Vessel's accident analysis with an overall approach

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1 Axe Cindynique Année Vessel's accident analysis with an overall approach Tuteur : Mr Guillaume CHANTELAUVE BRONDEL Anne Lise JACQUET Cyril PARTOUCHE Lauren 1

2 SUMMARY A. Presentation of the methods 1. Cindynique concept according to G.Y. KERVERN 2. Particle of experience B. Grounding of the Raven Arrow 1. History of the voyage 2. Causes 3. Cindynic approaches C. The impact with the quay by the P&OSL Aquitaine 1. The facts 2. Causes 3. Consequences 4. Cindynic approaches D. Collision between the Swedish vessel MT Tärnsjö and the Russian vessel MV Amur History of the voyage 2. Causes 3. Cindynic approaches E. and discussion 1. Cindynic approach by KERVERN 2. WYBO's particle of experience

3 A. Presentation of the methods 1. Cindynic concept according to G.Y. KERVERN Born in the mid-eighties, the sciences of hazards turned out to be a constructivist discipline, underlain by ethical, epistemological, axiological and deontological stakes. They are based on the systemic paradigm that presents a system of reference within which the different aspects of risk management are organized. G.Y. KERVERN describes acurately how to make a cindynic model of a system. He admits that hazard is diffuse in a complex system which involves lot of actors or and actors nets. KERVERN defines a hazardous situation by a systemic approach and he makes the description of a "situation which carries a hasard". The cindynic situation takes the form of a "hyperspace of hazard" in five dimensions in order to be as close as possible to the disparities or lacks perceived between the representations made by the members in a specific system. Thus a Cindynic situation is defined using the five following dimensions: - Data and facts - Representations and models - Objectives - Laws, norms, rules, codes - Values "Hyperspace of hazard" is a spatial representation which show us those five dimensions of the system where humans move about. Cindynometric plan Models Rules, laws Objectives Ethical plan Data Values A cindynic situation is a picture of a complex system, it gives us features of the system in a fixed instant. 3

4 The manufacture of a hazard is due to several process that cindynic analysis can distinguish in two categories : - Systemic Cindynogenic Deficits (SCD) which define lacks in an actor or a actors nets. - Disparities which are due to the disagreement between actors nets Systemic Cindynogenic Deficits With the "hyperspace of hazard" designed by G.Y. KERVERN, we can spot the lacks in the cindynic representation of complex systems. These lacks are often found in accidents or crisis and are the theoritical deficits called Systemic Cindynogenic Deficits (SCD). These deficits make hazards nevertheless the five dimensions of the hyperspace must exist. We are able to distinguish five kinds of SCD : - Lack of hyperspace : SCD 1 : lack of values SCD 2 : lack of rules SCD 3 : lack of models SCD 4 : lack of data SCD 5 : lack of objectives - Lack in a hyperspace : SCD 6 : absence of values SCD 7 : absence of rules SCD 8 : absence of models SCD 9 : absence of data SCD 10 : absence of objectives - Disjunction between dimensions : SCD 11 : disjunction values / objectives SCD 12 : disjunction values / rules SCD 13 : disjunction objectives / rules SCD 14 : disjunction models / data SCD 15 : disjunction cognitive / ethic SCD 16 : disjunction objectives / models SCD 17 : disjunction objectives / data SCD 18 : disjunction personal axis / relational axis - Degeneration (absence of hierarchy in a dimension) : SCD 19 : absence of values hierarchy SCD 20 : absence of rules hierarchy SCD 21 : absence of models hierarchy SCD 22 : absence of data hierarchy SCD 23 : absence of objectives hierarchy - Locking : 4

5 SCD 24 : cindynometric locking SCD 25 : ethical locking SCD 26 : locking of mechanism about objectives Correspondences between empirical causes of accident and DSC exist. Empirical deficits Theoritical deficits Conviction of absence of peril SCD 25 Adversion of complexity SCD 18 Non communication attitude SCD 25 No attention to the outside world SCD 18 Production dominates risk management SCD 23 Dilution of accountability SCD 26 No post accident informations storage and processing SCD 24 No risk management methodology SCD 7 / 24 No training for risk management SCD 24 No preparation for crisis management SCD 24 One idea grabs the spotlight. Empirical deficits refer to human factor. SCD which correspond to these deficits have a link with "ethical plan". G.Y. KERVERN highlights the "ethical plan" mechanism by two axis. Personal axis Relational axis - Criticize or study his thought is possible for an actor or an actors nets with the personal axis. - Relational axis creates relationships between actors Disparities 5

6 Disparities are the effects of the relations between actors or actors nets. Disparities are gaps ( ) in the five dimensions of the "hyperspace of hazard". Models Rules, laws Objectives Data Values 2. Particle of experience 2.1. Preliminary remarks The methodology that is presented hereunder does not claim to being universal, providing the answers to all questions on capitalization and sharing of experience. It must be seen as an example of an operational process for events that are significant or useful for training purposes. In the organizations in which it was implemented, it was suggested that it should be applied with a frequency of 3 to 4 analysis per year for each actor, this being a compromise between the time available and the fundation of a culture of experience sharing. This methodology positions itself as a complement to more systematic approaches of collecting information on incidents such as incidents reports or databases Formalization of experience When we want to memorize the management experience of accidents or crises, the first method generally applied consists of formalizing each accident as an elementary item. This approach is chosen for the design of most accidents databases because it is efficient when used for statistics and epidemiology of accidents. On the other hand, it has the drawbacks of losing two types of key information: the way in which an accident unfolds, and the justification of decisions which are taken. 6

7 When we ask someone to talk about the management of a situation, the person normally retraces the unfolding of events, recalling a series of key moments, therefore making reference to his or her episodic memory. This type of memorization only highlights events and actions that played an important role for him in the managing of a situation. Taking into account that any formalism should be based on familiar concepts or procedures in order to be accepted, we have chosen the narration of each actor and its episodic representation as our starting point. Our hypothesis is that these events, gathered with their associated decision cycles, form the basis of the actor s experience, which they refer to in the managing of new accidents. A study that was carried out on the mental actors representation during forest fires operations made it possible to identify a general representation of the unfolding of the management of an incident based on key events. A more detailed analysis showed that each significant event is linked with a decision cycle. In order to represent the evolution of the situation between two key events, we have defined this decision cycle in four phases: perception of the context, analysis, action and effects. This decision cycle represents the smallest element of experience because it still holds on its properties, allowing the characterization of an incident s management s dynamics. This leads to name it particle of experience plutot experience s particle, by analogy to the particle (atom) of material, which is the smallest part that keeps the properties of the element (particle of iron, oxygen, etc.). The four phases of an experience s particle are : - The perception phase that corresponds to the collecting of data and the observation of events that influence the evolution of the situation. - The analysis phase that corresponds to the evaluation by the person of the consequences of the new situation and of the possible actions to lead. - The action phase that describes the decisions details which have been selected and the executed actions. - The effect phase that corresponds to the description of the tangible effects of actions undertaken. Percepation of the context Hyperspace of hazard Situation i Action Particle of experience Effect Hyperspace of hazard Situation i+1 7

8 B.Grounding of the Raven Arrow 1. History of the voyage Map of Johnstone strait At 13h00 on the 23 th of September 1997, Pacific daylight saving time the partly loaded "RAVEN ARROW" departed from Vancouver, bound for Kitimatwith two coast pilots on board. The pilots alternate their shifts while on board. Pilot N 1 had the conduct of the vessel upon departure at 13h00 until 18h00, and pilot N 2 from 18h00 to 23h00. The voyage until Johnstone Strait was uneventful, but the pilot was occupied with concentrations of the fishing vessels encountered. The pilot exchange took place at 23h00, with the vessel off Knox Bay in Johnstone Strait. After the change in watches at midnight, on September the 24th, personnel on the bridge included the second officer, who was the officer of the watch, pilot N 1, who had the conduct of the vessel, and the quartermaster, who was at the helm, engaged in steering. At 00h02 the pilot reported to Marine Communications and Traffic Services (MCTS) Vancouver that the vessel was around Fanny Island and her estimated time of arrival at Boat Bay Light was 01h35. MCTS advised the vessel of the upcoming traffic. In the vicinity of Stimpson Reef the visibility was good as the vessel encountered traffic, including a few fishing vessels. On passing Broken Island, at the eastern end of West Cracroft Island, the vessel's course was altered. At 01h00, Broken Island Light is plotted and around this time the vessel began to experience a slight haze. Targets were picked up on the vessel's radar. Approaching Forward Bay, the vessel entered fog. By 01h20-01h25 the 8

9 visibility had decreased to about 150 m and the master was not informed about that. No dedicated look-out was posted. Between 01h00 and 01h30 the vessel encountered traffic (for which port-to-port passing arrangements were made) which altered course. At 01h13 a report was made to MCTS that the vessel was off Boat Bay Light and that her estimated time of arrival at Lizard Point was 02h40. At 01h15, the last position, as plotted on the chart by the officer of watch. At approximately 01h30 the pilot saw on the radar what he believed to be the entrance to Blackney Passage and began a course alteration to starboard. He did neither verify the vessel's position prior to the course alteration nor did he request the officer of watch to plot the vessel's position. Shortly after reaching the new heading, the pilot realized that the vessel was not at the alter-course position and ordered hard-a-starboard helm, in the hopes of bringing her around, but this was unsuccessful and the vessel grounded. Sketch of the grounding area 2. Causes The "RAVEN ARROW" grounded in fog when the pilot lost situational awareness and prematurely altered course to enter Blackney Passage after having elected to conduct the navigation of the vessel without assistance from the ship's complement. Contributing factors to the occurrence were the following ones : the pilot was probably tired; sound navigational principles were not implemented by the bridge team; the exchange of information between the pilot and the officer of watch was minimal and unprecise; and the officer of watch did not effectively monitor the pilot's communication with Marine Communications and Traffic Services. 9

10 3. Cindynic approaches 3.1. Cindynic model by G.Y. KERVERN Definition of the "hyperspace of hazard" The cindynic situation (which carries out a hazard) of the "Raven Arrow" can be visualized with five dimentions which are the five fundamental aspects defining a hazardous situation. We have to make sure that those dimensions exist for each actor on board of the "Raven Arrow". Indeed, it is from this representation that we are going to study failures and insufficiencies of our system which are called Systemic Cindynogenic Deficits (SCD). Furthermore, it will be possible to determine conflicts between the cindynic situation of each actor that are the disparities of the system. The tab on the next page show us the five dimensions (data & facts, representations & models, values, rules & laws and objectives) for each actor Systemic Cindynogenic Deficits (SCD) With the "hyperspace of hazard" designed by G.Y. KERVERN, we can spot the lacks in the cindynic representation of the "Raven Arrow". Those lacks are often found in accidents or crisis. The "Raven Arrow" grounded in fog because the pilot had not the information about its position, since he chose to conduct the navigation of the vessel without assistance. Consequently, the main reason of the grounding is a human failure. According to G.Y. KERVERN, those lacks have a link with the functionment of the "ethical plane" wich plays an important role in the human factor. We are going to study the locking of ethical mechanism (SCD 25), and the dislocations between the relational axis and the personal axis (SCD 18). In other words, we are going to study the "empirical SCD s" of the system. - Personal axis presents an insufficiency because the pilot refuse either to criticize himself or to study his thought (SCD 25). Indeed, he elected to conduct the navigation of the vessel without assistance from the officer of the watch or from the other pilot. So, the pilot's unique reliance on the course book, resulted in confusion as to which leg the vessel was on. Unless, the officer of watch plotted the vessel's position at frequent intervals, but the pilot didn't utilize this information. The pilot of the "Raven Arrow" had not reviewed his intellectual and physical performances. He did not appreciate the negative effects that irregular work schedule and lack of sleep can have on performance. 10

11 Actors Data Models Values Rules Objectives Pilot -He has the local navigational knowledge -Logbook -Course book -Radar -Course recorder -Depth sounder -Compass -Code of Nautical Procedures and Practices -Rules of Road To have the conduct of the vessel Officer of watch -Positions plotted on the chart -He is a new officer on board -Chart -GPS system -Code of Nautical Procedures and Practices -Rules of Road To monitor the vessel'sposition and communicate with MCTS MCTS -Communication with vessels -No radar coverage To manage traffic in Johnstone Strait in order to assure a safe navigation Crew The ship's crew has a great understanding of the ship's handling characteristics -Bridge Procedures Guide -Specfic objectives -To take part in pilot's decision and navigation 11

12 - Relational axis has also insufficiencies because the different actors refused to communicate and to put their heads together in order to take decisions (SCD 25). On account of a bad communication between the pilot and the officer of watch, their mental models about the location of the "Raven Arrow" were different. Furthermore, this lack of communucation made the officer of watch less likely to participate in the navigation of the vessel. - The fact that actors did not communicate, dislocates personal axis and relational axis (SCD 18). Indeed, the officer of watch was not aware of the complexity and stakes of his relationships with vessel s pilot. He did not understand the importance of monitoring, in an efficient manner, the pilot's communications with MCTS. Consequently, the officer of watch was not alerted when the pilot erroneously reported the vessel's position to MCTS some 20 minutes prior to the grounding. - Another dislocation into the "ethical plane" (SCD 18) can be picked up in the grounding of the "Raven Arrow". The pilot did not work with the crew and did not pay any attention to the outside world. The pilot s culture leads some pilots to think that the ship's complements will provide only minimal support to the navigation of the vessel. The pilot had received bridge s ressource s management training but he did not put it in practice. Besides, the ship's personnel did not agree upon the ship's passage plan. They could not monitor the vessel's progress. We can see others Systemic Cindynogenic Deficits with the grounding of the "Raven Arrow". Partidularly about the lacks in the five dimensions. - Omission of several rules (SCD 7) : A regime in order to monitor the application by the pilot of the bridge ressource management has not been put in place. There is not a regime to monitor pilot fatigue. - Omission of model (SCD 8) : There is not a ship's passage plan on which everybody agreed on board of the "Raven Arrow". This plan is necessary for the crew to monitor the vessel's progress. - Absence of rules hierarchy (SCD 20) : The pilot did not take his time-off to sleep but to make other tasks. For him, sleeping was not very important. The officer of watch did not fully appreciate the need to communicate with the pilot. For him, his work was to plot the position of the vessel on the chart. - Absence of priority hierarchy during the grounding (SCD 23) : When the pilot was aware of his mistake, he was acting quickly without knowing why the vessel was not on the right place. 12

13 - Absence of models hierarchy (SCD 21) : The pilot prefered following his course book without using the radar Disparities According to G.Y. KERVERN, disparities are the effects of the relationships between the actors of the system. Disparities can be about data, models, objectives, rules and values. In the grounding of the "Raven Arrow", two disparities are obviously. One is about the relationship between the pilot and MCTS. The other is about the relationship between the pilot and his officer of watch. - Disparities about data : The vessel grounded because the pilot did not know where the "Raven Arrow" was located. On account of the lack of communication between the pilot and his officer of watch, their mental models (which can be consider like data) of the location were different. Furthermore, MCTS did not get the right location of the "Raven Arrow" because, without radar, they had to monitor traffic by using the broadcast messages. Data which were given by the pilot were false and nobody, except the officer of watch, could discover the mistake. - Disparities about objectives : Common objective between the pilot and his officer of watch would have been to conduct the vessel in Jonhstone strait with a narrow relationship. Altough they had different tasks, they aimed to go safe throught Blackney Passage. Unfortunately, the pilot was very busy with encountering traffic and the officer of watch did not realize the importance in listening to the talk with MCTS. According to him, he just had to plot the location of the vessel on the chart. 13

14 3.2. The particle of experience by J.L. WYBO J.L. WYBO has developed a methodology for the representation and sharing of experience. This methodology can retrace the unfolding of events and the justification of the decisions taken. In case of the grounding of the "Raven Arrow", it is possible to cut the decision cycle in the smallest elements of experience which are called "particle of experience". We are going to study, for each particle of experience, the four stages of the decision : perception of the situation, analysis, action and effect. Real cycle Conduct of the vessel in Johnstone strait Johnstone strait is crowded. "Raven Arrow" meets lots of fishing boats and othter vessels. In order to avoid the collision, the vessel have to change her course following the rules of the Code of Nautical Procedures and Practices. The pilot makes port to port passing arrangements. The pilot is very busy and the vessel is no longer located on the planned course. The pilot is tired and forgets the benefits of a team work. 14

15 Real cycle Fog The vessel gets to Forward Bay. The vessel enters fog and the visibility is reduced to about 150 meters. Master has to be informed about the change of the weather. Neither decisions nor actions have been taken. No dedicated look-out is posted. The pilot does not distinguish marks on the coast. Real cycle Watch of the vessel's position The officer of watch has to check the vessel's position in order to anticipate the entrance to Blackney Passage. Consequently, he must warn the pilot about the course alteration he has to carry out. In order to know where the "Raven Arrow" is located, the pilot can check the radar or the course book. Above all, he has to put his head with the officer of watch's who reports the vessel's position every 20 minutes. The pilot chooses to conduct the vessel without assistance. The pilot sees on the radar what he believes to be the entrance to Blackney Passage. 15

16 Real cycle - Vessel in Boat Bay The vessel is going to enter what the pilot believes to be the entrance to Blackney Passage. In order to enter the passage, the pilot has to make a course alteration on starboard. The pilot begins his course alteration on starboard. "Raven Arrow" is not where it should be. Real cycle Grounding of the "Raven Arrow" The vessel does a course alteration on starboard and is located in Boat Bay. The pilot realizes that the vessel is not at the alter-course but his mental model always locates him near Blackney Passage. The pilot order hard-a-starboard helm without analysing the location with the officer of watch. "Raven Arrow" is grounded. 16

17 Hypothetical positive cycle Well communication between actors Conducting of a vessel like the "Raven Arrow" requires a team work between each actor. The pilot and the officer of watch must communicate in order to check the progress of the vessel. They use more than one method of monitoring the vessel's position. Prior to make a decision about course alteration, the pilot and his officer of watch put their heads together to locate the vessel's position. "Raven Arrow" is not located at the entrance to Blackney Passage. The pilot corrects the course in order to approach correctly Blackney Passage. Vessel sails without problems. Hypothetical positive cycle Management of the crisis situation Vessel has entered in Boat Bay by error. The pilot gives an account of the situation and he must avoid the grounding. Prior to make a decision, the pilot and the officer of watch locate the vessel's position. They study the best way to leave the risky situation. The pilot turns on portside and not on starboard. Effect / Consequences Vessel's turning circle can leave the "Raven Arrow" of the situation. 17

18 B. The impact with the quay by the P&OSL Aquitaine 1. The facts P&OSL Aquitaine is a ferry with a capacity of 1850 passengers, which entered service on Dover to Calais route in November P&OSL Aquitaine left Dover at 8h17 on 27 April 2000, bound for Calais. On board were 1241 passengers and 123 crew. It sails almost continuously between Dover and Calais, with a few hours lay over daily. At the time, the sailing schedule of the vessel consisted of three round trips during the day and two at night. The previous passage, Calais to Dover 27 April 2000 During this passage we can observe a succession of breakdowns of the port CPP stand-by pump and of the system s checking by the engineer of the engine room. Many hypotheses are made to explain the breakdowns. First Breakdown: While the P&OSL Aquitaine left Calais bound for Dover at 5h45, in the engine room, the watchkeepers observed that the port CPP stand-by pump had cut in. Checking: The third engineer went down to the gearbox room to check the port CPP system. He notices the pressures delivered by the port CPP system were lower than in the starboard side so he adjusted the valve to increase the pressure to match that of the starboard. After that the engineer met the chief engineer and advised him about the electrical stand-by pump cutting in on departure from Calais, and about the actions led. Second Breakdown: While the vessel arrived at Dover, the port CPP electrical stand-by pump cut in several times. Checking: The chief engineer sent the third engineer to investigate, he reported having found nothing untoward. The decision was taken to inspect the suction filter on the delivery side once the vessel had berthed at Dover. In Dover Checking: The third engineer checked the suction filter. It was clean. In accordance with standard procedure, the chief engineer reported to the master that the engineering plant was ready for the vessel to proceed to sea. The chief engineer had not informed the master of the electrical stand-by pump cutting in on departure from Calais, or on arrival at Dover, or that he was investigating an unsolved problem with the port CPP system. Events in the engine room during the Dover to Calais crossing During the first 8 minutes of manoeuvring from berth, the port CPP stand-by pump cut in on several occasions. The third engineer checked the system pressures and found them normal. 18

19 The chief, second and third engineer decided to do nothing until the plans for the system had been examined in detail. The second engineer found the plans for the CPP system. The plans were in English but the manual for the system was in Flemish. Arrival at Calais, the chief engineer went to the gearbox room to make his own visual inspection of both CPP systems. He found that pressures were normal. The second engineer suggested they should check the system control valves. Because of the delay in order to enter the harbour, the chief engineer thought, although there would be sufficient time to check the valve, there would be insufficient time to carry out any remedial work if found necessary. It was decided that if anything needed to be done to the valve, it would be carried out in Dover, after the next crossing. On the bridge As the chief engineer thought it was only a minor problem, he decided not to report his thoughts about the CPP system neither to the master nor to the bridge team. So they were unaware of problems with the port CPP system. Before the entrance in Calais the master went to the bridge to steer the vessel. About 2 minutes before the impact, the master realized he was moving faster than expected and put both pitch combinator levers to astern. This would normally be more than sufficient to slow the ship significantly. P&OSL Aquitaine then took a sudden sheer to starboard and towards P&OSL Kent, which was loading passengers and cars at No 6 berth; No 8 berth was unoccupied. To avoid collision with P&OSL Kent, the master re-engaged the starboard rudder by setting the starboard CPP to ahead pitch, and setting the bow thrusters to thrust to port. P&OSL Aquitaine was now lined up for No 7 berth but still proceeding too fast. Full astern pitch was set on both combinators, whereupon the vessel took a sheer to starboard. The master attempted to parallel the berth by using the bow thrusters to hold the bow off the quay. The passengers, meanwhile, were preparing to disembark. Although they had not yet been called to return to their vehicles, a few had made their own way down on to the car deck. Many people who used ferries frequently knew that the doors to the car deck would be opened locally, before an announcement is being made. As it was possible for them to open the door, the passengers had ready access to the car decks before they were permitted to do so. Others were still in the public areas standing with their baggage by the access stairways to the car decks, waiting for instructions. Most passengers were standing up ready to disembark; some carrying bags, suitcases and/or cases of beer. About 30 seconds before the impact, the master realized the vessel was not going to stop in time, and the collision with the quay was inevitable. The mooring party was ordered to clear the fo c sle, but no warning announcement was made to passengers. The vessel struck the port (north) pad of No 7 berth. The time of the impact taken from the VTS radar recording was seconds BST. Many people were thrown forward, falling on each other and hitting bulkheads and fixtures. Some passengers were thrown down stairways. Bottles, plates and glasses were smashed. 19

20 2. The causes Unknown to the engine room and bridge teams, control of the port CPP was lost as the vessel was entering Calais. Consequently, on its approach to the berth in Calais, the master was unable to properly control the vessel to enable a safe and normal docking. Contributory Causes 1. Port CPP control was lost because rotary vanes of the main shaft-driven pump were damaged. The pump was unable to produce sufficient pressure in the high pressure side of the CPP system to cause the blade pitch to change in response to movement of the pitch control combinator levers. Consequently, the blades locked into the position achieved, that is 70% ahead pitch. 2. The engineers were unable to detect the fault in the shaft-driven pump of the port CPP system. The reasons for this were: There was no facility for remotely monitoring the CPP system oil pressure, making it impractical to monitor the pressure continuously from the ECR. The lack of an audible alarm facility to indicate low system oil pressure on the high pressure side of the system. There was no obvious and convenient way for the engineers to monitor and compare bridge demand and achieved propeller pitch. The system was not designed to give warning of low CPP pump delivery pressure. 3. The consequences A total of 180 passengers and 29 crew were injured. The injuries ranged from bruising to broken limbs. There were no fatalities No 7 berth was badly damaged, and was out of use for several months. The vessel suffered from damage to her bulbous bow and bow apron. Some vehicles on the car decks were also damaged. 4. Cindynic approaches 3.3. Cindynic model by G.Y. KERVERN Definition of the "hyperspace of hazard" The cindynic situation (which carries a hazard) of the "P&OSL Aquitaine" can be visualized with five dimensions which are the five fundamental aspects defining a hazardous situation. We studied the hyperspace of hazard for six actors. Those hyperspaces correspond to the preaccidental period. 20

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