Claims at a glance 2012 - The Swedish Club

Claims at a glanceFrequencies & Severity

2012

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Check the conclusion at page 9

Read the case analysisat page 11

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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 5

FD&D 6

Marine 6

Causes and remedies 7Passage plan 7

Bridge equipment 7

Procedures 8

Risk assessment 8

Near misses 9

Safety culture 9

Conclusion 9

Executive summary 10Main 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 year’s publication will, as always, provide feedback as to the Club’s ex-periences in general on the claims side. We do this in order to share valuable information 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 of root cause. Apart from these recurring features of 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 of mixed experience. Q1 and Q2 left us with no surprises and the half-year results were actu-ally better than expected. Q3 and Q4, on the other hand, deviated negatively from the expected performance. We have dealt with complex, challenging

collisions and groundings that have involved both P&I and H&M elements of significance. We have also learned the hard way over the year how much the location of a casualty impacts on the response of it. 2011 was also a year of further financial instability. It seems as if 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 finally assessed. What can be said with some degree of 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 qualify such a suggestion and add

that in relation to the really large P&I claims there is virtually no such cor-relation. If one looks at the more at-tritional side of P&I claims the correla-tion appears much more concrete. This frequency is clearly something that we can address and manage. To this end, this is also where our main focus on Loss Prevention lies.

On the Marine side we noticed a slight reduction in the number of 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 of claims and the state of the global economy.

From Graph No. 1 below we can see that the numbers of H&M claims in excess of USD 500,000 is almost as forecasted (100%). On P&I the devia-tion from the expected (100%) is more pronounced, which is illustrated in Graph No. 2.

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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 of proper passage planning ` Lack of essential bridge equipment knowledge and poor

navigation policies ` Serious Maritime Resource Management (MRM) issues ` Lack of proper communication ` The Safety Management System (SMS) is lacking defined

and properly explained procedures ` Poorly implemented risk assessments and work permit

procedures

Remedies ` There should be a defined safety culture in the organisation ` The root causes of accidents need to be identified 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 specific navigational audits

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

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Although it is difficult 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 a while before we will reach a state of equilibrium where there is a balance struck between supply and demand. As a consequence of stable or slightly increasing shipping activities we see very little reason as to why the claims pattern should not follow suit. We anticipate that the number of claims will continue to increase in 2012.

Claims and vessel types for P&I and H&MFor P&I and H&M insurances in 2011 the average number of claims in excess of USD 5,000 was 0.49 claims/vessel/year. The corresponding figure for 2008 was 0.30 claims/vessel, representing an increase in frequency of 63%. Combin-ing the previous with an increase in the average claim cost since 2008 makes for a worrying trend. 20

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Graph No 32002—2011 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 focus on three different types: Bulkers, Containers and Tankers. They represent more than 75% of all insured vessels for P&I and H&M. This gives an accurate overview, as these vessels are more or less similar in the amount of crew members and trade patterns. Under Hull and Machinery (H&M) we define Collision, Contact, and Grounding as Navigational claims.

The average cost for a Navigational claim in excess of USD 10,000 in 2011 was more than USD 800,000. The corresponding amount for P&I claims (including only Cargo, Ill-ness and Injury) in excess of USD 5,000 was more than USD 35,000.

The average claim cost has

Graph No 42002—2011 H&M navigational claims for bulkers, con-tainers and tankers. Cost and frequency per vessel/year => USD 10,000.

Graph No 52002—2011 H&M navigational claims for bulkers, containers and tankers. Average cost and frequency per claim => USD 10,000.

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increased by 50% since 2008 and the frequency 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 of one single navigational claim could gener-ate major savings to owners as well as their Club and Underwriter. Preventing these casualties is The Swedish Club’s highest priority.



Graph No 62002—2011 P&I cargo, illness, injury claims for bulkers, containers and tankers. Cost and frequency per vessel/year => USD 5,000

Graph No 72002—2011 P&I cargo, illness, injury claims for bulkers, containers and tankers. Average cost and frequency per claim => USD 5,000.

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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 offered plenty of challenges apart from the pure casualty-related ones. Tsunamis, Sanctions, Piracy, and Cargo Liquefaction are just some of the topics that the Club dealt with over the year. The need for owners to receive correct, quick, advice on issues is ever-increasing.

We took one further step in simpli-fying our business partners’ access to correct and timely advice in relation to some of the current topical issues. We created a web-based portal called “Topical Issues”. Under this web portal you can find advice structured in Q&A format regarding Armed Guards Contract, sanctions and liquefaction. In addition to FAQs we provide lots of in-depth information for these differ-ent areas.

It has proven to be a much-appreci-ated move enabling our business part-ners to easily download the necessary information. In addition it also provides clarity and certainty as to the Club’s position in relation to specific issues. The initiative is a success and will be developed further in 2012.

Swedish Club On Line (SCOL)Another important feature launched last year was our Swedish Club On Line system. This web-based B2B platform enables our business partners to up-

load and download relevant informa-tion on underwriting and claims. The SCOL provides exceptional flexibility in terms of data compilation and of-fers a wide range of products from Certificate of Entry documents to Loss Prevention benchmarking. The plat-form will also be continually developed in 2012 and more interactive features will be launched.

Rules & ExceptionsWe are very pleased to report that the Club’s revised Rules & Exceptions hit the shelves in February 2012. Obviously, many people put a lot of dedication and hard work into the revision process, which took place in 2011. We are very pleased with the result and happy to of-fer this publication to anyone interested. We believe that this new edition will add to the Club’s already excellent reputa-tion as a first class P&I Club. The Rules & Exceptions is of course also available electronically on the SCOL platform.

P&IWe would like to start by say-

ing that P&I is very much a “double nature” class of 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 efforts of reducing the frequency of these claims. We can say, based on Graph No. 8 that the number of 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 of pool claims during 2011 was relatively low. However, we can see that these claims were quite costly. We know that the start of calendar year 2012 is not going to improve this picture.

Graph No 8International Group pool Claims

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The Club has experienced a rather steep overall increase in the number of claims. If we look at the average cost however this has actually dropped a bit.

As far as frequency is concerned we can see a clear trend in the increasing number of attritional claims. Not equally

Graph No 92006—2011 P&I frequency distribution (claims => USD 5,000)

Graph No 102006—2011 P&I cost distribution (claims => USD 5,000)

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as clear, but nevertheless, an increase can still be noted in the interval claims in excess of USD 500,000. If we look at the frequency 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 of the global economy. For FD&D this is much more the case than for other classes of insurance

This is because, generally speaking, in times of shifting markets, disputes tend to increase, and if markets are also depressed, disputes increase in line with contractual defaults and unpaid debts. We have, therefore, seen an increase in the number of 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 frequency and a

depressed market is clearly illustrated. It is expected that this trend will diminish if the economy and markets stabilize, although it will probably take some time before it is noticeable. As pre-viously mentioned the global economy is entering a phase of “recovery” but it is fair to assume that the recovery will take some time.

Graph No 112004—2011 FD&D claims frequency per vessel/year

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Injury and Illness are fairly even. If we take a look instead at how the claims cost is distributed, we can see from 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 of larger claims in excess of USD 500,000. Our assessment of the situation is also that it is reason-able to expect a continued soaring of claims frequencies as shipping activities around the world will be stable or even increase on the back of a recovery of the global economy. A higher level of shipping activities coupled with an ever increasing shortage of seafarers are

the main reasons why we believe that frequencies will continue to soar on the back of further tonnage being deliv-ered and entering into trade. The rate of scrapping seems to be insufficient for reaching a balance between supply and demand. The size of the new ships delivered are very often much larger than the ones scrapped. Consequently, scrapping is insufficient in balancing out the influx of new tonnage. Another area of concern for the industry has been the “moral hazard” element, which

some thought would generate quite an increase of both smaller and larger claims. We can, in this respect, not say that we have noticed such a correla-tion. We are mindful of many own-ers’/managers’ financially challenging situations. In times of extremely poor earnings one must, out of 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 122006—2011 H&M frequency distribution (claims => USD 10,000)

Graph No 132006—2011 H&M cost distribution (claims => USD 10,000)

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Causes and remediesA vessel is a high-risk environment where people can die if safety is dis-regarded. This, coupled with a diverse crew from different countries and backgrounds shows that it is paramount that there is an established safety 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 safety culture onboard. For an accident to occur there is normally an underlying chain of errors. This is defined as several unidentified errors being committed that lead to an accident. By identifying and rectifying one of these errors the chain is broken and the accident can be prevented. To be able to identify these errors there needs to be an established functioning safety culture.The compa-ny’s procedures are established through the Safety Management System (SMS), which is a living document that requires continuous reviews and updates.

Many of the navigational accidents happened during critical operations where the master is usually on the bridge with a pilot or there are at least two officers present. Speed is also a re-curring issue. If the officer had reduced speed he would have improved his own situational awareness.

Passage planTo safely take the vessel from berth to berth there needs to be a detailed pas-sage plan, which should be based on a risk assessment of the relevant voyage. There are numerous deficiencies with passage planning in the IRCA cases reported below.The passage plan should be based on information about the most favourable route gathered from officially updated charts, pilot books, tide tables, tidal current tables, and notices to mariners and radio navigation warnings. All possible means and information should be utilised.

If 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 of-ficers. This will include relevant infor-mation received from the pilot.

The following should at least be included;

` Ensure that all charts, publications and ENCs are updated for the current voyage

` Courses should be laid down in the charts and, where appropriate, wheel over position and turning radius 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 special regulations for the current trading area

This information 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 awareness is a radar map of the intended voy-age. It is the master’s responsibility to ensure that the vessel has an approved berth to berth passage plan for the intended voyage and in particular pilot-age waters.

Bridge equipmentEvidence from many collisions or groundings show that the officer had been monitoring the situation but had misunderstood the information displayed on the bridge equipment. It is not uncommon that the root cause is

not to anticipate any consequence in this respect.

If we take a look at how the num-bers of claims are distributed, we can

see from Graph No. 12 below that breakdown of Machinery is still the main driver of claims frequency on H&M. If 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 of knowledge, inexperience and poor procedures.

The International Maritime Organiza-tion (IMO) made ECDIS mandatory on new passenger vessels and new tankers from 2012. By 2018 all vessels must have ECDIS onboard, which means that owners and managers will have to invest in this system.

It is paramount that all bridge offi-cers are fully converse with how ECDIS works, its limits, chosen settings and what actually an approved ECDIS is. Having an officer operating this essen-tial equipment and lacking knowledge about it could be a great risk.

Another area of extreme concern is officers actually thinking that they know 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 officer continually verifies that the system is working properly and is aware of potential risks. The risk of 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 if the equip-ment will enhance the performance of the officer and increase safety or not.

Advancement in technology is some-thing positive but it is very important to have a contingency plan in the event of a malfunction and to know the limits of the specific equipment. This can be addressed with defined procedures within the vessel’s Safety Management System (SMS).

It will not matter if the bridge has the most advanced ECDIS system if the officers have not received proper training or gained sufficient knowledge. Knowledgeable officers and technol-ogy is a great tool and will enhance safety and relieve pressure. Lacking the required knowledge might instead increase the risk.

Extensive training in simulators can also be very beneficial for building a safety culture especially if the training is not focused only on ship handling

but instead, establishing proper MRM procedures with the entire bridge team from junior to senior officers.

How an efficient 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 defined duties for all different bridge team members. Proper communication and defined duties will improve situational awareness.

To be able to prevent navigational claims there needs to be a thorough navigational policy addressing all key issues for the safe navigation of the vessel in correlation with MRM. This, coupled with specific navigational au-dits focussing on how the navigational watch is carried out and verifying that the bridge team is following the com-pany’s own navigational procedures, will be very effective in preventing navigational claims. The basis of these measures will be the company’s own safety culture.

ProceduresIt is evident that disregarding procedures has been a leading cause of almost all IRCA cases. This means that the crew thought that the procedures were not worth following 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 confidence in the procedures. The crew need to be aware that it is also their responsibility to inform the company if they believe there are issues with SMS procedures instead of disregarding them. The reason for this is a failure within the company to establish a proper safety culture.

There are also numerous claims where third parties have acted in an unsafe way, which have led to seri-ous injuries. This is difficult to monitor onboard the vessel but essential as the master is responsible for the safety of everyone onboard. It is essential to have defined procedures on how to deal with third parties onboard the vessel.

In a good safety culture all involved will know that it is imperative that procedures are followed.

They know that disregarding proce-dures the consequences could be severe and endanger the entire vessel and crew.

Cargo, Injury and Illness claims are a little different to Navigational claims but still have many similarities. P&I claims emphasize the importance of having correct procedures in place and need a lot of thought to be established. It is not enough to just have binders with SMS procedures if the crew do not believe in them or do not see their ben-efit. The crew should be given the tools to comply with all requirements.

It is the same with training as it is not enough just to send people on training courses if there is no follow up onboard the vessel and the onboard procedures do not coincide with the training.

Except for 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 assessmentSince 1 July 2010 there is an ISM re-quirement for companies to have ship-board operational procedures, which are based on risk assessments. The purpose of a risk assessment is to carry out a careful examination of shipboard operations to verify that there are adequate controls in place, which will make the risk levels acceptable.

To carry out a correct risk assessment there first has to be a risk analysis, which uses all available information to identify hazards and estimate the risk to the environment, property or individual.

The risk assessment evaluates the risk arising from a hazard and evaluates if the controls in place are sufficient and if the risks are acceptable.

A proper risk assessment will be cooperation between the office and the vessel. The office should provide a generic assessment and the vessel should make a detailed assessment of



the critical job. To be able to achieve the best result there should be cooper-ation between the office and the vessel to utilise the experience from both to compile a useful database.

It should be easy to access the database for specific jobs or planning of jobs. The database could also be useful for training. It is imperative that all onboard are aware of how to access the database and how to use it.

The procedures of how the risk as-sessment should be completed and used are addressed in the company’s SMS. If the risk assessment has been com-pleted correctly it is likely that most risks will be addressed. If a work permit has also been issued for the specific job it should be obvious to the crew mem-bers how to safely complete the job.

This will also mean that all depart-ments concerned have been informed 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 followed 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 fatal consequences.

Near missesNear misses is an efficient, approved way of identifying problems within a system or organisation. It can some-times be hard for a vessel to see the benefit of reporting a near miss as it seems to be such an insignificant event, error or misjudgement. This is under-standable but unfortunately misses the entire point as the benefit comes in numbers, especially if there is a huge database to compare against. Then the issue can be identified and hopefully established if this near miss is a reoc-curring event on other vessels. If it is at a large company with many vessels,

a near miss system might be able to identify some procedural problems that need to be changed.

Shipping companies are supposed to collect information about near misses and share this experience within the company. Sometimes the near misses are shared with external organisations. There are many public databases that collect information about near misses like MARS by the Nautical institute, CHIRP in the UK and Insjö/ForeSea in Sweden, Finland and Denmark. All these systems are improving safety worldwide with special magazines and reports. Unfortunately there is not one univer-sal system that everyone reports to. It seems that it would be beneficial for the shipping industry to be more open about sharing best practices and how to improve safety and technology onboard our vessels as the aviation industry does.

It is essential to understand that near misses are an important way of identifying problems before they be-come a disaster. It is very important for the organisation receiving these near misses to give positive feedback, but for the systems to further improve they need to receive more reports from both vessels and shipping companies.

Safety cultureA foundation for safety needs to be established in the company’s culture. There need to be clear goals concerning what the company stands for and what is expected of all employees. Top man-agement “buy in” is essential. All on-board are trained well enough to carry out their assigned duties; this is verified by valid certificates. What they will not know is what the company expects of them. This is what the company needs to focus on.

This kind of attitude training can be carried out during company semi-nars, newsletters, masters’ reviews and discussed during the monthly safety meeting onboard the vessel.

Probably the most effective way for a company to verify that the crew has the desired knowledge and attitude will be during superintendent’s visits and most importantly during the annual internal audit.

The company should provide the master with sufficient tools to ensure that the crew onboard has easy access to the SMS and that they understand the importance of the procedures. It is at this point that a comprehensive and detailed SMS will be most beneficial.Some companies have been so efficient with training and implementation of really impressive safety organisations, that they have almost reduced their navigational claims statistics to zero. They have achieved this by having an established plan from top management. In a positive safety culture mistakes are allowed but negligence and disregard-ing procedures are not.

ConclusionMost accidents are caused by human error, not technological or mechani-cal failure, the immediate cause is very often that a person made a disastrous decision or mistake. Investing in equip-ment, training facilities, training of employees and carrying out compre-hensive audits and inspections will be a good investment compared to being involved in a serious accident.

It is difficult and time consuming to establish a positive safety culture – the payback, however, will be substantial.

The most common causes in the IRCA cases are lack of knowledge, poor MRM, disregarding approved procedures, or procedures have not been implemented correctly or as intended. The root cause to this is failure from the shoreside or-ganisation to establish a positive safety culture onboard their vessels. This can be rectified with the correct motivation and belief because accidents can be prevent-ed and should be prevented.



WHAT? Loss of power in main engine

Turbocharger breakdownWHY?

Rotor is malfunctioningWHY?

Bearing failureWHY?

The bearing is well beyond its useful service life

WHY?

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 for H&M navigational claims:

Main areas of concern ` Lack of proper passage planning

` Lack of essential bridge equipment knowledge and poor navigation policies

` Serious Maritime Resource Manage- ment (MRM) issues

` Lack of proper communication

` The Safety Management System (SMS) is lacking defined and properly explained procedures

` Poorly implemented risk assessments and work permit procedures

Remedies ` There should be a defined safety

culture in the organisation

` The root causes of accidents need to be identified 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 specific navigational audits

Interactive Root Cause Analysis Two years have now passed since we launched an initiative, in co-operation with our members, designed to facilitate finding the “true” cause of damage. It is called “interactive root cause analysis” (IRCA) and includes assisting members in taking action to prevent recurrence of accidents and covers the Club’s feed-back to its members in general.

IRCA has proven to be a powerful loss prevention tool and allows mem-bers and ourselves to discover the true root cause of a casualty. We do not waste time addressing symptoms, but rather the cause.

The purpose is not to point fingers but to raise awareness about the reason why accidents occur. If the root cause can be established and rectified the risk

of 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 find and identify one or several root causes to a problem. The method is closely related to cause-effect diagrams (fishbone), which are often used in conjunction with the “Five Whys”.

By asking “Why?” five times succes-sively you move beyond symptoms and delve deep enough to understand the root cause(s). By the time you get to the fourth or fifth “Why?” you will prob-ably be looking squarely at management practices. A “Why?” can have several possibilities and each answer has to be looked into for likely root causes.

However, the “Five Whys” tool does not provide a resolution to the prob-lem itself, 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 of the people performing the task.

The “Cherry picking” processOne way for us to undertake this process efficiently is to screen one

Interactive root cause analysis (IRCA) — an example

large area of concern. This year we have focused on “P&I Claims; Cargo, Illness & Injury” – with a view to finding out whether we were “on to some-thing” and to find suitable cases for us to investigate in greater detail. This year’s screening will take the shape of a stand-alone publication called “P&I Claims Analysis”.

As one can imagine, interactive root cause analysis is a time-consuming business. It pays off instantly so, to that end, the time and money invested is very well spent, but to be as effec-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 process we obviously try to hit the claims categories where frequencies coincide with costs. As such we have in this publication decided to scrutinize the following 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 casesGrounding The 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 of 2 meters. It was evening and two pilots boarded the vessel, with no pilot brief being held. The mas-ter, two pilots, the chief officer and helmsman were present on the bridge. The maximum draft for vessels entering the port was 9 meters.

At the time of departure it was just after low tide with a height of 0.4 meters, maximum draft was aft at 8.2 meters. When the vessel departed it swung with the bow towards the quay. According to the 2nd officer on the stern, the vessel was swing-ing 80 meters clear of the buoy that marked the channel. The vessel had a speed of 1.2 knots astern in a channel which was about 250 meters wide and 1.5 times the vessel’s length overall.

A couple of minutes later the vessel touched bottom and the master informed 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 refloated with the help of the tug and proceeded towards the pilot station with difficulty, because the bridge team had not realized that the rudder was stuck at an angle of 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 further out from its original position. At the time of 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 affected area. After the grounding this was denied by the port captain but a navigation warning was issued about a month later regarding the changed position of the buoys.

It is possible that the pilot did know that the buoy had been moved but this has not been confirmed. The reason why the harbour authority had not reported the buoy’s changed position is unknown. In this case the electronic chart showed

WHAT? Grounding in harbour area

Lack of proper communicationWHY?

The chief officer was monitoring the electronic chart and the vessel was shown to be outside the channel, but he did not voice any concern.

WHY?

No unified plan within the bridge team and no specific team duties were assigned.

WHY?

The passage plan did not address the risks of 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.

CONSEQUENCESVessel grounded, resulting in extensive damage. It carried a lot of reefer container’s that were a total loss and resulted in a huge cargo claim.

Preventing recurrence ` Information 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 briefing is mandatory. ` A similar case will also be developed for the company’s simulator. ` The company will soon be introducing more MRM training for officers. ` It is imperative that the bridge officers voice their concerns when the information displayed on the electronic

chart displays any discrepancy. ` The passage plan should have addressed the risks with the narrow channel. ` If there is any discrepancy from the approved passage plan a new plan should be produced and agreed upon. ` The company should review its internal procedures for passage planning.

the vessel aground but the officer on the stern reported that the vessel was swinging clear. This discrepancy should have alerted the officer on the bridge further as the vessel ap-peared to be aground.



CollisionVessel A was on a southbound course and vessel B was north-bound. It was shortly after dusk, a light breeze, calm seas and visibility of around 8 nautical miles. The vessels were transiting an area of high traffic density with many merchant and fish-ing vessels. There were a number of small fishing vessels in the area, some moving, and others stationary.

Vessel A had a group of small fishing vessels on its starboard bow. To stay clear of the fishing vessels, the officer, on watch by himself 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 of 25 knots. The fishing vessels had bright lights, making it difficult to see any traffic behind them.

The master on vessel A was doing administrative jobs and visited the bridge a couple of times during the watch. The of-ficer on vessel A tried to plot the multiple fishing vessels, but lost the targets or they moved on the radar.

The officer on vessel B was on watch with a designated lookout. The vessel maintained a speed of 12 knots. Vessel B saw vessel A at 5 miles, or 8 minutes before the collision and could see vessel A’s red light on her port bow. The echo trails of both vessels were parallel. He did not recognise that there was a danger of collision.

Five minutes before the collision, vessel B observed that vessel A was showing a green light. The officer on vessel B gave the order to stop the engine and go hard to starboard. The officer did not plot vessel A. Just before the collision ves-sel A made another alteration to port. Neither of the vessels sounded any warning signals.

The officer on vessel A did not see vessel B until a couple of seconds before the collision and maintained full speed the entire time. The officer on vessel A did not consider slowing down, even when traffic started to become dense. The officer was not fully aware of the situation, as the northbound vessel was not identified behind the cluster of smaller vessels.

Preventing recurrence ` The company now provides bridge simulator training for officers and different seminars. ` This accident has been integrated into a simulator and is trained on regularly. ` The company organizes regular fleet meetings, where all important information and incidents are discussed with

the officers on board. ` An extra internal audit was carried out after the collision. ` The company has sent a circular to all vessels in its fleet about this accident. They once again request proper

watch keeping and the use of all navigational equipment onboard the vessel. ` The company should consider introducing specific navigational audits on all vessels verifying that SMS procedures

are adhered to. ` The company should review its navigational procedures and especially procedures for safe 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 company’s SMS and also under STCW regulations.

WHY?

The chief officer showed an acceptance to take risks and over-confidence in his own ability. The master visited the bridge but did not raise concern about the lack of a designated lookout.

WHY?

Vessel A:s chief officer had not com-plete situational awareness. The master showed a lack of enforcing policies and following company procedures as the manning on the bridge was insufficient.

WHY?

Lack of onboard safety cultureWHY?

WHY? The company had not been able to es-tablish safety culture onboard that fol-lowed the company’s own procedures.

CONSEQUENCESThis collision led to the total loss of vessel B which was almost split in half by vessel A. Vessel B broke in half a couple of days later and sank. There was no loss of life, or injuries, on either of the vessels.



Contact The vessel departed from the terminal in the morning. The master, pilot, chief officer and helmsman were on the bridge. A proper pilot brief was not held as there was no specific plan and no discussion about risks regarding the departure.The vessel was facing downstream and departed under pilotage. One tug was available astern but was let go just after departure. However, another vessel was known to be proceeding upriver and approaching the area and it appears that the pilot decided to head further to the south side of 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 flood tide and the bow started to swing to starboard. The standby tug could not assist, as it had been let go just after departure.

The vessel increased power ahead but continued swinging to starboard, proceeding directly across the river at a speed of around 7 knots and heading for a vessel berthed at the terminal on the south bank. This high speed made the thrust-ers useless.

At this point the master feared that the risk of collision was imminent, relieved the pilot and ordered full astern in order to reduce the speed and also take advantage of the transverse thrust effect of the right hand propeller to swing the bow further to starboard. At the same time the anchor was dropped but it was too late. As a result of these ac-tions the vessel’s bow cleared the berthed vessel by about 30 meters but the vessel made heavy contact with the berth at a speed of about 4 knots.

Findings from the accident investigation by the flag state inspectors were:

` The port state investigation found that the pilot had applied port helm too late to prevent the vessel’s bow from swinging to starboard once it entered the tidal stream.

` This accident might have been prevented if the pilot had retained the option of using the tug for longer.

` The master and pilot did not exchange detailed information. Had they discussed areas of the river transit that may have posed a risk, they might have decided to retain the use of the tug until the vessel was clear of the complex tidal flows.

` The investigation recommends the port authority to include in its procedures a requirement for vessels departing the terminal to retain the use of a tug until they have fully entered the stream, when a strong tidal counter-flow is present off the berth.

WHAT? Contact with berth during strong flood tide

The vessel was south of the planned course lineWHY?

There was inbound traffic so the pilot decided to position the vessel closer to shore

WHY?

There was no specific plan and no discussion about risks regarding the departure between the pilot and bridge team. A proper pilot brief was not held.

WHY?

The bridge team disregarded the com-pany’s own departure procedures which required a pilot briefing which should address possible risks.

WHY?

WHY?

The company had not been able to explain the importance of follow-ing approved procedures, MRM and the company’s procedures on how to interact with the pilot were not thor-ough enough.

CONSEQUENCESExtensive repairs to own vessel and quay, which also caused further loss of earnings.



Preventing recurrence ` Feedback about this accident has been sent to all the company’s vessels trading in this area. ` The company has started a project called port card focusing on high-risk ports. The card will have information

about specific risks for the port and other suggestions for 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 of collision or grounding. ` Officers 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 briefing need to be reviewed and changed to address the deficiencies in this case. ` Training about assertiveness should be introduced. ` MRM needs to be improved on the vessel, as the officer in the bridge did not inform the master about the current,

or other relevant information.



CollisionThe collision happened in the evening in a traffic separation scheme. The bridge was manned by one officer and a cadet, with no lookout present. The OOW had joined the vessel just two days previously and it was much larger with differ-ent bridge equipment than he was used to. The OOW had signed the familiarisation checklist where he stated that he was conversant with all bridge equipment.

Visibility was about 6 miles, there was a rough sea, and the wind was from the NE with a force of 8-9, which was almost directly ahead. Vessel A had a course of 030° and a speed of 23 knots. In front of 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 of 040°, which took about five minutes.

The settings on the autopilot were set to a rudder limit of 15° and a rate of turn of 10° per minute but this had not been verified by the OOW. These limitations should have been apparent to him following the overtaking manoeuvre, as the autopilot responded slowly to the alteration. Vessel B was passed with a CPA of 0.4 miles and kept on the portside. Additional factors not taken into account by the OOW were the force 8-9 NE wind on the starboard bow, the tendency of 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, fine to port and proceeding in the same di-rection with a speed of 2.5 knots. Vessel C was being quickly overtaken by vessel A. There was some other traffic in the vicinity that was proceeding in the same direction. About 20 minutes before the collision, the OOW identified the stern light and deck lights of vessel C. According to the OOW’s own statement he had been overconfident in this visual observation.

Vessel C was identified on the radar 14 minutes before the collision. Ten minutes before the collision Vessel C showed a CPA of 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 of turn. This was not suf-ficient. Four minutes before the collision, vessel C was 1.4 miles away with a CPA of 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 before the collision the of-ficer 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 A’s side.

Findings from the accident investigation by the flag 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 of attempted last minute manoeuvre by vessel C ` absence of a lookout on the bridge. They recommended

the company to improve the process of OOW to be able to get enough familiarisation before they resume command of the watch. They also suggested that officers should receive simulator training.

WHAT? Vessel collided with a smaller vessel in front of them while overtaking

The OOW lacked sufficient knowledge about the bridge equipmentWHY?

The OOW had not been provided the usual handover time when transferring to a new vessel and did not realise the consequences of not being fully con-versant with the bridge equipment

WHY?

The bridge equipment was completely new to the officer and he did not in-form the master about this. Instead he disregarded proper procedures when he signed the Familiarisation Manual without being fully conversant with the equipment, which is a requirement.

WHY?

Shore side lack of implementing com-pany procedures onboard and not iden-tifying the risk of not providing suffi-cient handover period for the officer.

WHY?

WHY?

Lack of leadership onboard as the master did no verification of the offi-cer’s familiarisation, which is a re-quirement as per the company’s SMS. The master did not voice any concern about the short handover period to shore side management.

CONSEQUENCESExtensive repairs to both vessels and further loss of earnings during reparation.



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

vessels there should always be two bridge officers and one AB on watch and on the smaller vessels there should always be one officer 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 sufficient

handover period. ` All officers will now receive simulator training, not just senior officers. ` The company has also identified 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 verified the settings on all the different bridge

equipment. ` All returning officers should go through all bridge equipment with the navigating officer. ` The company should introduce a more specific 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 briefing with the pilot before proceeding to the allocated quay. Present on the bridge was the master, chief officer and pilot. Suddenly the vessel lost all power. The engines came back on before 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 floating 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 of the quay. The pilot’s intention was to berth behind it. He had the conn and the master was monitoring.

Because of 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 of 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 fast. The pilot did not communicate in English with the tug and the master had difficulties understanding what was happening.

When the vessel was about 25 m from the berth, the port anchor was dropped and the helm ordered hard to port. A minute later full astern was ordered by the pilot but the CPP (controlled pitch propeller) responded very slowly. The pilot stated that he had no opportunity of 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 full astern and told the tug to position itself on the portside and to pull firmly 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.

After the accident the vessel was boarded by Port State Control (PSC) inspectors, who issued a number of non-con-formities. These were cleared during an internal audit by the company in the given time span.

The master stated that he didn’t fully understand the pilot’s commands to the tug or thought them to be wrong. He also believed the cause of the accident was the ice situation and that the pilot wanted to approach the quay faster 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 of the accident were the low water table at the given draft, the quay being unprepared, the ice unbroken, the crane in the middle and cir-cumstances resulting in the ship's bow drifting to starboard. Even having these concerns he still proceeded.

The company’s internal conclusion was the lack of commu-nication between the pilot and the tug and that the master should have relieved the pilot at an early stage. Regarding the power failure, the machinery was tested by both PSC inspectors and class inspectors and was found to be working satisfactorily.

The chief officer who was on the bridge did not inform the master and pilot about the speed and other critical informa-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 difficulty 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 if not the master should have requested this. It is essen-tial that all bridge team members have clearly defined roles. This could be addressed with defined 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 company’s arrival and pilotage proce-dures were not extensive enough

WHY?

The assisting tug was positioned wrong-ly and the pilot used excessive speed and angle

WHY?

The pilot berthed without having full control of the situation or communi-cating his intentions to the master

WHY?

There was no proper pilot brief which addressed the risks of 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 further losses of earnings for both the port and vessel because of 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 feel

something is wrong instead of just warning the pilot. ` The company carried out an additional internal audit and all issued non-conformities from the PSC inspection

were closed. ` The company should consider introducing specific MRM training regarding communication, how to interact with

the pilot and the importance of 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 defined roles.



Grounding The second officer prepared the passage plan to the next port while alongside. During the approach to the port, the master had deviated from the planned course line because he was uncomfortable about an area with water that was not as deep as the rest of the channel. This made the sec-ond officer change the outbound track to correlate with the master’s inbound deviation. The second officer then pro-grammed all waypoints into the electronic chart and GPS.

It was night and the vessel was outbound from port, the weather was fine with only a light westerly breeze and vis-ibility of 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 of ebb tide. Manual steering was done by the helmsman; the second officer was monitoring the electronic chart on which he had ARPA radar overlay project-ed. He was also plotting the ship’s 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 of 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. Satisfying himself 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 second officer had also been busy responding to the VTS, who were making repeated calls on the VHF warning the vessel that they were heading for shallow waters. Shortly after this the vessel ran aground.

It seems that the master was over-reliant on information provided by the electronic chart, which had not been updated with the latest issue and did not display known significant 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 of the many criteria for the elec-tronic chart unit to become an ECDIS type approved as per IMO resolution A. 817 (19) is for the charts to use official ENC (vectorised electronic navigational charts) which are as per IHO S57 standard, which must be supplied by a national hydrographic office. If this is not complied with the ECDIS should not be considered as an approved ECDIS. The master stated that he had expected the ECDIS to include the shallow area. The vessel did not have an approved ECDIS even if the master thought it did. The company had previously sent warn-

ings about the difficult 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 from the chart. In addition to the courses written on the chart being wrong, the chart itself contained very little of the information that would customarily be seen as no-go areas, wheel-over positions, frequency of position fixing, off-track margins or parallel index markings.

WHAT? Vessel running aground outside buoyed channel

The master left the buoyed channelWHY?

The master was cautious about an area with less water a couple of 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 overconfident about the electronic chart and realised the danger too late. The area where the vessel ran aground was visible on the paper chart. The second officer 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 full situational awareness.

WHY?

WHY?

The bridge team did not practice MRM and did not follow company procedures. The company’s navigation policy was not extensive enough.

CONSEQUENCESThe vessel was refloated on the falling high tide due to a greater water level as a result of chang-ing weather conditions. It was imperative to refloat the vessel as there was a risk that it would break apart during the next high tide because less than half it was aground.



Preventing recurrence ` The company has acknowledged that there was a lack of MRM and improving this is the next action plan. ` The company had previously sent warnings about the difficult 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 for determined high-risk areas. ` The company changed its recruitment policy after this accident. It now looks specifically at which individuals will

be fit for specific vessels. ` Information regarding ECDIS and what the difference is between an ECDIS and ECS (Electronic Chart System)

would be very beneficial to distribute within the company, as it is very common that people both ashore and onboard are confused to what an approved ECDIS is.

` The company is considering introducing specific navigational audits on all vessels. ` The company is considering introducing specific company-approved waypoints and tracks for all the different

routes. ` All passage plans, charts and electronic charts should at least include under-keel clearance, no-go areas etc. ` If there is any discrepancy from 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 for departure and the mooring parties were standing by forward and aft. The master gave the order to let go all lines and the second officer, who was at the forward mooring station, gave the order to let go both headlines. One of the ABs who was working in front of the mooring winch put the mooring line on a hook on the roller bollard instead of 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 of the large mooring winch.

For some unknown reason the second officer gave the order to heave in both head lines while one of them was still at-tached to the shore bollard. It is imperative that the person in charge of the mooring operation has complete situational awareness.

The headline tightened very quickly and it came off the bollard hook and hit the AB hard in the waist. The AB was wearing correct PPE equipment (Helmet, safety shoes, coverall and gloves) but this did not protect him against the snap from the mooring rope. The master believed that the main reason for the accident was because the mooring team was not vigilant enough.

Mooring accidents are unfortunately not uncommon but can usually be avoided if the mooring team follows correct procedures and work as a team with clearly defined duties. It is imperative that the mooring team involved is aware of the risks, which should be defined in the risk assessment.

WHAT? AB hit by mooring rope during departure

The mooring line was still on the shoreside bollard when the order to heave in was given by the second officer, causing the line to snap and hit the AB in the waist.

WHY?

The AB had put the mooring line on the hook of the roller bollard instead of around the roller bollard.

WHY?

The mooring party had poor situational awareness as no party member recog-nised the risk of the mooring line on the hook.

WHY?

The mooring party did not follow the company’s risk assessment and mooring procedures.

WHY?

WHY?

The company has not been able to implement a safety culture onboard the vessel which follows risk assess-ments and procedures.

CONSEQUENCESThe AB received injuries to his back and is unlikely to be able to resume sea duties.

Preventing recurrence ` After this accident, training and toolbox meetings

have taken place onboard regarding safe mooring practices.

` An article about safe mooring practices has been distributed to the company’s vessels.

` The vessel had a risk assessment for mooring operations, which addresses dangers and risks associated with mooring operations. The company’s specialist for safe working practices periodically reviews the risk assessment. It has been revised since this accident.

` The company should consider having specific training of the importance of risk assessments onboard all vessels.

Injury — mooring accident



A vessel started receiving HFO bunker from a barge while moored alongside a terminal. The first tank was filled to the ordered level by the chief engineer and the bunkering continued into a second tank.

The chief engineer and second engineer left for dinner, leav-ing the fourth engineer in charge alone, without any means of communicating with the barge. While monitoring the loading of fuel into the second tank the fourth engineer panicked because he thought there was a risk of the tank overflowing, which was not the case. He tried to contact the barge unsuc-cessfully. He then decided to slightly open the valve to the first tank and throttle the valve to the second tank to 50%. The volume in the first 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 unsuccessful. As there was no action taken on the barge or on the vessel itself, the first tank finally overflowed through the air vent and con-taminated the deck and water in the port. Fortunately the pollution was contained in the vessel’s vicinity by a mooring rope, which was laid on the surface. To stop the overflow, the wing tank valve was opened and the valve to the first tank was closed. Shortly after the bunker operation was suspended the barge left the vessel.

Despite the presence of the scupper plugs, and also as a consequence of the heavy rain, some HFO had overflowed the edge of the portside deck plating, contaminating the shell plating and surrounding waters. A professional completed the cleaning operation of the vessel’s hull and the port.

At the time of the overflow, the fourth engineer was at-tending the bunkering operation alone although the decision

of the chief engineer to only bunker 891mt of HSFO in tank 1 and 2 to a total 93% to 94% of their capacity must have war-ranted extra precautions to be taken.

The fourth engineer had no VHF available and could not communicate with the barge’s crew although the pre-bunker-ing check list confirmed that “ship shore / barge communica-tion channels established”.

The fourth engineer was in charge of both sounding of the FO tanks (on deck) and handling the tanks’ valves (in the engine room) when the latter is the second engineer’s respon-sibility as per the bunkering plan.

It was discovered that the engineers had serious difficulties communicating with each other because the second engineer did not speak English.

From interviewing the chief engineer, it appeared he was convinced that the overflow occurred from tank 2, although all evidence pointed to the fact that the overflow occurred from tank 1. Therefore there was a lack of communication between the engineers.

There were serious ISM breaches by the vessel where the most serious were:

` Not sending the correct notification to the authorities about the incident according to IMO resolution 851(20).

` Disregarding bunkering and safety procedures as per SMS.

` The crew not being familiar with vessel and bunker procedures.

` Lack of 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 officers are to be provided.

` The company sent out a technical circular to all vessels requesting that they follow the correct bunkering procedures in the SMS.

` Bunker drills should be carried out by new crew members and training for new crew is also emphasized.

` The company should review its bunker procedures and ensure the deficiencies found by the PSC inspectors have been rectified.

` The company should carry out an audit of the crewing agent.

` The company should have more specific 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 followed.

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

` The company should consider having specific training about the importance of risk assessments and SMS procedures onboard all vessels.

` The company should increase the scope and number of internal audits and visits to company vessels to verify that the SMS is followed and that crews have adequate knowledge. There were numerous SMS procedures breached in this case.

` Introduce MRM, as there is lack of proper communication onboard the vessel.

WHAT? Oil spill during bunkering

The fourth engineer was overseeing the bunker operation by himself and thought there was a risk of the tank overflowing. He panicked and decided to open the valve to the first tank, which was almost full.

WHY?

The chief engineer and second engi-neer had left for dinner and the fourth engineer had no means of communi-cating with the barge, bridge or other engineers. As he could not contact the barge, or anyone on the vessel itself, the first tank finally overflowed.

WHY?

The company’s bunkering procedures were ignored by the chief engineer. No risk assessment was carried out; no record of any toolbox meeting exists, which is a requirement. The bunkering checklist was filled out but ignored.

WHY?

Serious lack of communication, fa-miliarisation and inefficient shipboard management by the chief engineer.

WHY?

WHY?

The company has not been able to establish an acceptable onboard safety culture and SMS procedures are not thorough enough.

CONSEQUENCES ` Vessel was detained because of serious failure of

the ISM code. ` Substantial costs for cleaning the vessel’s hull

and surrounding water. ` Loss of time and employment of vessel due to

the incident. ` An additional audit was carried out by the

classification society to verify that the non- conformities had been rectified.



InjuryIt was morning; the weather was good with a northerly wind force of 3-4 Beaufort. The vessel was proceeding at 14 knots. The chief engineer, first engineer and third engi-neer were scheduled to carry out routine maintenance on one of the ballast pumps.

They dismantled the pump and removed the shaft and impeller, while the nuts on the pump case had also been removed. This had been prepared in advance. The shaft had been secured in a threaded hole with a chain to an eyebolt. The engineers used a five-tone SWL chain block, which was secured in a monorail, and the shaft was raised so the engineers could work on it more easily. The shaft was to be moved so another chain block could be attached.

While waiting for the chain block the engineers started to inspect the shaft and rotated it a couple of times. Sud-denly the shaft dropped from the eyebolt and the third engineer’s hand was severed. The first engineer was also seriously injured but his hand was fortunately 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 of the accident the injured crewmembers were wearing safety shoes, gloves, boiler suits and helmets, but this obviously didn’t protect them.

It could not be completely established why the eyebolt was unscrewed. The lifting appliances were certified and ap-proved for the lifted weight and it was not damaged.

WHAT? Engineers severely injured during maintenance work

Shaft was unscrewed and droppedWHY?

It was not correctly secured WHY?

Not paying enough attention and lack of experience WHY?

Lack of proper preparation and proce-dures. No work permit issued and no risk assessment performed.

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 chief engineer did not require a work permit. This would indicate that there was a lack of safety culture onboard the vessel.

CONSEQUENCESThe engineers stated that they had secured the bolt tightly. The immediate cause of the accident according to the company’s 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 shaft. Be-cause of the accident’s 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 for this kind of job.

` There is now a requirement to follow a checklist before using any lifting gear.

` The company has also produced a poster regarding correct lifting procedures, which has been distributed throughout the fleet.

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

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

` The company should improve the procedures regarding work permits.

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

` The company needs to ensure that crew members follow correct safety standards and procedures during internal audits.



The crew member had been smoking for around 40 years. He had a valid health certificate. While he was working onboard he suffered a heart attack and was rushed to hospital. In the days prior to this he had apparently experi-enced shortness of breath and a rapid heart rate.

At the hospital he was found to have respiratory failure and required mechanical ventilation, he had little if 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 flow of air from the lungs. The most common cause is from smoking.

The crew member was admitted to the hospital for a cou-ple of weeks and his condition was very serious. He was finally allowed to leave hospital and fly home to his native country to rest and receive further treatment. A couple of weeks later he was found dead at home.

It does not seem that a normal health certificate will be sufficient to determine a crew member’s health. If doctors do not treat health certificates seriously, it could lead to severe consequences as in this case. This does not relieve the com-pany from ensuring that their crew members are fit for duty.

WHAT? Crew member died from the effects of heavy smoking

The crew member most probably did not realize his critical conditionWHY?

He had been issued a health certificate while suffering from COPDWHY?

Failure to assess his own state of health and the poor quality of the health examination at the initial health check. The crew member did not raise any concern about his own well-being but the company did suspect him of being in poor physical condition.

WHY?

He was sent for a more thorough medi-cal examination, which stated that he was once again fit for duty. The second medical examination did not either discover the poor lung capacity.

WHY?

WHY?

This indicates that the examination was not properly done as COPD takes many years to develop and should have been discovered if his lung capacity had been tested.

CONSEQUENCESThe death of the crew member is very tragic. The sicknesses of the crew member also created a lot of issues and stress onboard the vessel.

Preventing recurrence ` The company has now introduced stricter procedures regarding the wellbeing of their employees and if there are any

suspicions of a person being unwell they are sent for a medical examination.

` The company now also demands a copy of the medical report.

` The company should consider introducing an enhanced Pre Engagement Medical Examination (PEME), which is a more thorough examination than a normal health certificate.

Illness



Cargo The vessel was carrying paper rolls on a voyage from Canada to Europe during winter in the North Atlantic. Dur-ing the loading operation the stevedores left a lot of void space between the stacks. Cargo of different heights and width had also been stowed in the same stacks.

The chief officer voiced his concern to the stevedores about the poor loading. The stevedores threatened to stop working and involve the union. This could potentially delay the vessel so the chief officer decided not to request the stevedores to reload the vessel. It has not been established why the chief officer did not realize that there was a substantial risk that the cargo would shift if it was not properly loaded and secured.

The vessel departed on a SW course at a speed of about 13 knots, visibility was limited. At the beginning of the journey the vessel was protected by islands but when entering the North Atlantic the vessel encountered even more adverse weather with force 9-10 ENE winds which later fell to force 6-8 ESE with rough seas of around 6m. During this time the vessel heeled heavily 12-15 times in excess of 30°, causing the paper rolls to shift due to not being properly stowed. The crew tried to secure the cargo by inflating and placing extra air cushions and rubber bags between the cargo rolls that had shifted, but without much success. One AB was ordered to stay in the cargo hold and monitor the situation.

By taking at least some minimum proactive measures the crew could have tried to secure the cargo with air cushions and rubber bags. The anti-heeling system could have been started earlier and the GM lowered.

It is likely that there would have been less damage if the vessel had applied varying courses and reduced speed to avoid the major heeling as soon as they encountered severe weather.

Anti-heeling tanks were finally started by the chief officer, side tanks filled and double bottom tanks emptied to lower the GM but it was too late. The vessel eventually altered course to avoid most of the adverse weather.

WHAT? Damage to cargo in severe weather

The stevedores had not secured the cargo correctly and had not followed correct procedures

WHY?

The crew did not request the stevedores to load the cargo correctlyWHY?

Stevedores had threatened that they would stop loading if the crew interferedWHY?

The crew was not firm enough with the stevedores and was unfamiliar with how to deal with the situation and let the stevedores continue loading.

WHY?

WHY?

No clear guidelines from the office on how to deal with stevedores. The ves-sel did not carry out enough preven-tive matters before proceeding into adverse weather.

CONSEQUENCESThe cargo shift caused extensive damage to over 2000 rolls, which resulted in a serious claim.

Preventing recurrence ` All officers working on this type of vessel have now received training about the anti-heeling system.

` The company sent a memo to affected vessels where they stressed the crew’s obligation to monitor the cargo operation and to be firm with stevedores and stop loading if the stevedores did not comply.

` The company needs to review their cargo handling procedures, because it is unacceptable to leave port with cargo not properly loaded and secured.

` The company should review their procedures dealing with severe weather.

` The vessel should consider introducing weather routing because the vessel knew it was entering adverse weather as per weather forecast.

www.swedishclub.com


Loss Prevention

Anders HultmanLoss Prevention, Project Co-ordinator

Telephone: +46 31 638 426E-mail: [email protected]

Joakim EnströmLoss Prevention Officer


The Loss Prevention unit is placed within Risk & Operations department and provides active loss prevention support, analysis, reports as well as advice to members.

Lars A. MalmDirector, Risk & Operations


www.swedishclub.com

Head Office GothenburgVisiting address: Gullbergs Strandgata 6, 411 04 GothenburgPostal address: P.O. Box 171, SE-401 22 Gothenburg, SwedenTel: +46 31 638 400, Fax: +46 31 156 711E-mail: [email protected]

Emergency: +46 31 151 328

Piraeus5th Floor, 87 Akti Miaouli, GR-185 38 Piraeus, GreeceTel: +30 211 120 8400, Fax: +30 210 452 5957E-mail: [email protected]

Emergency: +30 6944 530 856

Hong KongSuite 6306, Central Plaza, 18 Harbour Road, Wanchai, Hong KongTel: +852 2598 6238, Fax: +852 2845 9203E-mail: [email protected]

Emergency: +852 2598 6464

TokyoRoom 103, 6-1, 1 Chome, Kaigan, Minato-Ku Tokyo 105-0022, JapanTel: +81 3 6459 0870, Fax: +81 3 6459 0871E-mail: [email protected]

Emergency: +81 3 6459 0870

OsloTjuvholmen Allé 3, House of Business, 6th Floor, N-0252 OsloTel: +47 9828 0514E-mail: [email protected]

Emergency: +46 31 151 328

Contact

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Claims at a glance 2012 - The Swedish Club