Claims at a glance. Frequencies & Severity. Read the case analysis at page 11. Check the conclusion at page 9.

Transcription

1 Claims at a glance Frequencies & Severity Read the case analysis at page 11 Check the conclusion at page 9 212

2 Contents 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 7 Passage plan 7 Bridge equipment 7 Procedures 8 Risk assessment 8 Near misses 9 Safety culture 9 Conclusion 9 Executive summary 1 Main areas of concern 1 Remedies 1 Interactive Root Cause Analysis 1 Method used FIVE WHYS 1 The Cherry picking process 1 Interactive Root Cause Analysis IRCA cases 11

3 Executive summary In relation to P&I (Cargo, Illness and Injury) and for H&M navigational claims: Main areas of concern Remedies Lack of proper passage planning There should be a defined safety culture in the organisation Lack of essential bridge equipment knowledge and poor The root causes of accidents need to be identified and navigation policies addressed Serious Maritime Resource Management (MRM) issues Introduce MRM throughout the entire organisation Lack of proper communication MRM procedures should be implemented into the SMS The Safety Management System (SMS) is lacking defined and audited and properly explained procedures SMS procedures need to be easily understood Poorly implemented risk assessments and work permit Introduce risk assessments and work permit procedures procedures Introduce specific navigational audits Opening remarks This year s publication will, as always, provide feedback as to the Club s experiences 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 reported 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 regarding claims and in particular Cargo, Illness and Injury claims. 211 was a year of mixed experience. Q1 and Q2 left us with no surprises and the half-year results were actually 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. 211 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 28/9. 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 manageable Most Clubs/Underwriters would subscribe to the suggestion that there is a correlation between world economy and claims experience. We also accept 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 correlation. If one looks at the more attritional side of P&I claims the correlation 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 29/1. 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 5, is almost as forecasted (1%). On P&I the deviation from the expected (1%) is more pronounced, which is illustrated in Graph No. 2. Graph No 1 Frequency of H&M claims in exess of USD 5, vs. forecast Graph No 2 Frequency of P&I claims in exess of USD 5, vs. forecast /6/29 1/7/29 1/8/29 1/9/29 1/1/29 1/11/29 1/12/29 1/1/21 1/2/21 1/3/21 1/4/21 1/5/21 1/6/21 1/7/21 1/8/21 1/9/21 1/1/21 1/11/21 1/12/21 1/1/211 1/2/211 1/3/211 1/4/211 1/6/29 1/7/29 1/8/29 1/9/29 1/1/29 1/11/29 1/12/29 1/1/21 1/2/21 1/3/21 1/4/21 1/5/21 1/6/21 1/7/21 1/8/21 1/9/21 1/1/21 1/11/21 1/12/21 1/1/211 1/2/211 1/3/211 1/4/211 3

4 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 recovery 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 212. Claims and vessel types for P&I and H&M For P&I and H&M insurances in 211 the average number of claims in excess of USD 5, was.49 claims/vessel/ year. The corresponding figure for 28 was.3 claims/vessel, representing an increase in frequency of 63%. Combining the previous with an increase in the average claim cost since 28 makes for a worrying trend. 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 1, in 211 was more than USD 8,. The corresponding amount for P&I claims (including only Cargo, Illness and Injury) in excess of USD 5, was more than USD 35,. The average claim cost has Graph No H&M navigational claims for bulkers, containers and tankers. Cost and frequency per vessel/year => USD 1,. Cost per vessel increased by 5% since 28 and the frequency has increased by 6%. The total increase in cost over the same period is 11%. This could mean that when there is a navigational claim, the cost is on average USD 8,. Preventing the occurrence of one single navigational claim could generate major savings to owners as well as their Club and Underwriter. Preventing these casualties is The Swedish Club s highest priority. Graph No P&I and H&M claims for all vessel types. Cost and frequency per vessel/year => USD 5, Graph No H&M navigational claims for bulkers, containers and tankers. Average cost and frequency per claim => USD 1, Frequency Cost per vessel Frequency Average claim cost Frequency

5 Graph No P&I cargo, illness, injury claims for bulkers, containers and tankers. Cost and frequency per vessel/ year => USD 5, Graph No P&I cargo, illness, injury claims for bulkers, containers and tankers. Average cost and frequency per claim => USD 5, Cost per vessel Frequency Average claim cost Frequency The average claim cost since 28 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 world 211 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 simplifying 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 different areas. It has proven to be a much-appreciated move enabling our business partners 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 212. 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 upload and download relevant information on underwriting and claims. The SCOL provides exceptional flexibility in terms of data compilation and offers a wide range of products from Certificate of Entry documents to Loss Prevention benchmarking. The platform will also be continually developed in 212 and more interactive features will be launched. Rules & Exceptions We are very pleased to report that the Club s revised Rules & Exceptions hit the shelves in February 212. Obviously, many people put a lot of dedication and hard work into the revision process, which took place in 211. We are very pleased with the result and happy to offer this publication to anyone interested. We believe that this new edition will add to the Club s already excellent reputation as a first class P&I Club. The Rules & Exceptions is of course also available electronically on the SCOL platform. 5 Graph No 8 International Group pool Claims USD Million P&I We would like to start by saying 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 211 was relatively low. However, we can see that these claims were quite costly. We know that the start of calendar year 212 is not going to improve this picture No of claims

6 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 as clear, but nevertheless, an increase can still be noted in the interval claims in excess of USD 5,. If we look at the frequency distribution in Graph No. 9 it is clear that the three main categories are Cargo, Injury and Illness. It also shows that Cargo is the largest while 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. 1 below that Cargo is the more dominant, while the rest are slightly more evenly distributed. Graph No P&I frequency distribution (claims => USD 5,) 22% 4% 4% 6% Cargo liability 23% 2% 2% 37% Collision (RDC) Contact (FFO) Illness Injury Pollution liability Stowaways Other third party liabilities Graph No P&I cost distribution (claims => USD 5,) 41.5%.3% 1.1% 3.7%.5% 1.9% 3.5% 38.6% Cargo liability Collision (RDC) Contact (FFO) Illness Injury Pollution liability Stowaways Other third party liabilities FD&D FD&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 7 claim category Unpaid hire. In Graph 6No. 11 to the right the correlation between 7 5 an increased claims frequency and a 6 4 Index Index 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 previously mentioned the global economy is entering a phase 7 of recovery but it is fair to assume 6 that the recovery 5 will take some time. 6 Index Graph No FD&D claims frequency per vessel/year Baltic Index Dry Baltic Index Dry Clarkson containership rates Clarkson containership rates Claim frequency per vessel Baltic Index Dry Claim frequency per vessel 4 Clarkson containership rates Marine 5 3 Claim frequency per vessel 3 the main reasons why we believe that some thought would generate quite As mentioned at the 4 start, we 2 are currently in a phase where 3 we are seeing back of further tonnage being deliv- claims. We can, in this respect, not say frequencies will continue to soar on the an increase of both smaller and larger 2 1 a greater number of larger claims in 1 ered and entering into trade. The rate that we have noticed such a correlation. We are mindful of many own- 2 excess of USD 5,. Our assessment of scrapping seems to be insufficient of the situation is 1 also that it is reasonable for reaching a balance between 28supply 29 21ers /managers 211 financially challenging to expect a continued soaring of and demand. The size of the new ships situations. In times of extremely poor claims frequencies as shipping activities delivered are very 21 often 211 much larger earnings one must, out of necessity, around the world will be stable or even than the ones scrapped. Consequently, cut back on spending as much as possible. increase on the back of a recovery of scrapping is insufficient in balancing In this process we anticipate that the global economy. A higher level of out the influx of new tonnage. Another overall spending on maintenance and shipping activities coupled with an ever area of concern for the industry has loss prevention will be less than in a increasing shortage of seafarers are been the moral hazard element, which good market. As such, it would be naive Index

7 not to anticipate any consequence in this respect. If we take a look at how the numbers 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 distribution, it is more evenly distributed between Machinery, Groundings and Collisions, as can be seen in Graph No. 13 below. Graph No H&M frequency distribution (claims => USD 1,) Graph No H&M cost distribution (claims => USD 1,) 8% 13% Collision Contact 7% 22% Collision Contact 51% 12% 2% 11% Fire or explosion Grounding Heavy weather Machinery or equipment Other 33% 4% 7% Fire or explosion Grounding Heavy weather Machinery or equipment Other 3% 2% 25% Causes and remedies A vessel is a high-risk environment where people can die if safety is disregarded. This, coupled with a diverse crew from different countries and backgrounds shows that it is paramount that there is an established safety culture to address these issues. In the "interactive root cause analysis" (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 company 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 recurring issue. If the officer had reduced speed he would have improved his own situational awareness. Passage plan To safely take the vessel from berth to berth there needs to be a detailed passage 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 approved passage plan a new passage plan needs to be produced, agreed and signed by the master and all bridge officers. This will include relevant information 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 7 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 voyage. 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 pilotage waters. Bridge equipment Evidence 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

8 a lack of knowledge, inexperience and poor procedures. The International Maritime Organization (IMO) made ECDIS mandatory on new passenger vessels and new tankers from 212. By 218 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 officers are fully converse with how ECDIS works, its limits, chosen settings and what actually an approved ECDIS is. Having an officer operating this essential 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 actually lack important knowledge. This might be because they have received poor training or none at all. It is essential 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 technology is to embrace it but also question its purpose and then learn if the equipment will enhance the performance of the officer and increase safety or not. Advancement in technology is something 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 technology 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 communication 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 audits focussing on how the navigational watch is carried out and verifying that the bridge team is following the company 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. Procedures It 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 serious 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 procedures 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 benefit. 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 assessment Since 1 July 21 there is an ISM requirement for companies to have shipboard 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 8

9 the critical job. To be able to achieve the best result there should be cooperation 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 assessment should be completed and used are addressed in the company s SMS. If the risk assessment has been completed 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 members how to safely complete the job. This will also mean that all departments 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 misses Near misses is an efficient, approved way of identifying problems within a system or organisation. It can sometimes 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 understandable 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 reoccurring 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 universal 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 become 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 culture A 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 management buy in is essential. All onboard 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 seminars, 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 disregarding procedures are not. Conclusion Most accidents are caused by human error, not technological or mechanical failure, the immediate cause is very often that a person made a disastrous decision or mistake. Investing in equipment, training facilities, training of employees and carrying out comprehensive 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 organisation to establish a positive safety culture onboard their vessels. This can be rectified with the correct motivation and belief because accidents can be prevented and should be prevented. 9

10 Executive summary In relation to P&I (Cargo, Illness and Injury) 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 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 of the accident reoccurring is substantially 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 causeeffect diagrams (fishbone), which are often used in conjunction with the Five Whys. By asking Why? five times successively 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 probably 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 problem 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 observations of the people performing the task. The Cherry picking process One way for us to undertake this process efficiently is to screen one 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 something 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 effective as possible we need to cherry pick the cases we decide to investigate 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 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 feedback to its members in general. IRCA has proven to be a powerful loss prevention tool and allows members 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 Interactive root cause analysis (IRCA) an example Correcting symptoms wastes resources correcting root causes removes the problem. WHAT? Loss of power in main engine Turbocharger breakdown Rotor is malfunctioning Bearing failure The bearing is well beyond its useful service life Turbocharger has not been maintained according to service schedule 1

11 Interactive Root Cause Analysis IRCA cases Grounding The vessel was departing a port when it ran aground. The tide in the harbour was running at around knots, with a height of 2 meters. It was evening and two pilots boarded the vessel, with no pilot brief being held. The master, 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.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 2 nd officer on the stern, the vessel was swinging 8 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 25 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 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 appeared to be aground. WHAT? Grounding in harbour area Lack of proper communication 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. No unified plan within the bridge team and no specific team duties were assigned. 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. The company had not been able to implement MRM onboard the vessel and the navigation procedures were not extensive enough. CONSEQUENCES Vessel grounded, resulting in extensive damage. It carried a lot 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. 11

12 Collision Vessel A was on a southbound course and vessel B was northbound. 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 fishing 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 starboard and altered course to port three times over a 2 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 officer 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 vessel 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. WHAT? Collision in congested waters Vessel A was maintaining 25 knots in congested waters. There was no dedicated lookout, which is a requirement as per the company s SMS and also under STCW regulations. 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. Vessel A:s chief officer had not complete situational awareness. The master showed a lack of enforcing policies and following company procedures as the manning on the bridge was insufficient. Lack of onboard safety culture The company had not been able to establish safety culture onboard that followed the company s own procedures. CONSEQUENCES This 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. 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. 12

13 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 thrusters 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 actions the vessel s bow cleared the berthed vessel by about 3 meters but the vessel made heavy contact with the berth at a speed of about 4 knots. WHAT? Contact with berth during strong flood tide The vessel was south of the planned course line There was inbound traffic so the pilot decided to position the vessel closer to shore 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. 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. The bridge team disregarded the company s own departure procedures which required a pilot briefing which should address possible risks. The company had not been able to explain the importance of following approved procedures, MRM and the company s procedures on how to interact with the pilot were not thorough enough. CONSEQUENCES Extensive repairs to own vessel and quay, which also caused further loss of earnings. 13

14 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. 14

15 Collision The 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 different 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 3 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 starboard. This was done using the autopilot. The vessel came around slowly to starboard to the new course of 4, which took about five minutes. The settings on the autopilot were set to a rudder limit of 15 and a rate of turn of 1 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.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 1 miles away, fine to port and proceeding in the same direction 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 2 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.2 miles. The OOW changed course again to port using the autopilot. The vessel applied minimal rudder with an 8 per minute rate of turn. This was not sufficient. Four minutes before the collision, vessel C was 1.4 miles away with a CPA of.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 officer 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 equipment The bridge equipment was completely new to the officer and he did not inform 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. 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 conversant with the bridge equipment Lack of leadership onboard as the master did no verification of the officer s familiarisation, which is a requirement as per the company s SMS. The master did not voice any concern about the short handover period to shore side management. Shore side lack of implementing company procedures onboard and not identifying the risk of not providing sufficient handover period for the officer. CONSEQUENCES Extensive repairs to both vessels and further loss of earnings during reparation. 15

16 The OOW had signed the familiarisation checklist in spite of the fact that he was not conversant with bridge equipment. 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. 16

17 Contact The 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 25-3 cm thick. There was no wind and visibility was good. One tug was assisting at the bow with a 3m-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 4 o. 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 instruments 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-conformities. 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 circumstances 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 communication 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 information. 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 essential 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 The assisting tug was positioned wrongly and the pilot used excessive speed and angle The pilot berthed without having full control of the situation or communicating his intentions to the master There was no proper pilot brief which addressed the risks of the berthing operation The master was not assertive and did not request the pilot to explain his actions Poor MRM as there is a clear communication breakdown, as well as the company s arrival and pilotage procedures were not extensive enough CONSEQUENCES The 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. 17

18 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. 18

19 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 second officer change the outbound track to correlate with the master s inbound deviation. The second officer then programmed 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 visibility 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 projected. He was also plotting the ship s position on the paper chart. The master decided to leave the channel because he was concerned 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 electronic 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 warnings 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 previous 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 channel 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 doublecheck with the paper chart. 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. 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. The bridge team did not practice MRM and did not follow company procedures. The company s navigation policy was not extensive enough. CONSEQUENCES The vessel was refloated on the falling high tide due to a greater water level as a result of changing 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. 19

20 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. 2