Incident / Accident Analysis

Being retired and at a minor loose end, I decided to troll through various accident reports. Human factors is an interesting subject and having worked in this profession I can relate to many of the findings.
The refreshing find this morning was a Marine Accident Investigation Report undertaken by the Japan Transport Safety Board in 2020.
IT ACTUALLY CONTAINED AND DETAILED EXCERPTS FROM THE VDR AUDIO………for once! Time stamped and very revealing. Why is it that all reports are not structured in this way? Legal concerns?

We learnt absolutely nothing from the “Ever Given” yet, hopefully, the NTSB will incorporate the VDR transcript into their long awaited report on the “Ever Forward”. There were some minor VDR references in the “El Faro” report so it is doable although clearly, in this instance, sensitivities owing to fatalities needed to be considered.

Should you be interested here is the link to the Japanese report.


Good day. :joy:

Excellent thread and thx for the report, which has been promptly added to my collection.

We may never learn because it is…complicated.

The lack of clear definitions in the existing legislation as to what constitutes marine casualties and serious injury may lead to certain incidents not being investigated . end quote.

I think it was abt two years ago or a bit later , when I came across the 2nd legal verdict on CMA CGM Libra and upon reading it asked myself a question: " where the hell is the investigation report" ??? if this case has such wide ranging ramifications .

I could not find any. Then I contacted a person who could pull some strings in IMO and my inquiry flew directly to some Guru there, who could provide some answers. I was referred to IMO regulations regarding casualty investigations and informed that Libra case was not a serious maritime casualty : no death , no pollution …blah , blah , blah :joy:

So i read some resolutions , which explained the basic rules which parties and when are obligated to create the report and submit it within two years from the accident date. The problem is that each signatory state has different definition and/or interpretation of what is " a serious casualty" .

When i got through this difficult legal jargon it occurred to me at that time , that i was missing Maersk Honam report . So I hit them again with the question : where the hell is it as two years have passed , 5 children were dead roasted like fried chicken and I can not find the report on GISIS.

I was in cc: of exchanged correspondence and hey presto in few days I got what was due. :joy:

Meantime I was informed by the contacted individual , that anybody can contact IMO with such questions directly and I was even encouraged to report such things as these people there are very busy "discussing, meeting and having lunch and cocktail parties and pondering on the new legislation that is reducing the paper work load on board by increasing it 10 fold.

So in the fury of such activity they are fully justified to miss something. :joy:

Hastily and ad hoc i collected links , which pls find below but when You Google with " IMO rules on maritime accident investigation" You surely will get a truck-load of links , which explain the issue in detail.

Emily-Marie-Antoinette-Natalie-Gonthier-.pdf (

Reporting (

By the way I have just grabbed NTSB report on a bulker hitting a rig in US coastal waters and it is " FUN-FU…ING-TASTIC" !!! :joy: Guess why??? :joy:

MIR2218.pdf (840.4 KB)

Legal concerns??? well it could be but every report whether submitted by MAIB, Malta Administration or Burkina Faso contains the following wording as in below example :

The United Kingdom Merchant Shipping
(Accident Reporting and Investigation)
Regulations 2012 – Regulation 5:
“The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting and Investigation) Regulations 2012 shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of an investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.”
This report is not written with litigation in mind and, pursuant to Regulation 14(14) of the Merchant Shipping (Accident Reporting and Investigation) Regulations 2012, shall be inadmissible in any judicial proceedings whose purpose, or one of whose purposes is to
attribute or apportion liability or blame.


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Many thanks for your response and your references have cleared up some inconsistencies for me.

I found this interesting………
“From about 0055 until 0120, about a minute before the casualty, the S-VDR captured the master engaged in a mostly one-sided conversation about non-navigational, non-pertinent matters with the second officer.”

This augers well for NTSB reports. I am keeping my eye out for the “Ever Forward” findings and no doubt you are doing something similar.

Nice to chat again.

From what I have observed, these are released a year to the day from the original incident. I believe there is a law for this.

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In that case, some time to go yet.

Many thanks.

These might be of interest

Engineering a Safer World - Systems Thinking Applied to Safety: (PDF)



“Minor references”? The full transcription of the EL FARO VDR is in the NTSB Docket. Item 251


This is the report that I am referring to.

Yes, it is a European Union regulation.
If it is not possible to publish the Final Report within 12 months of a “very serious or serious incident", an Interim Report must be published.

That is a precious gem .THX

An NTSB report is a document negotiated between the various panel leaders and as such can have the usual faults of a compromise decision. Not always, but some times, and especially if there are multiple causal factors.

If the incident is important to you, you should go to the trouble of reading the whole docket.



My apologies.

I was unaware that there are other parts to the primary NTSB report. In Australia, we have a single document representing the investigation into an incident.

It fascinates me that, occasionally, the NTSB “negotiate” a report leading to a compromise decision.

It is my understanding that NTSB is not conducting an investigation of the Ever Forward grounding as it does not meet the criteria for accident severity. Additionally, USCG Baltimore public affairs would not comment on any investigation or even confirm one was underway. It was suggested that a FOIA request be submitted, which has been done.

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The docket contains all the material collected in the course of the investigation, including that deemed by participants as being insignificant. The latter is a value judgement that you may not agree with.

To some observers (myself included) the El Faro docket gives a substantially different view of the casualty than the official report. There are old threads on this site that hash that over.




Question about dockets on the NTSB site: why do they in some cases only publish a summary of the interview rather than the interview itself? Is this negotiated as well?

USS Fitzgerald and ACX Crystal collision: The Fifth Circuit Court of Appeals delineates the reach of personal jurisdiction (

In footnotes 5 through 7 of the majority Opinion, the Court felt it was important to place the Opinion in further context.

The Court emphasized that NYK was a time charterer of the ACX Crystal, and that time charterers typically have little or no control over the vessel’s navigation. As such, a time charterer “almost never bears liability for a collision stemming from navigational error.

Citing Moore v. Phillips Petroleum Co., 912 F.2d 789, 792 (5th Cir. 1990).

Thus, in the Court’s view, even if plaintiffs could establish personal jurisdiction over NYK, “their claims would face other substantial hurdles.”

Including the fact that the after-accident reports issued by the National Transportation Safety Board and the Japanese Transport Safety Board largely fault the United States Navy for the collision and, according to the Court, neither places any fault on NYK.

The Court noted that the personal representatives of the deceased sailors and the injured sailors and their families also sued the owner of the ACX Crystal, Olympic Steamship Company, and its bareboat charterer, Vega Carriers Corporation, both Panamanian corporations, in Japan for the same injuries at issue in this lawsuit.

Source: US Court of Appeals



Name: ACX CRYSTAL (effective 2008-08) !
IMO Number: IMO 9360611
Flag: Panama (effective 2021-06)

Panama (effective 2008-08)
Philippines (effective 2008-08) !
Call sign: 3ESV6
MMSI: 370439000
Ship UN Sanction: Not on list
Owning/operating entity under UN Sanction: Not on list


Type:|Container Ship (Fully Cellular) (effective 2008-08)
|Date of build:|2008-08||
|Gross tonnage:|29,060||


|Registered owner:||Olympic Steamship Co SA||(effective 2008-11-30)|
|IMO Company Number|[4021665]IMOCompanyNumber=4021665)|
|Nationality of registration|Panama|
|Address|Care of Sea Quest Ship Management Inc , 1418, San Marcelino Street, Ermita, 1000 Manila, Philippines.|
|Company status|Active||

Is this Guy something or is He something?? Have just finished watching and my jaw dropped.

Surely the fourth edition of stability booklet will not help him as it appears neither did the 1st .

May be there should be a separate thread??? : debunking SAL.

I got really pissed off today as in one of the very first of his episodes he claimed to make a VERY THOROUGH research on every topic .

quote: each of these containers can hold as

much as 40 tons " end quote.

What do You think??

(97) How Does A Ship Capsize at a Berth? - YouTube

Cargo ship with containers capsized at Iskenderun port, VIDEO – Maritime Bulletin


EMSA-Navigation-Accidents-Summary-report-V1.pdf (

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Human Actions accounted for 75% of grounding investigations.

Fatigue represented the highest percentage in individual factors.

Can this be associated with the “Ever Forward” incident?

I believe so.

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CHIRP-Feedback-2022_09.pdf (

The human element in incident investigation: What to watch - SAFETY4SEA

MARS 347 September 2021.pdf (