Incident Analysis

This is not intended to be a comprehensive resource for incident analysis. Some links and resources are provided at IncidentResources.

The aim is to provide a resource for discussing human element aspects of incidents of particular interest, where there may be lessons to be learned as regards regulation, manning, training, equipment design, ship design or operation. Where there are issues that cut across a number of incidents and are of significance for the human element, then it is probably best to use a new WikiWord and create a new page.

The types of incidents identified on this page are:

• Navigation Incidents#NavigationIncidents
• Cargo Management Incidents #CargoIncidents

Navigation Incidents

Swedish Incident Report with poor control ergonomics (contributed by Margareta Lützhöft)

Did this happen in 2005?

A ship in a restricted waters with pilot on board. It was dark and fine adjustments to the course was made with bowthrusters.

On a panel there are three levers, see picture.

• Spakarrangemang.JPG:
  

A steering lever: when moved to starboard, gave starboard rudder and thus turned ship to starboard.

A lever for one bowthruster which had to be moved to port to move arrow indicator and ship to starboard. When the arrow points to starboard – ship moves to starboard. To get arrow to point to starboard, lever must be moved to port.

A lever/joystick for second bowthruster, when moved to starboard, turned ship to starboard.

The pilot mistook the levers in the dark, and the ship ran aground.

There are long-standing sources of ergonomic guidance, such as ISO 1503 Spatial orientation and direction of movement — Ergonomic requirements, Woodson and Conover, MIL STD 1472 that could have helped the designer.

Cepheus J and Ileksa (contributed by Vaughan Pomeroy)

A paragraph from the synopsis:

"On Cepheus J’s bridge, the chief officer had sent the lookout to clean the crew mess room, while he continued completing paperwork, standing at the chart table on the port side of the bridge. From there, he had an unrestricted view ahead, and close by, to his right, the displays of the ECDIS and radar were available. He did not see Ileksa until after the collision."

* Cepheus20J_Ileksa.pdf:

Gerda

Interesting incident supplied by Michelle Grech; lots of ice, some pilotage issues, and an unfavourable usability evaluation of the Kelvin Hughes radar in a particular context of use.

• 1998-Gerda-G6copy.pdf:

Aratere incidents

Supplied by Wayne Perkins. Well worth a read and with points for discussion.

• AratereKent-FinalReport.pdf:

• Aratere-NearGrounding-FinalReport.pdf:

Aratere - Kent Close Quarters.

a) nobody actually watches the bridge team at work; the investigators seem keen to change that. Will require new inspector/auditor skills - could the simulator instructors do it?

b) Very personal remark from BrianSherwoodJones^? about situation awareness; it really doesn't help the analysis here and gets in the way - seems to do that quite often - am not convinced it is a useful intermediate variable.

c) How effective is BRM training likely to be? If you have established 'wrong stuff' leadership - does it work?

d) depending on the automation suits the lazy; taking visual bearings and getting people to do things is more work.

e) all these instructions etc on using available means are great with hindsight but nmuch less clear on what is good enough at the time.

f) 21 incidents with one company!

Aratere near grounding.

a) ECDIS from NORCONTROL not good for parallel indexing. Perhaps the INS CG could compile known hazards; in some contexts such activity would be considered good practice.

b) master distracted by a health and safety manager!

c) alarms again

d) echo sounder off in both incidents; this is so common there has to be something there.

e) no IBS training and not knowing DGPS accuracy despite problems; royal majesty replica there.

f) issues of documentation and information presentation e.g. on Vessel Operating Manuals and their absence. also problems of mode awareness etc. also assumptions by manufacturer in their documentation.

g) some of it comes down to conning display gestalt. How could that be regulated?

h) six previous similar incidents not reported to MSA and crew still depend on automation.

j) broken CD drive too expensive to fix, so no ENC updates. Paper charts not used.

k) couldn't change an IBS passage plan or alter alarm settings

l) no documented risk assessment but I wonder what one would look like.

m) MSA took over ISM audits from DNV.

Can we get a collection of incidents passed around the INS CG to pick up the lessons? sounds a good idea.

The near grounding cites MSC/Circ. 1061 which is attached (it is available on the IMO website).

• 1061.pdf:

Canadian Incident contributed by Paul Drouin

* wheelhouse_layout_Canadian_incident.gif:

1- Bridge Layout; although the vessel is over 20 years old and the bridge layout is not ideal - I had the feeling many new ships were still being build in this fashion. I have since visited some 2005 and 2003 built ships in the port of Montreal and this was (anecdotally) confirmed. Maybe the group can contribute by helping answer these questions: a- given the IMO guidelines on bridge layout (and SOLAS V, reg 15 on navigation safety) , why are vessel bridges still being configured in such a manner? b- what is the incidence of this ''traditional'' layout in newbuildings? c- what are Class societies doing in this respect? d- are any Flag states making the IMO guidelines an imperative?

2- Electronic Chart System; while not a panacea, ECS will dramatically improve ''berth to berth'' passage planning. This will be particularly helpful during the pilotage phase of the journey. Groundings of this nature will continue to happen at regular intervals in pilotage waters if industry does not adjust its modus operendi. In all fairness, it is unreasonable to expect the OOW, unfamiliar with a particular pilotage area, to effectively and in a timely manner monitor the vessel's progress and compare it to a pre-arranged passage plan. Unreasonable, that is, if the OOW continues to rely soley on the standard positioning equipment of most ocean going vessels - the radar.

In order to be an effective team member the OOW must possess, at all times, a situational awareness that is similar to that of the pilot. This requires real-time, continuous monitoring of the vessel's position and comparison to the intended track. This is possible with a radar over a limited area using the parallel indexing technique. However, for an extended area of pilotage (such as Les Escoumins to Montreal, or the Thames up to London), with many tens of course alterations and similar numbers of parallel index reference points, the task is without hope.

One instrument that has the potential to revolutionize passage planning in pilotage waters is the ECS. The vessel under study is not equipped with an ECS, nor was it required to be. However, this equipment, if properly used, could have helped the OOW intervene in time to prevent the vessel from grounding. A recent MAIB report on another grounding cites;

The vessel was not fitted with an electronic chart system, which would give the navigator a virtually continuous and accurate position of the vessel shown on a chart of the appropriate scale. Had one been fitted, and monitored, the probability that the vessel would have run aground would have been reduced.

Without the benefit of local knowledge or other means to continually compare real time vessel position with the intended track, the OOW on the vessel under study could not effectively intervene or otherwise challenge the pilot in time to prevent the grounding. (the pilot had not ordered the intended course alteration).

a- since almost every vessel voyage involves a pilot at arrival and departure points (effectively giving the con of the vessel to a person who is not answerable to the Master and has the ''voyage plan'' in his head), why have not ECSs become standard equipment on vessels?

Incidents associated with cargo management, including hazardous cargos

Coral Acropora

* CoralAcropora.pdf:

This is a complex incident. Nobody got hurt but it is a near miss of great interest.

-- BrianSherwoodJones - 16 Jul 2005

*

IIG Submission to IMO on cargo incidents

This report was triggered by the Cassiron incident, reports an analysis of a number of cargo incidents and is the starting point for the IIG Human Factors group activity.

• IIWGReportonExplosionsJan06.pdf: IIG Submission to IMO on explosions

Cassiron

• RDChassironEnglish.pdf: Cassiron, the incident that triggered the IIG activity

Bow Mariner

• bowmar1.pdf: Bow Mariner, a very serious incident