 was also a year o

urther nancial instability. It seems as

i it has had a lesser impact on shipping

activities than the crisis in 2008/09.

Whether that statement is entirely true

or not remains to be nally assessed.

What can be said with some degree o

certainty though is that current trading

conditions will have some impact on

the claims pattern.

Managing the manageableMost Clubs/Underwriters would sub-

scribe to the suggestion that there is

a correlation between world economy

and claims experience. We also ac-

cept this. One must, however, hasten

to qualiy such a suggestion and add

that in relation to the really large P&I

claims there is virtually no such cor-

relation. I one looks at the more at-

tritional side o P&I claims the correla-tion appears much more concrete. This

requency is clearly something that we

can address and manage. To this end,

this is also where our main ocus on

Loss Prevention lies.

On the Marine side we noticed a

slight reduction in the number o larger

claims in 2009/10. We are now seeing

an increase in this claims interval. There

is a strong correlation on the Marine

side between number o claims and the

state o the global economy.

From Graph No. 1 below we can

see that the numbers o H&M claims

in excess o USD 500,000 is almost as

orecasted (100%). On P&I the devia-

tion rom the expected (100%) is more

pronounced, which is illustrated in

Graph No. 2.

1/6/2009

1/7/2009

1/8/2009

1/9/2009

1/10/2009

1/11/2009

1/12/2009

1/1/2010

1/2/2010

1/3/2010

1/4/2010

1/5/2010

1/6/2010

1/7/2010

1/8/2010

1/9/2010

1/10/2010

1/11/2010

1/12/2010

1/1/2011

1/2/2011

1/3/2011

1/4/2011

0

20

40

60

80

100

1/6/2009

1/7/2009

1/8/2009

1/9/2009

1/10/2009

1/11/2009

1/12/2009

1/1/2010

1/2/2010

1/3/2010

1/4/2010

1/5/2010

1/6/2010

1/7/2010

1/8/2010

1/9/2010

1/10/2010

1/11/2010

1/12/2010

1/1/2011

1/2/2011

1/3/2011

1/4/2011

0

10

20

30

40

50

60

70

80

Graph No 1Frequency of H&M claims in exess of USD 500,000 vs.forecast

Graph No 2Frequency of P&I claims in exess of USD 500,000 vs.forecast

Main areas of concern` Lack o proper passage planning

` Lack o essential bridge equipment knowledge and poor

navigation policies

` Serious Maritime Resource Management (MRM) issues

` Lack o proper communication

` The Saety Management System (SMS) is lacking dened

and properly explained procedures

` Poorly implemented risk assessments and work permit

procedures

Remedies` There should be a dened saety culture in the organisation

` The root causes o accidents need to be identied and

addressed

` Introduce MRM throughout the entire organisation

` MRM procedures should be implemented into the SMS

and audited

` SMS procedures need to be easily understood

` Introduce risk assessments and work permit procedures

` Introduce specic navigational audits

In relation to P&I (Cargo, Illness and Injury) and or H&M navigational claims:


4/28www.swedishclub.com 4


www.swedishclub.com

Although it is dicult to predict

what direction the global economy

will take, it is more likely than not to

assume that we are entering a re-

covery phase. It is also likely that

this recovery will take some time. At

the moment there still seems to be awhile beore we will reach a state o

equilibrium where there is a balance

struck between supply and demand.

As a consequence o stable or slightly

increasing shipping activities we see

very little reason as to why the claims

pattern should not ollow suit. We

anticipate that the number o claims

will continue to increase in 2012.

Claims and vessel types forP&I and H&MFor P&I and H&M insurances in 2011

the average number o claims in excess

o USD 5,000 was 0.49 claims/vessel/

year. The corresponding gure or 2008

was 0.30 claims/vessel, representing an

increase in requency o 63%. Combin-

ing the previous with an increase in the

average claim cost since 2008 makes

or a worrying trend. 200

2

2003

2004

2005

2006

2007

2008

2009

2010

2011

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

200000

0

0.0

0.1

0.1

0.2

0.2

0.3

0.3

0.4

0.4

0.5

Costpervessel

Graph No 320022011 P&I and H&M claims for all vessel types.Cost and frequency per vessel/year => USD 5,000.

To compare vessel types we will ocus

on three dierent types: Bulkers,

Containers and Tankers. They represent

more than 75% o all insured vessels

or P&I and H&M. This gives an accurate

overview, as these vessels are more

or less similar in the amount o crewmembers and trade patterns. Under

Hull and Machinery (H&M) we dene

Collision, Contact, and Grounding as

Navigational claims.

The average cost or a Navigational

claim in excess

o USD 10,000

in 2011 was

more than USD

800,000. The

correspondingamount or P&I

claims (including

only Cargo, Ill-

ness and Injury)

in excess o USD

5,000 was

more than USD

35,000.

The average

claim cost has

Graph No 420022011 H&M navigational claims for bulkers, con-tainers and tankers. Cost and frequency per vessel/year=> USD 10,000.

Graph No 520022011 H&M navigational claims for bulkers,containers and tankers. Average cost and frequencyper claim => USD 10,000.

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

0

20000

40000

60000

80000

100000

120000

0

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.09

Costpervesse

l

Frequency

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

0

200000

400000

600000

800000

1000000

1200000

1400000

1600000

1800000

0

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.09

Averageclaimco

st

Frequency

increased by 50% since 2008 and the

requency has increased by 60%. The

total increase in cost over the same

period is 110%. This could mean that

when there is a navigational claim,

the cost is on average USD 800,000.

Preventing the occurrence o onesingle navigational claim could gener-

ate major savings to owners as well as

their Club and Underwriter. Preventing

these casualties is The Swedish Clubs

highest priority.




Graph No 620022011 P&I cargo, illness, injury claims for bulkers,containers and tankers. Cost and frequency per vessel/

year => USD 5,000

Graph No 720022011 P&I cargo, illness, injury claims for bulkers,containers and tankers. Average cost and frequency perclaim => USD 5,000.

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

Costpervessel

Frequency

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

0

20000

40000

60000

80000

100000

120000

140000

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

Averageclaimc

ost

Frequency

The average claim cost since 2008 has fallen by 37% but the frequency has risen by 79%. As a result of the increase, the

increase in total claim costs is 23%.

An ever-changing world2011 oered plenty o challenges apart

rom the pure casualty-related ones.

Tsunamis, Sanctions, Piracy, and Cargo

Liqueaction are just some o the topics

that the Club dealt with over the year.

The need or owners to receive correct,

quick, advice on issues is ever-increasing.

We took one urther step in simpli-

ying our business partners access to

correct and timely advice in relation

to some o the current topical issues.

We created a web-based portal called

Topical Issues. Under this web portal

you can nd advice structured in

Q&A ormat regarding Armed Guards

Contract, sanctions and liqueaction.

In addition to FAQs we provide lots o

in-depth inormation or these dier-

ent areas.It has proven to be a much-appreci-

ated move enabling our business part-

ners to easily download the necessary

inormation. In addition it also provides

clarity and certainty as to the Clubs

position in relation to specic issues.

The initiative is a success and will be

developed urther in 2012.

Swedish Club On Line (SCOL)Another important eature launched

last year was our Swedish Club On Line

system. This web-based B2B platorm

enables our business partners to up-

load and download relevant inorma-

tion on underwriting and claims. The

SCOL provides exceptional fexibility

in terms o data compilation and o-

ers a wide range o products rom

Certicate o Entry documents to Loss

Prevention benchmarking. The plat-

orm will also be continually developed

in 2012 and more interactive eatures

will be launched.

Rules & ExceptionsWe are very pleased to report that the

Clubs revised Rules & Exceptions hit

the shelves in February 2012. Obviously,

many people put a lot o dedication

and hard work into the revision process,

which took place in 2011. We are very

pleased with the result and happy to o-

er this publication to anyone interested.We believe that this

new edition will add

to the Clubs already

excellent reputa-

tion as a rst class

P&I Club. The Rules

& Exceptions is o

course also available

electronically on the

SCOL platorm.

P&IWe would like

to start by say-

ing that P&I is very much a double

nature class o insurance. On the one

hand you have the really large claims

that will hit randomly and, on the

other hand you have the attritional

claims where Loss Prevention plays an

important role in assisting members in

their eorts o reducing the requency

o these claims. We can say, based on

Graph No. 8 that the number o really

large claims seems to have decreased.

The industry as a whole shares this

experience. Again, according to Graph

No. 8, we can see that the number o

pool claims during 2011 was relatively

low. However, we can see that these

claims were quite costly. We know that

the start o calendar year 2012 is not

going to improve this picture.

Graph No 8International Group pool Claims

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

0

50

100

150

200

250

300

350

400

450

500

0

5

10

15

20

25

30

35

40

45

USDMillion

Noofclaims




The Club has experienced a rather

steep overall increase in the number o

claims. I we look at the average cost

however this has actually dropped a bit.

As ar as requency is concerned we

can see a clear trend in the increasing

number o attritional claims. Not equally

Graph No 920062011 P&I frequency distribution (claims =>

USD 5,000)

Graph No 1020062011 P&I cost distribution (claims => USD 5,000)

37%

2%2%

23%

22%

4%

4%6%

Cargo liability

Collision (RDC)

Contact (FFO)

Illness

Injury

Pollution liability

Stowaways

Other third party liabilities

10.1%

3.7%

0.5%1.9%

3.5%

38.6%0.3%

41.5%

Cargo liability

Collision (RDC)

Contact (FFO)

Illness

Injury

Pollution liability

Stowaways

Other third party liabilities

as clear, but nevertheless, an increase

can still be noted in the interval claims

in excess o USD 500,000. I we look at

the requency distribution in Graph No.

9 it is clear that the three main catego-

ries are Cargo, Injury and Illness. It also

shows that Cargo is the largest while

FD&DFD&D is legal cost insurance, and there

is a strong correlation between the

claims pattern and the state o the

global economy. For FD&D this is much

more the case than or other classes o

insurance

This is because, generally speaking,

in times o shiting markets, disputes

tend to increase, and i markets are also

depressed, disputes increase in line with

contractual deaults and unpaid debts.

We have, thereore, seen an increase in

the number o registered FD&D claims.

In particular this applies to the claim

category Unpaid hire. In Graph No.

11 to the right the correlation between

an increased claims requency and a

depressed market is

clearly illustrated.

It is expected

that this trend

will diminish i

the economy and

markets stabilize,

although it will

probably take some

time beore it is

noticeable. As pre-

viously mentioned

the global economy

is entering a phase

o recovery but

it is air to assume

that the recovery

will take some time.

Graph No 1120042011 FD&D claims frequency per vessel/year

2004 2005 2006 2007 2008 2009 2010 2011

0

1000

2000

3000

4000

5000

6000

7000

Index

Baltic Index Dry

Claim frequency per vessel

Clarkson containership rates

Injury and Illness are airly even.

I we take a look instead at how the

claims cost is distributed, we can see

rom Graph No. 10 below that Cargo is

the more dominant, while the rest are

slightly more evenly distributed.

MarineAs mentioned at the start, we are cur-

rently in a phase where we are seeing

a greater number o larger claims in

excess o USD 500,000. Our assessment

o the situation is also that it is reason-

able to expect a continued soaring o

claims requencies as shipping activities

around the world will be stable or evenincrease on the back o a recovery o

the global economy. A higher level o

shipping activities coupled with an ever

increasing shortage o seaarers are

the main reasons why we believe that

requencies will continue to soar on the

back o urther tonnage being deliv-

ered and entering into trade. The rate

o scrapping seems to be insucient

or reaching a balance between supply

and demand. The size o the new ships

delivered are very oten much larger

than the ones scrapped. Consequently,scrapping is insucient in balancing

out the infux o new tonnage. Another

area o concern or the industry has

been the moral hazard element, which

some thought would generate quite

an increase o both smaller and larger

claims. We can, in this respect, not say

that we have noticed such a correla-

tion. We are mindul o many own-

ers/managers nancially challenging

situations. In times o extremely poor

earnings one must, out o necessity,

cut back on spending as much as pos-sible. In this process we anticipate that

overall spending on maintenance and

loss prevention will be less than in a

good market. As such, it would be naive




Graph No 1220062011 H&M frequency distribution (claims =>

USD 10,000)

Graph No 1320062011 H&M cost distribution (claims =>

USD 10,000)

13%

12%

2%

11%

3%

51%

8%

Collision

Contact

Fire or explosion

Grounding

Heavy weather

Machinery or equipment

Other

22%

7%

4%

25%

2%

33%

7%

Collision

Contact

Fire or explosion

Grounding

Heavy weather

Machinery or equipment

Other

Causes and remediesA vessel is a high-risk environment

where people can die i saety is dis-

regarded. This, coupled with a diverse

crew rom dierent countries and

backgrounds shows that it is paramount

that there is an established saety cul-

ture to address these issues.

In the "interactive root cause analy-

sis" (IRCA) cases elaborated on in this

publication, the companies have not

been able to establish a sustainable

saety culture onboard. For an accident

to occur there is normally an underlying

chain o errors. This is dened as several

unidentied errors being committed

that lead to an accident. By identiying

and rectiying one o these errors the

chain is broken and the accident can be

prevented. To be able to identiy theseerrors there needs to be an established

unctioning saety culture.The compa-

nys procedures are established through

the Saety Management System (SMS),

which is a living document that requires

continuous reviews and updates.

Many o the navigational accidents

happened during critical operations

where the master is usually on the

bridge with a pilot or there are at least

two ocers present. Speed is also a re-

curring issue. I the ocer had reduced

speed he would have improved his own

situational awareness.

Passage plan

To saely take the vessel rom berth to

berth there needs to be a detailed pas-

sage plan, which should be based on a

risk assessment o the relevant voyage.

There are numerous deciencies with

passage planning in the IRCA cases

reported below.

The passage plan should be based on

inormation about the most avourable

route gathered rom ocially updated

charts, pilot books, tide tables , tidal

current tables, and notices to mariners

and radio navigation warnings. All

possible means and inormation should

be utilised.

I there are any changes to the ap-

proved passage plan a new passage

plan needs to be produced, agreed and

signed by the master and all bridge o-cers. This will include relevant inor-

mation received rom the pilot.

The following should at least beincluded;

` Ensure that all charts, publications

and ENCs are updated or the cur-

rent voyage

` Courses should be laid down in the

charts and, where appropriate,

wheel over position and turningradius should be marked on the

chart to be used when possible

` Keep only the present voyage track

in the chart

` The passage plan should be berth to

berth

` Maximum allowable cross track

margins should be indicated on

the chart as well as danger zones

with minimum clearing distances

` Environmental areas should be

marked in the plan as per MARPOL

regulations, port state regulations,

i.e. SECA area or other local regu

lations, to be aware when discharge

is allowed or not or any other spe-

cial regulations or the current

trading area

This inormation should not only be

included on the chart but also imported

into ECDIS, thus increasing situational

awareness. Another excellent tool that

will also enhance situational awarenessis a radar map o the intended voy-

age. It is the masters responsibility to

ensure that the vessel has an approved

berth to berth passage plan or the

intended voyage and in particular pilot-

age waters.

Bridge equipment

Evidence rom many collisions or

groundings show that the ocer had

been monitoring the situation buthad misunderstood the inormation

displayed on the bridge equipment. It

is not uncommon that the root cause is

not to anticipate any consequence in

this respect.

I we take a look at how the num-

bers o claims are distributed, we can

see rom Graph No. 12 below that

breakdown o Machinery is still the

main driver o claims requency on

H&M. I we instead look at cost dis-

tribution, it is more evenly distributed

between Machinery, Groundings and

Collisions, as can be seen in Graph No.

13 below.




a lack o knowledge, inexperience and

poor procedures.

The International Maritime Organiza-

tion (IMO) made ECDIS mandatory on

new passenger vessels and new tankers

rom 2012. By 2018 all vessels must

have ECDIS onboard, which meansthat owners and managers will have to

invest in this system.

It is paramount that all bridge o-

cers are ully converse with how ECDIS

works, its limits, chosen settings and

what actually an approved ECDIS is.

Having an ocer operating this essen-

tial equipment and lacking knowledge

about it could be a great risk.

Another area o extreme concern

is ocers actually thinking that theyknow the equipment when they actu-

ally lack important knowledge. This

might be because they have received

poor training or none at all. It is essen-

tial that the ocer continually veries

that the system is working properly

and is aware o potential risks. The risk

o assuming that all equipment is in a

good condition can be catastrophic.

The best approach to new technol-

ogy is to embrace it but also question

its purpose and then learn i the equip-

ment will enhance the perormance o

the ocer and increase saety or not.

Advancement in technology is some-

thing positive but it is very important

to have a contingency plan in the event

o a malunction and to know the limits

o the specic equipment. This can be

addressed with dened procedures

within the vessels Saety ManagementSystem (SMS).

It will not matter i the bridge has

the most advanced ECDIS system i

the ocers have not received proper

training or gained sucient knowledge.

Knowledgeable ocers and technol-

ogy is a great tool and will enhance

saety and relieve pressure. Lacking

the required knowledge might instead

increase the risk.

Extensive training in simulators can

also be very benecial or building a

saety culture especially i the training

is not ocused only on ship handling

but instead, establishing proper MRM

procedures with the entire bridge team

rom junior to senior ocers.

How an ecient bridge team is set

up is discussed in our booklet Bridge

instructions and also in detail in MRM.

This is based on closed loop com-munication and dened duties or all

dierent bridge team members. Proper

communication and dened duties will

improve situational awareness.

To be able to prevent navigational

claims there needs to be a thorough

navigational policy addressing all key

issues or the sae navigation o the

vessel in correlation with MRM. This,

coupled with specic navigational au-

dits ocussing on how the navigationalwatch is carried out and veriying that

the bridge team is ollowing the com-

panys own navigational procedures,

will be very eective in preventing

navigational claims. The basis o these

measures will be the companys own

saety culture.

Procedures

It is evident that disregarding procedures

has been a leading cause o almost all

IRCA cases. This means that the crew

thought that the procedures were

not worth ollowing and disregarding

them was not a big issue. This might be

because the procedures are unclear in

their intentions, not thorough enough or

maybe too complicated. This can mean

that the crew loses condence in the

procedures. The crew need to be aware

that it is also their responsibility toinorm the company i they believe there

are issues with SMS procedures instead

o disregarding them. The reason or

this is a ailure within the company to

establish a proper saety culture.

There are also numerous claims

where third parties have acted in an

unsae way, which have led to seri-

ous injuries. This is dicult to monitor

onboard the vessel but essential as the

master is responsible or the saetyo everyone onboard. It is essential to

have dened procedures on how to deal

with third parties onboard the vessel.

In a good saety culture all involved

will know that it is imperative that

procedures are ollowed.

They know that disregarding proce-

dures the consequences could be severe

and endanger the entire vessel and crew.

Cargo, Injury and Illness claims area little dierent to Navigational claims

but still have many similarities. P&I

claims emphasize the importance o

having correct procedures in place and

need a lot o thought to be established.

It is not enough to just have binders

with SMS procedures i the crew do not

believe in them or do not see their ben-

et. The crew should be given the tools

to comply with all requirements.

It is the same with training as it is notenough just to send people on training

courses i there is no ollow up onboard

the vessel and the onboard procedures

do not coincide with the training.

Except or a comprehensive SMS,

these issues can be addressed with

comprehensive risk assessments and a

near misses reporting system. It is also

essential that the SMS procedures are

very clear in what they want to achieve.

Risk assessment

Since 1 July 2010 there is an ISM re-

quirement or companies to have ship-

board operational procedures, which

are based on risk assessments. The

purpose o a risk assessment is to carry

out a careul examination o shipboard

operations to veriy that there are

adequate controls in place, which will

make the risk levels acceptable.To carry out a correct risk assessment

there rst has to be a risk analysis, which

uses all available inormation to identiy

hazards and estimate the risk to the

environment, property or individual.

The risk assessment evaluates the

risk arising rom a hazard and evaluates

i the controls in place are sucient

and i the risks are acceptable.

A proper risk assessment will be

cooperation between the oce andthe vessel. The oce should provide

a generic assessment and the vessel

should make a detailed assessment o




the critical job. To be able to achieve

the best result there should be cooper-

ation between the oce and the vessel

to utilise the experience rom both to

compile a useul database.

It should be easy to access the

database or specic jobs or planning ojobs. The database could also be useul

or training. It is imperative that all

onboard are aware o how to access the

database and how to use it.

The procedures o how the risk as-

sessment should be completed and used

are addressed in the companys SMS.

I the risk assessment has been com-

pleted correctly it is likely that most

risks will be addressed. I a work permit

has also been issued or the specic jobit should be obvious to the crew mem-

bers how to saely complete the job.

This will also mean that all depart-

ments concerned have been inormed

about current jobs in progress and e.g.

which equipment has been isolated and

how long the job will take.

In many accidents it is common that

risk assessments or work permits are

disregarded or not ollowed as intended

as the individual might believe that the

preventive matters are unimportant or

that it will take to much time to comply

with the requirements. This can lead to

serious injuries with atal consequences.

Near misses

Near misses is an ecient, approved

way o identiying problems within a

system or organisation. It can some-

times be hard or a vessel to see thebenet o reporting a near miss as it

seems to be such an insignicant event,

error or misjudgement. This is under-

standable but unortunately misses the

entire point as the benet comes in

numbers, especially i there is a huge

database to compare against. Then the

issue can be identied and hopeully

established i this near miss is a reoc-

curring event on other vessels. I it is

at a large company with many vessels,

a near miss system might be able to

identiy some procedural problems that

need to be changed.

Shipping companies are supposed to

collect inormation about near misses

and share this experience within the

company. Sometimes the near misses areshared with external organisations.

There are many public databases that

collect inormation about near misses

like MARS by the Nautical institute,

CHIRP in the UK and Insj/ForeSea in

Sweden, Finland and Denmark. All these

systems are improving saety worldwide

with special magazines and reports.

Unortunately there is not one univer-

sal system that everyone reports to. It

seems that it would be benecial orthe shipping industry to be more open

about sharing best practices and how to

improve saety and technology onboard

our vessels as the aviation industry does.

It is essential to understand that

near misses are an important way o

identiying problems beore they be-

come a disaster. It is very important or

the organisation receiving these near

misses to give positive eedback, but

or the systems to urther improve they

need to receive more reports rom both

vessels and shipping companies.

Safety cultureA oundation or saety needs to be

established in the companys culture.

There need to be clear goals concerning

what the company stands or and what

is expected o all employees. Top man-

agement buy in is essential. All on-board are trained well enough to carry

out their assigned duties; this is veried

by valid certicates. What they will not

know is what the company expects o

them. This is what the company needs

to ocus on.

This kind o attitude training can

be carried out during company semi-

nars, newsletters, masters reviews and

discussed during the monthly saety

meeting onboard the vessel.

Probably the most eective way or

a company to veriy that the crew has

the desired knowledge and attitude will

be during superintendents visits and

most importantly during the annual

internal audit.

The company should provide themaster with sucient tools to ensure

that the crew onboard has easy access

to the SMS and that they understand

the importance o the procedures. It is

at this point that a comprehensive and

detailed SMS will be most benecial.

Some companies have been so ecient

with training and implementation o

really impressive saety organisations,

that they have almost reduced their

navigational claims statistics to zero.They have achieved this by having an

established plan rom top management.

In a positive saety culture mistakes are

allowed but negligence and disregard-

ing procedures are not.

ConclusionMost accidents are caused by human

error, not technological or mechani-

cal ailure, the immediate cause is very

oten that a person made a disastrous

decision or mistake. Investing in equip-

ment, training acilities, training o

employees and carrying out compre-

hensive audits and inspections will be

a good investment compared to being

involved in a serious accident.

It is dicult and time consuming to

establish a positive saety culture the

payback, however, will be substantial.

The most common causes in the IRCAcases are lack o knowledge, poor MRM,

disregarding approved procedures, or

procedures have not been implemented

correctly or as intended. The root cause

to this is ailure rom the shoreside or-

ganisation to establish a positive saety

culture onboard their vessels. This can be

rectied with the correct motivation and

belie because accidents can be prevent-

ed and should be prevented.




WHAT? Loss o power in main engine

Turbocharger breakdownWHY?

Rotor is malunctioningWHY?

Bearing ailureWHY?

The bearing is well beyond its

useul service lieWHY?

Turbocharger has not been maintained

according to service scheduleWHY?

Correcting

symptoms wastes

resources

correcting root

causes removes

the problem.

Executive summaryIn relation to P&I (Cargo, Illness and In-

jury) and or H&M navigational claims:

Main areas of concern

` Lack o proper passage planning

` Lack o essential bridge equipment

knowledge and poor navigation

policies

` Serious Maritime Resource Manage-

ment (MRM) issues

` Lack o proper communication

` The Saety Management System

(SMS) is lacking dened and prop-

erly explained procedures

` Poorly implemented risk assess-

ments and work permit procedures

Remedies

` There should be a dened saety

culture in the organisation

` The root causes o accidents need to

be identied and addressed

` Introduce MRM throughout the

entire organisation

` MRM procedures should be imple-

mented into the SMS and audited

` SMS procedures need to be easily

understood

` Introduce risk assessments and work

permit procedures

` Introduce specic navigational audits

Interactive Root Cause Analysis

Two years have now passed since we

launched an initiative, in co-operation

with our members, designed to acilitate

nding the true cause o damage. It is

called interactive root cause analysis(IRCA) and includes assisting members

in taking action to prevent recurrence

o accidents and covers the Clubs eed-

back to its members in general.

IRCA has proven to be a powerul

loss prevention tool and allows mem-

bers and ourselves to discover the true

root cause o a casualty. We do not

waste time addressing symptoms, but

rather the cause.

The purpose is not to point ngers

but to raise awareness about the reason

why accidents occur. I the root cause

can be established and rectied the risk

o the accident reoccurring is substan-

tially reduced.

Methodes used FIVE WHYS

This is an analytical tool, originally

used by the Toyota Motor Corporation,

designed to nd and identiy one or

several root causes to a problem. The

method is closely related to cause-

eect diagrams (shbone), which are

oten used in conjunction with the

Five Whys.

By asking Why? ve times succes-

sively you move beyond symptoms and

delve deep enough to understand the

root cause(s). By the time you get to the

ourth or th Why? you will prob-

ably be looking squarely at managementpractices. A Why? can have several

possibilities and each answer has to be

looked into or likely root causes.

However, the Five Whys tool does

not provide a resolution to the prob-

lem itsel, but it is an excellent tool to

get an analysis going. The Five Whys

method relies heavily on experience, as

it draws on the opinions and observa-

tions o the people perorming the task.

The Cherry picking processOne way or us to undertake this

process eciently is to screen one

Interactive root cause analysis (IRCA) an example

large area o concern. This year we

have ocused on P&I Claims; Cargo,

Illness & Injury with a view to nding

out whether we were on to some-

thing and to nd suitable cases or

us to investigate in greater detail. This

years screening will take the shape oa stand-alone publication called P&I

Claims Analysis.

As one can imagine, interactive root

cause analysis is a time-consuming

business. It pays o instantly so, to

that end, the time and money invested

is very well spent, but to be as eec-

tive as possible we need to cherry

pick the cases we decide to investi-

gate in greater depth together with

the relevant member. In the processwe obviously try to hit the claims

categories where requencies coincide

with costs. A s such we have in this

publication decided to scrutinize the

ollowing 11 cases, using the IRCA

method:

` 1 pollution

` 2 groundings

` 1 cargo matters

` 2 collision

` 2 contact

` 2 injuries

` 1 illness




Interactive Root Cause Analysis IRCA cases

GroundingThe vessel was departing a port when it ran aground. The

tide in the harbour was running at around 1.5 2.5 knots,

with a height o 2 meters. It was evening and two pilots

boarded the vessel, with no pilot brie being held. The mas-

ter, two pilots, the chie ocer and helmsman were present

on the bridge. The maximum drat or vessels entering the

port was 9 meters.

At the time o departure it was just ater low tide with a height

o 0.4 meters, maximum drat was at at 8.2 meters. When

the vessel departed it swung with the bow towards the quay.

According to the 2nd ocer on the stern, the vessel was swing-

ing 80 meters clear o the buoy that marked the channel. The

vessel had a speed o 1.2 knots astern in a channel which was

about 250 meters wide and 1.5 times the vessels length overall.A couple o minutes later the vessel touched bottom and

the master inormed the pilot. The vessel was now swinging

quickly to port and the pilot tried to stop it by using both

rudder and bow thruster. The turn continued and the vessel

struck the bottom once again. The vessel was refoated with

the help o the tug and proceeded towards the pilot station

with diculty, because the bridge team had not realized that

the rudder was stuck at an angle o 35 to port.

The electronic chart showed that the stern was outside the

buoyed channel and in shallow water. It was later discovered

that the buoy had been moved urther out rom its original

position. At the time o the grounding this had not been

updated with any notice to mariners. Apparently the buoy

had been moved so a dredger could work in the aected area.

Ater the grounding this was denied by the port captain but a

navigation warning was issued about a month later regarding

the changed position o the buoys.

It is possible that the pilot did know that the buoy had

been moved but this has not been conrmed. The reason why

the harbour authority had not reported the buoys changed

position is unknown. In this case the electronic chart showed

WHAT? Grounding in harbour area

Lack o proper communicationWHY?

The chie ocer was monitoring the

electronic chart and the vessel was

shown to be outside the channel, but

he did not voice any concern.

WHY?

No unied plan within the bridge

team and no specic team duties

were assigned.

WHY?

The passage plan did not address the

risks o the narrow channel. There was

poor communication between the pilot

and the other bridge team members.

WHY?

WHY?

The company had not been able to

implement MRM onboard the vessel

and the navigation procedures were

not extensive enough.

CONSEQUENCES

Vessel grounded, resulting in extensive damage. It

carried a lot o reeer containers that were a total

loss and resulted in a huge cargo claim.

Preventing recurrence` Inormation about this accident and concerns about the port have been sent by the company to all vessels,

which are trading in this area.

` All vessels have been reminded that the master has overall responsibility, that the bridge team is required to

monitor the pilot.

` All vessels have been reminded that a pilot brieng is mandatory.

` A similar case will also be developed or the companys simulator.

` The company will soon be introducing more MRM training or ocers.

` It is imperative that the bridge ocers voice their concerns when the inormation displayed on the electronic

chart displays any discrepancy.` The passage plan should have addressed the risks with the narrow channel.

` I there is any discrepancy rom the approved passage plan a new plan should be produced and agreed upon.

` The company should review its internal procedures or passage planning.

the vessel aground but the ocer on the stern reported that

the vessel was swinging clear. This discrepancy should have

alerted the ocer on the bridge urther as the vessel ap-

peared to be aground.




CollisionVessel A was on a southbound course and vessel B was north-

bound. It was shortly ater dusk, a light breeze, calm seas and

visibility o around 8 nautical miles. The vessels were transiting

an area o high trac density with many merchant and sh-

ing vessels. There were a number o small shing vessels in the

area, some moving, and others stationary.Vessel A had a group o small shing vessels on its starboard

bow. To stay clear o the shing vessels, the ocer, on watch

by himsel at the time, decided to keep the vessels to star-

board and altered course to port three times over a 20 minute

period, while maintaining a speed o 25 knots. The shing

vessels had bright lights, making it dicult to see any trac

behind them.

The master on vessel A was doing administrative jobs and

visited the bridge a couple o times during the watch. The o-

cer on vessel A tried to plot the multiple shing vessels, but

lost the targets or they moved on the radar.

The ocer on vessel B was on watch with a designated

lookout. The vessel maintained a speed o 12 knots. Vessel B

saw vessel A at 5 miles, or 8 minutes beore the collision and

could see vessel As red light on her port bow. The echo trails

o both vessels were parallel. He did not recognise that there

was a danger o collision.

Five minutes beore the collision, vessel B observed that

vessel A was showing a green light. The ocer on vessel B

gave the order to stop the engine and go hard to starboard.

The ocer did not plot vessel A. Just beore the collision ves-sel A made another alteration to port. Neither o the vessels

sounded any warning signals.

The ocer on vessel A did not see vessel B until a couple

o seconds beore the collision and maintained ull speed the

entire time. The ocer on vessel A did not consider slowing

down, even when trac started to become dense. The ocer

was not ully aware o the situation, as the northbound vessel

was not identied behind the cluster o smaller vessels.

Preventing recurrence` The company now provides bridge simulator training or ocers and dierent seminars.

` This accident has been integrated into a simulator and is trained on regularly.

` The company organizes regular feet meetings, where all important inormation and incidents are discussed with

the ocers on board.

` An extra internal audit was carried out ater the collision.

` The company has sent a circular to all vessels in its feet about this accident. They once again request proper

watch keeping and the use o all navigational equipment onboard the vessel.

` The company should consider introducing specic navigational audits on all vessels veriying that SMS procedures

are adhered to.

` The company should review its navigational procedures and especially procedures or sae speed.

` The company should continue to improve MRM.

WHAT? Collision in congested waters

Vessel A was maintaining 25 knots in

congested waters. There was no dedi-

cated lookout, which is a requirement

as per the companys SMS and alsounder STCW regulations.

WHY?

The chie ocer showed an acceptance

to take risks and over-condence in

his own ability. The master visited the

bridge but did not raise concern about

the lack o a designated lookout.

WHY?

Vessel A:s chie ocer had not com-

plete situational awareness. The master

showed a lack o enorcing policies and

ollowing company procedures as the

manning on the bridge was insucient.

WHY?

Lack o onboard saety cultureWHY?

WHY?The company had not been able to es-

tablish saety culture onboard that ol-

lowed the companys own procedures.

CONSEQUENCESThis collision led to the total loss o vessel B which

was almost split in hal by vessel A. Vessel B broke

in hal a couple o days later and sank. There was

no loss o lie, or injuries, on either o the vessels.




ContactThe vessel departed rom the terminal in the morning. The

master, pilot, chie ocer and helmsman were on the bridge.

A proper pilot brie was not held as there was no specic

plan and no discussion about risks regarding the departure.

The vessel was acing downstream and departed under

pilotage. One tug was available astern but was let go justater departure. However, another vessel was known to be

proceeding upriver and approaching the area and it appears

that the pilot decided to head urther to the south side o

the river in order to pass the other vessel.

By the time the pilot ordered port helm in order to head

downriver, the vessel was caught in the food tide and the

bow started to swing to starboard. The standby tug could not

assist, as it had been let go just ater departure.

The vessel increased power ahead but continued swinging

to starboard, proceeding directly across the river at a speed

o around 7 knots and heading or a vessel berthed at the

terminal on the south bank. This high speed made the thrust-

ers useless.

At this point the master eared that the risk o collision

was imminent, relieved the pilot and ordered ull astern in

order to reduce the speed and also take advantage o the

transverse thrust eect o the right hand propeller to swing

the bow urther to starboard. At the same time the anchor

was dropped but it was too late. As a result o these ac-

tions the vessels bow cleared the berthed vessel by about 30

meters but the vessel made heavy contact with the berth at aspeed o about 4 knots.

Findings rom the accident investigation by the fag state

inspectors were:

` The port state investigation ound that the pilot had

applied port helm too late to prevent the vessels bow rom

swinging to starboard once it entered the tidal stream.

` This accident might have been prevented i the pilot had

retained the option o using the tug or longer.

` The master and pilot did not exchange detailed inorma-

tion. Had they discussed areas o the river transit thatmay have posed a risk, they might have decided to retain

the use o the tug until the vessel was clear o the complex

tidal fows.

` The investigation recommends the port authority to

include in its procedures a requirement or vessels depart-

ing the terminal to retain the use o a tug until they have

ully entered the stream, when a strong tidal counter-fow

is present o the berth.

WHAT? Contact with berth during strongfood tide

The vessel was south o the plannedcourse line

WHY?

There was inbound trac so the pilot

decided to position the vessel closer

to shoreWHY?

There was no specic plan and no

discussion about risks regarding the

departure between the pilot and bridge

team. A proper pilot brie was not held.

WHY?

The bridge team disregarded the com-

panys own departure procedures which

required a pilot brieng which should

address possible risks.

WHY?

WHY?

The company had not been able to

explain the importance o ollow-

ing approved procedures, MRM and

the companys procedures on how tointeract with the pilot were not thor-

ough enough.

CONSEQUENCESExtensive repairs to own vessel and quay, which

also caused urther loss o earnings.




Preventing recurrence` Feedback about this accident has been sent to all the companys vessels trading in this area.

` The company has started a project called port card ocusing on high-risk ports. The card will have inormation

about specic risks or the port and other suggestions or the master to think about and will be distributed

to all vessels concerned.

`As per company procedure, both anchors should be dropped when there is an imminent risk o collision or grounding.

` Ocers will be trained on the simulator about how to interact with pilots.

` Procedures on how to interact with the pilot and bridge team need to be changed to address the issues in this case.

` Procedures regarding pilot brieng need to be reviewed and changed to address the deciencies in this case.

` Training about assertiveness should be introduced.

` MRM needs to be improved on the vessel, as the ocer in the bridge did not inorm the master about the current,

or other relevant inormation.




CollisionThe collision happened in the evening in a trac separation

scheme. The bridge was manned by one ocer and a cadet,

with no lookout present. The OOW had joined the vessel

just two days previously and it was much larger with dier-

ent bridge equipment than he was used to. The OOW had

signed the amiliarisation checklist where he stated that hewas conversant with all bridge equipment.

Visibility was about 6 miles , there was a rough sea, and

the wind was rom the NE with a orce o 8-9, which was

almost directly ahead. Vessel A had a course o 030 and a

speed o 23 knots. In ront o vessel A was vessel B and to

be able to pass vessel B the OOW altered course to star-

board. This was done using the autopilot. The vessel came

around slowly to starboard to the new course o 040,

which took about ve minutes.

The settings on the autopilot were set to a rudder limit

o 15 and a rate o turn o 10 per minute but this had not

been veried by the OOW. These limitations should have

been apparent to him ollowing the overtaking manoeuvre,

as the autopilot responded slowly to the alteration. Vessel B

was passed with a CPA o 0.4 miles and kept on the portside.

Additional actors not taken into account by the OOW were

the orce 8-9 NE wind on the starboard bow, the tendency o

the vessel to point into the wind, and that this would slow the

change to port.

The other vessel involved in the collision Vessel C was

10 miles away, ne to port and proceeding in the same di-rection with a speed o 2.5 knots. Vessel C was being quickly

overtaken by vessel A. There was some other trac in the

vicinity that was proceeding in the same direction. About 20

minutes beore the collision, the OOW identied the stern

light and deck lights o vessel C. According to the OOWs

own statement he had been overcondent in this visual

observation.

Vessel C was identied on the radar 14 minutes beore

the collision. Ten minutes beore the collision Vessel C

showed a CPA o 0.2 miles. The OOW changed course again

to port using the autopilot. The vessel applied minimal rud-

der with an 8 per minute rate o turn. This was not su-

cient. Four minutes beore the collision, vessel C was 1.4

miles away with a CPA o 0.16 miles. The OOW hesitated in

deciding on which side to pass vessel C. When he had made

up his mind, it was too late. Just beore the collision the o-

cer switched to manual steering and put the rudder hard to

port. Vessel A hit vessel C on her port quarter and vessel C

scraped vessel As side.

Findings rom the accident investigation by the fag state

inspectors were that the collision between the two vessels

was attributable to human error:

` Late decision due to a misjudgement by the OOW on vessel A

` Lack o attempted last minute manoeuvre by vessel C

` absence o a lookout on the bridge. They recommended

the company to improve the process o OOW to be able toget enough amiliarisation beore they resume command

o the watch. They also suggested that ocers should

receive simulator training.

WHAT? Vessel collided with a smaller vesselin ront o them while overtaking

The OOW lacked sucient knowledge

about the bridge equipmentWHY?

The OOW had not been provided the

usual handover time when transerringto a new vessel and did not realise the

consequences o not being ully con-

versant with the bridge equipment

WHY?

The bridge equipment was completely

new to the ocer and he did not in-

orm the master about this. Instead he

disregarded proper procedures when

he signed the Familiarisation Manual

without being ully conversant with

the equipment, which is a requirement.

WHY?

Shore side lack o implementing com-

pany procedures onboard and not iden-

tiying the risk o not providing su-

cient handover period or the ocer.

WHY?

WHY?

Lack o leadership onboard as the

master did no verication o the o-

cers amiliarisation, which is a re-

quirement as per the companys SMS.

The master did not voice any concern

about the short handover period to

shore side management.

CONSEQUENCESExtensive repairs to both vessels and urther loss

o earnings during reparation.




Preventing recurrence` The company has now added two extra ocers on all their large vessels and one more AB on all vessels. On the large

vessels there should always be two bridge ocers and one AB on watch and on the smaller vessels there should

always be one ocer and one AB on watch.

` The company sent a directive to all vessels about changes to the watch system.

` The company has also changed its handover procedures and now requires that new crew should be given a sucient

handover period.

` All ocers will now receive simulator training, not just senior ocers.

` The company has also identied that it must increase its MRM training.

` A lookout should always be present on the bridge at night, which is also a SOLAS requirement.

` The OOW should have changed course early and should have veried the settings on all the dierent bridgeequipment.

` All returning ocers should go through all bridge equipment with the navigating ocer.

` The company should introduce a more specic Navigation policy.

The OOW had signed

the familiarisation

checklist in spite of

the fact that he was

not conversant with

bridge equipment.




ContactThe master had a brieng with the pilot beore proceeding

to the allocated quay. Present on the bridge was the master,

chie ocer and pilot. Suddenly the vessel lost all power.

The engines came back on beore any incident occurred, but

the bow thruster did not. The vessel was approaching the

quay to berth starboard side alongside.It was winter and there was some ice foating by the berth,

which was about 25-30 cm thick. There was no wind and

visibility was good. One tug was assisting at the bow with a

30m-long wire hawser attached. It was dawn and the berth

was unlit. An orange light was suppose to be lit by the port

but was never switched on. A gantry crane was positioned

in the middle o the quay. The pilots intention was to berth

behind it. He had the conn and the master was monitoring.

Because o the ice, the pilot decided to approach with a

little more speed than usual and a larger angle than normal,

which was about 40o. The tug was pulling the vessel towards

the quay. The vessel had a speed o about 3 knots. The pilot

was not monitoring the speed because there were no instru-

ments on the bridge wing. He trusted his own experience. The

master said he was concerned that the speed was too ast.

The pilot did not communicate in English with the tug and the

master had diculties understanding what was happening.

When the vessel was about 25 m rom the berth, the port

anchor was dropped and the helm ordered hard to port. A

minute later ull astern was ordered by the pilot but the CPP

(controlled pitch propeller) responded very slowly. The pilotstated that he had no opportunity o watching the rudder

indicator or the engine's revs and that the vessel kept moving

ahead, with a tendency to starboard. The pilot advised the

master to work the engine ull astern and told the tug to

position itsel on the portside and to pull rmly to port. The

master ordered the rudder to mid-ship and once again voiced

his concern about the excess speed. It was too late and the

vessel made contact with the gantry crane.

Ater the accident the vessel was boarded by Port State

Control (PSC) inspectors, who issued a number o non-con-

ormities. These were cleared during an internal audit by the

company in the given time span.

The master stated that he didnt ully understand the

pilots commands to the tug or thought them to be wrong. He

also believed the cause o the accident was the ice situation

and that the pilot wanted to approach the quay aster and at

a steeper angle to move the ice away, which he was not happy

about. The tug was also ordered to pull the bow to port too

late. The master did not relive the pilot.

The pilot stated that he believed the causes o the accident

were the low water table at the given drat, the quay beingunprepared, the ice unbroken, the crane in the middle and cir-

cumstances resulting in the ship's bow driting to starboard.

Even having these concerns he still proceeded.

The companys internal conclusion was the lack o commu-

nication between the pilot and the tug and that the master

should have relieved the pilot at an early stage. Regarding

the power ailure, the machinery was tested by both PSC

inspectors and class inspectors and was ound to be working

satisactorily.

The chie ocer who was on the bridge did not inorm themaster and pilot about the speed and other critical inorma-

tion. The master did voice his concern about the speed but did

not act on it and was not assertive enough towards the pilot.

The master had diculty understanding the pilot as he was

communicating in Polish with the tugboat. The pilot should

have explained the orders he was giving to the tug in English

and i not the master should have requested this. It is essen-

tial that all bridge team members have clearly dened roles.

This could be addressed with dened bridge team roles and

closed loop communication.

WHAT? Contact with gantry crane

Poor MRM as there is a clear com-

munication breakdown, as well as the

companys arrival and pilotage proce-

dures were not extensive enough

WHY?

The assisting tug was positioned wrong-

ly and the pilot used excessive speed

and angleWHY?

The pilot berthed without having ull

control o the situation or communi-

cating his intentions to the master

WHY?

There was no proper pilot brie which

addressed the risks o the berthing

operation

WHY?

WHY?The master was not assertive and did

not request the pilot to explain his

actions

CONSEQUENCESThe vessel needed extensive repairs, which could

only be carried out in a dry dock. Fortunately there

was no extensive damage to the gantry crane.

There were urther losses o earnings or both the

port and vessel because o the required repairs.




Preventing recurrence

` The accident was addressed in a Management Review meeting.` The company is considering instructing their its masters to act more assertively towards lots pilots when they eel

something is wrong instead o just warning the pilot.

` The company carried out an additional internal audit and all issued non-conormities rom the PSC inspection

were closed.

` The company should consider introducing specic MRM training regarding communication, how to interact with

the pilot and the importance o all members in the bridge team being assertive.

` The company should review their its navigational procedures regarding pilotage and ensure that closed loop

communication is used and that all bridge team members have clearly dened roles.




GroundingThe second ocer prepared the passage plan to the next

port while alongside. During the approach to the port, the

master had deviated rom the planned course line because

he was uncomortable about an area with water that was

not as deep as the rest o the channel. This made the sec-

ond ocer change the outbound track to correlate with themasters inbound deviation. The second ocer then pro-

grammed all waypoints into the electronic chart and GPS.

It was night and the vessel was outbound rom port, the

weather was ne with only a light westerly breeze and vis-

ibility o about 5-6 miles. The vessel had missed its allocated

berthing slot at the next port so there was some urgency to

clear the buoyed channel.

There were about 3 knots o ebb tide. Manual steering was

done by the helmsman; the second ocer was monitoring the

electronic chart on which he had ARPA radar overlay project-

ed. He was also plotting the ships position on the paper chart.

The master decided to leave the channel because he was con-

cerned about the same area with more shallow water as when

the vessel was inbound. He altered the vessel to starboard to

stay clear o a buoy that was close to an area with shallow

water. The vessel was changing course slowly and ended up

being close to the buoy. Satisying himsel that the electronic

chart showed clear water he decided to keep the buoy to port

and then rejoin the buoyed route once clear.

The master then realised that it was too late to change

course back into the channel. At the same time the secondocer had also been busy responding to the VTS, who were

making repeated calls on the VHF warning the vessel that

they were heading or shallow waters. Shortly ater this the

vessel ran aground.

It seems that the master was over-reliant on inormation

provided by the electronic chart, which had not been updated

with the latest issue and did not display known signicant

reduced depths consistent with the paper chart corrections.

On the British Admiralty paper chart it was evident that there

was not enough water where the vessel ran aground. The

master was navigating solely on the electronic chart and had

not double-checked with the paper chart.

This would also indicate that the master was navigating

with an electronic chart that was not approved as per the

IHO S57 standard. One o the many criteria or the elec-

tronic chart unit to become an ECDIS type approved as per

IMO resolution A. 817 (19) is or the charts to use ocial

ENC (vectorised electronic navigational charts) which are as

per IHO S57 standard, which must be supplied by a national

hydrographic oce. I this is not complied with the ECDIS

should not be considered as an approved ECDIS. The masterstated that he had expected the ECDIS to include the shallow

area. The vessel did not have an approved ECDIS even i the

master thought it did. The company had previously sent warn-

ings about the dicult navigation conditions that existed in

this area.

Whilst the course lines and waypoints were changed on the

paper chart, and programmed into the electronic chart, the

written passage plan was not updated. Neither was the previ-

ous courses erased rom the chart. In addition to the courses

written on the chart being wrong, the chart itsel containedvery little o the inormation that would customarily be seen

as no-go areas, wheel-over positions, requency o position

xing, o-track margins or parallel index markings.

WHAT? Vessel running aground outsidebuoyed channel

The master let the buoyed channelWHY?

The master was cautious about an

area with less water a couple o miles

ahead in the channel. He thought it

was enough that the electronic chart

showed clear water and did not double-

check with the paper chart.

WHY?

The master was overcondent about

the electronic chart and realised the

danger too late. The area where thevessel ran aground was visible on the

paper chart. The second ocer had

plotted a position on the paper chart

but did not voice his concern.

WHY?

Poor communication on the bridge

and overall poor passage planning. The

bridge team lacked knowledge about

what an ECDIS is and did not have ull

situational awareness.

WHY?

WHY?

The bridge team did not practice MRM

and did not ollow company procedures.

The companys navigation policy was

not extensive enough.

CONSEQUENCESThe vessel was refoated on the alling high tide

due to a greater water level as a result o chang-

ing weather conditions. It was imperative to refoatthe vessel as there was a risk that it would break

apart during the next high tide because less than

hal it was aground.




Preventing recurrence` The company has acknowledged that there was a lack o MRM and improving this is the next action plan.

` The company had previously sent warnings about the dicult navigation conditions that existed in this area.

` Sent a reminder to all vessels that the electronic chart is secondary to the paper chart.

` Vessels should have local charts onboard or determined high-risk areas.

` The company changed its recruitment policy ater this accident. It now looks specically at which individuals will

be t or specic vessels.

` Inormation regarding ECDIS and what the dierence is between an ECDIS and ECS (Electronic Chart System)

would be very benecial to distribute within the company, as it is very common that people both ashore and

onboard are conused to what an approved ECDIS is.

` The company is considering introducing specic navigational audits on all vessels.

` The company is considering introducing specic company-approved waypoints and tracks or all the dierent

routes.

` All passage plans, charts and electronic charts should at least include under-keel clearance, no-go areas etc.

` I there is any discrepancy rom the approved passage plan, a new plan should be produced and agreed.

` The company should review its navigational procedures and especially passage planning.




The vessel was preparing or departure and the mooring

parties were standing by orward and at. The master gave

the order to let go all lines and the second ocer, who was

at the orward mooring station, gave the order to let go

both headlines. One o the ABs who was working in ront o

the mooring winch put the mooring line on a hook on the

roller bollard instead o around the roller, which was the

normal procedure. An OS was operating the mooring winch

but he could not see the AB who was handling the line

because o the large mooring winch.

For some unknown reason the second ocer gave the order

to heave in both head lines while one o them was still at-

tached to the shore bollard. It is imperative that the person

in charge o the mooring operation has complete situational

awareness.

The headline tightened very quickly and it came o the

bollard hook and hit the AB hard in the waist. The AB was

wearing correct PPE equipment (Helmet, saety shoes, coverall

and gloves) but this did not protect him against the snap rom

the mooring rope. The master believed that the main reason

or the accident was because the mooring team was notvigilant enough.

Mooring accidents are unortunately not uncommon but

can usually be avoided i the mooring team ollows correct

procedures and work as a team with clearly dened duties. It

is imperative that the mooring team involved is aware o the

risks, which should be dened in the risk assessment.

WHAT? AB hit by mooring ropeduring departure

The mooring line was still on the

shoreside bollard when the order to

heave in was given by the secondocer, causing the line to snap and

hit the AB in the waist.

WHY?

The AB had put the mooring line on the

hook o the roller bollard instead o

around the roller bollard.

WHY?

The mooring party had poor situational

awareness as no party member recog-

nised the risk o the mooring line onthe hook.

WHY?

The mooring party did not ollow the

companys risk assessment and mooring

procedures.

WHY?

WHY?

The company has not been able to

implement a saety culture onboard

the vessel which ollows risk assess-

ments and procedures.

CONSEQUENCESThe AB received injuries to his back and is unlikely

to be able to resume sea duties.

Preventing recurrence` Ater this accident, training and toolbox meetings

have taken place onboard regarding sae mooring

practices.

` An article about sae mooring practices has been

distributed to the companys vessels.

` The vessel had a risk assessment or mooring

operations, which addresses dangers and risks

associated with mooring operations. The companys

specialist or sae working practices periodically

reviews the risk assessment. It has been revised since

this accident.

` The company should consider having specic train-

ing o the importance o risk assessments onboardall vessels.

Injury mooring accident




A vessel started receiving HFO bunker rom a barge while

moored alongside a terminal. The rst tank was lled to

the ordered level by the chie engineer and the bunkering

continued into a second tank.

The chie engineer and second engineer let or dinner, leav-

ing the ourth engineer in charge alone, without any means ocommunicating with the barge. While monitoring the loading

o uel into the second tank the ourth engineer panicked

because he thought there was a risk o the tank overfowing,

which was not the case. He tried to contact the barge unsuc-

cessully. He then decided to slightly open the valve to the

rst tank and throttle the valve to the second tank to 50%.

The volume in the rst tank was 87% and the second tank

was 71%. Then he tried to contact the barge again to suspend

bunker operations but once again was unsuccessul. As there

was no action taken on the barge or on the vessel itsel, the

rst tank nally overfowed through the air vent and con-

taminated the deck and water in the port. Fortunately the

pollution was contained in the vessels vicinity by a mooring

rope, which was laid on the surace. To stop the overfow, the

wing tank valve was opened and the valve to the rst tank

was closed. Shortly ater the bunker operation was suspended

the barge let the vessel.

Despite the presence o the scupper plugs, and also as a

consequence o the heavy rain, some HFO had overfowed

the edge o the portside deck plating, contaminating the shell

plating and surrounding waters. A proessional completed thecleaning operation o the vessels hull and the port.

At the time o the overfow, the ourth engineer was at-

tending the bunkering operation alone although the decision

o the chie engineer to only bunker 891mt o HSFO in tank 1

and 2 to a total 93% to 94% o their capacity must have war-

ranted extra precautions to be taken.

The ourth engineer had no VHF available and could not

communicate with the barges crew although the pre-bunker-

ing check list conrmed that ship shore / barge communica-tion channels established.

The ourth engineer was in charge o both sounding o

the FO tanks (on deck) and handling the tanks valves (in the

engine room) when the latter is the second engineers respon-

sibility as per the bunkering plan.

It was discovered that the engineers had serious diculties

communicating with each other because the second engineer

did not speak English.

From interviewing the chie engineer, it appeared he was

convinced that the overfow occurred rom tank 2, although

all evidence pointed to the act that the overfow occurredrom tank 1. Thereore there was a lack o communication

between the engineers.

There were serious ISM breaches by the vessel where the

most serious were:

` Not sending the correct notication to the authorities

about the incident according to IMO resolution 851(20).

` Disregarding bunkering and saety procedures as per SMS.

` The crew not being amiliar with vessel and bunker

procedures.` Lack o communication between engine crew, i.e. the

second engineer could not speak English.

Pollution




Preventing recurrence

` The company has reiterated to the crewing agent

that only English-speaking ocers are to be

provided.

` The company sent out a technical circular to all

vessels requesting that they ollow the correct

bunkering procedures in the SMS.

` Bunker drills should be carried out by new crew

members and training or new crew is also

emphasized.

` The company should review its bunker procedures

and ensure the deciencies ound by the PSC

inspectors have been rectied.

` The company should carry out an audit o the

crewing agent.

` The company should have more specic requirements

about provided crew.

` The company should improve procedures about work

permits as the checklist had been ignored.

` The company should ensure that toolbox meetings

are ollowed.

` The company should introduce risk assessment or

all critical jobs.

` The company should consider having specic training

about the importance o risk assessments and SMSprocedures onboard all vessels.

` The company should increase the scope and number

o internal audits and visits to company vessels to

veriy that the SMS is ollowed and that crews have

adequate knowledge. There were numerous SMS

procedures breached in this case.

` Introduce MRM, as there is lack o proper communi-

cation onboard the vessel.

WHAT? Oil spill during bunkering

The ourth engineer was overseeing

the bunker operation by himsel and

thought there was a risk o the tank

overfowing. He panicked and decidedto open the valve to the rst tank,

which was almost ull.

WHY?

The chie engineer and second engi-

neer had let or dinner and the ourth

engineer had no means o communi-

cating with the barge, bridge or other

engineers. As he could not contact the

barge, or anyone on the vessel itsel,

the rst tank nally overfowed.

WHY?

The companys bunkering procedures

were ignored by the chie engineer.

No risk assessment was carried out; no

record o any toolbox meeting exists,

which is a requirement. The bunkering

checklist was lled out but ignored.

WHY?

Serious lack o communication, a-

miliarisation and inecient shipboardmanagement by the chie engineer.

WHY?

WHY?

The company has not been able to

establish an acceptable onboard saety

culture and SMS procedures are not

thorough enough.

CONSEQUENCES` Vessel was detained because o serious ailure o

the ISM code.` Substantial costs or cleaning the vessels hull

and surrounding water.

` Loss o time and employment o vessel due to

the incident.

` An additional audit was carried out by the

classication society to veriy that the non-

conormities had been rectied.




InjuryIt was morning; the weather was good with a northerly

wind orce o 3-4 Beauort. The vessel was proceeding at

14 knots. The chie engineer, rst engineer and third engi-

neer were scheduled to carry out routine maintenance on

one o the ballast pumps.

They dismantled the pump and removed the shat andimpeller, while the nuts on the pump case had also been

removed. This had been prepared in advance. The shat had

been secured in a threaded hole with a chain to an eyebolt.

The engineers used a ve-tone SWL chain block, which

was secured in a monorail, and the shat was raised so the

engineers could work on it more easily. The shat was to be

moved so another chain block could be attached.

While waiting or the chain block the engineers started

to inspect the shat and rotated it a couple o times. Sud-

denly the shat dropped rom the eyebolt and the third

engineers hand was severed. The rst engineer was also

seriously injured but his hand was ortunately not severed

but crushed.

The vessel diverted to the nearest harbour. Medical as-

sistance was established with an MRCC and a helicopter was

dispatched which arrived three hours later.

At the time o the accident the injured crewmembers were

wearing saety shoes, gloves, boiler suits and helmets, but

this obviously didnt protect them.

It could not be completely established why the eyebolt

was unscrewed. The liting appliances were certied and ap-proved or the lited weight and it was not damaged.

WHAT? Engineers severely injured duringmaintenance work

Shat was unscrewed and droppedWHY?

It was not correctly securedWHY?

Not paying enough attention and lack

o experienceWHY?

Lack o proper preparation and proce-

dures. No work permit issued and no

risk assessment perormed.

WHY?

WHY?

The company and crewmembers in-

volved had not recognised that this job

was dangerous prior to the accident, as

there was no available risk assessment

and the chie engineer did not require

a work permit. This would indicate

that there was a lack o saety culture

onboard the vessel.

CONSEQUENCESThe engineers stated that they had secured the

bolt tightly. The immediate cause o the accident

according to the companys own report suggests

that the bolt unscrewed because it was not tight-

ened correctly, the engineers were in a hurry and

more than one person was rotating the shat. Be-

cause o the accidents severity, the injured crew-

members could not continue working at sea.

Preventing recurrence` The company has sent out a circular to all vessels regarding the accident and changes to the SMS.

` The company now requires a work permit or this kind o job.

` There is now a requirement to ollow a checklist beore using any liting gear.

` The company has also produced a poster regarding correct liting procedures, which has been distributed

throughout the feet.

` Training on how to use liting appliances correctly has been carried out onboard the vessel.

` Additional rst aid training has also been carried out onboard.

` The company should improve the procedures regarding work permits.

` The company should introduce risk assessment or all critical jobs.

` The company needs to ensure that crew members ollow correct saety standards and procedures during

internal audits.




The crew member had been smoking or around 40 years.

He had a valid health certicate. While he was working

onboard he suered a heart attack and was rushed to

hospital. In the days prior to this he had apparently experi-

enced shortness o breath and a rapid heart rate.

At the hospital he was ound to have respiratory ailure and

required mechanical ventilation, he had little i any respira-

tory reserve. The cause was diagnosed to be Chronic Obstruc-tive Pulmonary Disease (COPD). This means that the airways

become narrowed, limiting the fow o air rom the lungs. The

most common cause is rom smoking.

The crew member was admitted to the hospital or a cou-

ple o weeks and his condition was very serious. He was nally

allowed to leave hospital and fy home to his native country

to rest and receive urther treatment. A couple o weeks later

he was ound dead at home.

It does not seem that a normal health certicate will be

sucient to determine a crew members health. I doctors do

not treat health certicates seriously, it could lead to severe

consequences as in this case. This does not relieve the com-

pany rom ensuring that their crew members are t or duty.

WHAT? Crew member died rom theeects o heavy smoking

The crew member most pr

Claims at a Glance 2012

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