Safer Seas

Systematic Accident Prevention

Koji Fukuoka

• Publisher: CRC Press
• Year: 2019
• Print ISBN: 9780367779504
• eBook ISBN: 9780429754449
• Edition: 1
• Topic: Biological Sciences
• Subtopic: Biology
• Index: Biological Sciences

Marine accidents can occur at any time and everywhere in the world, resulting in loss of life, property, environment and reputation of the companies involved. Preventing accidents and establishing a safer world without accidents is an important agenda for the maritime industry. Since the enforcement of the International Safety Management Code in 1998, companies have taken various kinds of measures to prevent accidents. Unfortunately, measures have been undertaken in a disorganized manner, and have not been effective. Experts of risk management, the safety management system, and accident models have each undertaken accident preventive measures within the scope of their specific fields, but have not looked beyond the realm of their own fields.

This book discusses systematic accident prevention by integrating multi-disciplinary expertise based on academic research, the quality management system which has already proved its effectiveness in other fields, and findings of the author's research. In systematic accident prevention, the weaknesses of a system within which accidents and incidents have occurred are viewed by combining scientific accident investigation data based on the International Maritime Organization model and the accident model. The nature of every type of marine accident, such as collisions, groundings, occupational casualties, etc., are derived by combining the accident model and statistical data. System weaknesses are rectified by the risk reduction method of risk management, and the rectified performance is incorporated in improvement in the system by the PDCA cycle, which is the core of the Safety Management System. We can see the weakness in the system and reduce the number of accidents and incidents while utilizing limited resources optimally to prevent accidents and incidents.

Chapter 1

History of Marine Accidents, Accident Investigation and Prevention

1.1 Prior to the loss of the TITANIC

During and after the industrial revolution in the United Kingdom in the 18th century, raw materials and manufactured goods were transported throughout the world mainly by ships. Seafarers had only the use of rudimentary navigational devices and charts. The accuracy of a ship’s position mostly depended on circumstances such as weather, the waters being navigated, and the skills of navigators. There were no radars, gyro compass, global positioning systems (GPS), accurate navigational charts, significant navigational aids, predictable weather news, and seaworthy ships. Then there were no guarantees of a ship’s safe return, but land-based society ignored the tragedies that happened out at sea. Maritime accidents increased according to the square of the increase in traffic by the middle of the 19th century in the UK. For instance, merchant navy was losing more than 2,000 ships a year. There were between 30,000 and 33,000 known wrecks around the coast of the UK.

In 1870, Samuel Plimsoll found that most shipwrecks were caused by overloading, and launched a parliamentary campaign on behalf of the British Merchant Seamen. He criticized shipowners’ lack of concern for the safety of seafarers and the fact that they always stood to gain, irrespective of the outcome of the maritime adventure, and that what really mattered for them was the carriage of goods, and at worst, the collection of insurance money if their ships were lost.

Plimsoll’s efforts materialized in the constitution of Merchant Shipping Act. The act granted strong power of inspection to the Board of Trade and introduced the Plimsoll line, which was intended to decrease accidents caused by overloading. But it wasn’t until 1890 that the current Plimsoll line was established.

1.2 The TITANIC

In 1912, the loss of the TITANIC, regarded as an unsinkable ship, was significant both in scale of an accident and investigations that followed and were recorded and issued officially, both in the UK and in the United States.

The TITANIC sailed from Southampton, England, on her maiden voyage to New York at noon on 10 April 1912. She stopped at Cherbourg in France and Queenstown in Ireland, picking up additional passengers and mail, steaming west with 2,208 passengers and crew onboard. On 14 April, when she was proceeding about 700 miles east of Halifax, Nova Scotia in the North Atlantic at approximately 21.5 knots, one of the lookouts stationed at the crow’s nest noticed an object in the distance, and then rang the warning bell, warning the bridge. However, it was too late for navigators to avoid a collision with the iceberg. Crew began preparing for evacuation, uncovering lifeboats. The capacity of lifeboats was little more than half of those onboard. Two hours and 40 minutes after the collision, the TITANIC broke into two and sank, taking more than 1,500 lives at 02:20 on 15 April.

According to the TITANIC Inquiry Project 2017, after the accident, two separate extensive investigations called inquiries were conducted in first the USA and then the UK.

The United State Senate inquiry was authorized and directed by the Committee on Commerce to summon witnesses to take testimony. The hearings were opened at the Waldorf-Astoria Hotel in New York city on 20 April 1912. Over the course of 18 days of inquiry, the testimonies of 86 witnesses were recorded, the inquiry transcript was over 1,000 pages long.

Since most of passengers and crew that survived were transported to the USA, the inquiry by British Wreck Commissioner on behalf of the British Board of Trade was conducted on 2 May 1912. The hearings were opened in the Wreck Commissioner’s Court at the London Scottish Drill Hall on Buckingham Gate, and Caxton Hall on Westminster. The hearings closed on 3 July 1912.

1.3 SOLAS Convention

As a result of the sinking of the TITANIC, some 13 countries signed the first Safety of Life at Sea Convention (SOLAS Convention) in 1914 in order to regulate equipment and procedures intended to make seafarers safer. The regulations on SOLAS Convention included watertight bulkhead, fire-resistant bulkhead, lifesaving appliances, fire prevention, firefighting appliances, radio telegraphy, and the North Atlantic Ice Patrol. It did not include regulation of a marine accident investigation.

It wasn’t until Inter-Governmental Maritime Consultative Organization (IMCO), which was established in 1948, adopted the SOLAS Convention 1948 that flag states were required to conduct investigations into incidents involving ships under their flags if the investigation might show regulatory issues as a contributory factor. The convention did not regulate the unified investigation methods and relevant regulations which harmonize the regulations that coastal states or flag states instituted. Therefore, each state conducted investigations under their own regulatory regime.

1.4 Accidents and international efforts

In the 1960s and 1970s, more and more maritime companies adopted flagging out, having their ships owned by other countries or Flag of Convenience (FOC), which became capable of the existence of open registry starting from 1948 by Liberian registry. As the number of FOC ships increased, the number of accidents within the sovereign water of a coastal state involving FOC ships was also increasing.

The TORREY CANYON, the Liberia flagged oil tanker, ran aground on Pollard rock on the Seven Stones reef, near Land’s End, Cornwall, England due to mainly human error on 18 March 1967. The vessel was one of the first generation of supertankers. Thousands of tons of oil were soon spilling along the shores of the south coast of England and the Normandy coast of France from the ruptured tanks. During the next 12 days the entire cargo of approximately 119,000 tons of Kuwait crude oil was lost.

The AMOCO CADIZ, the Liberia flagged oil tanker, ran aground on Portsall rocks, three miles off the coast of Brittany, France, due to failure of the steering mechanism on 16 March 1978. The vessel had been en route from the Arabian gulf to Le Havre, France, when it encountered stormy weather which contributed to grounding. The resulting spill of 223,000 tons of crude oil polluted some 360 km of Brittany coastline.

In the wake of these marine accidents, the maritime industry acknowledged that loss of life at sea and marine pollution were unacceptable and had to be prevented, and that the gateway to the prevention of a marine casualty was an adequate investigation. International efforts lead by the IMCO were made in the form of resolutions in 1970s: The conduct of investigations into casualties, Exchange of information for investigations into marine casualties, and Personal and material resource needs of administrations for the investigation of casualties and contravention of conventions. During these periods, most coastal states investigated marine casualties under the framework of the United Nations Convention on the Law of the Sea (UNCLOS).

1.5 The HERALD OF FREE ENTERPRISE and EXXON VALDEZ disaster

The HERALD OF FREE ENTERPRISE, UK flagged roll on/roll off passenger and freight ferry, capsized about four minutes after sailing from Zeebrugge, Belgium, to Dover, England at 18:05 on 6 March 1987, manned by 80 crewmembers, laden with 131 vehicles, and 459 passengers in the good weather. Due to shallow water, the vessel came to rest with its starboard side above the surface. Water rapidly filled the vessel below the surface level. Not less than 150 passengers and 38 crewmembers lost their lives, and many others were injured. The position in which the vessel came to rest was less than seven cables from the harbor entrance. The extensive accident investigation found hardware issues, human errors and organizational issues (DOT 1987).

In this case, just like the TITANIC accident investigation, public enquiries were set up because a governmental organization specializing in marine accidents investigation had not been created in the UK. The board of enquiry which lead the public enquires put liability first and safety second, not leading to greater safety. In the aftermath of the capsize of the HERALD OF FREE ENTERPRISE, a new maritime accident investigation authority, Marine Accident Investigation Branch (MAIB), was established in 1989.

Similar to the UK, there was an increasing number of marine accident investigation organizations in the world: The USA, Canada, Australia, Sweden, France, etc.

The EXXON VALDEZ, the U.S. flagged oil tanker, ran aground on Bligh reef, Prince William Sound, Alaska in the U.S. at 00:09 on 24 March 1989. The resulting spill of an estimated 42 million liters of crude oil covered more than 26,000 km² of water in Prince William Sound and the Gulf of Alaska, and polluted more than 1,900 km of coastline. The accident extensive investigation conducted by the National Transportation Safety Board (NTSB) revealed, among other contributing fact...

Table of contents

• Cover
• Title Page
• Copyright Page
• Preface
• Acknowledgements
• Table of Contents
• 1. History of Marine Accidents, Accident Investigation and Prevention
• 2. Mechanism of Accident Occurrence
• 3. Accident Model
• 4. Contributing Factors of Accident Occurrence
• 5. Preparation for Accident Investigation
• 6. On-site Investigation
• 7. Analysis Methods
• 8. Visualization of Weakness in the System
• 9. Statistical Science and Characteristics of Each Types of Accidents
• 10. Convergence of Accident Models
• 11. Rectification of the Weakness and Improvement of the System
• References
• Index
• Color Figures Section