Incident / Accident Analysis

Professional Mariner Forum
1

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.

3

Spowiednick,

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.

4

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.

5

In that case, some time to go yet.

Many thanks.

6

These might be of interest

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

MODELS OF THREAT, ERROR, AND CRM IN FLIGHT OPERATIONS (PDF)

7

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

https://data.ntsb.gov/Docket/?NTSBNumber=DCA16MM001

8

This is the report that I am referring to.

9

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.

11

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.

Cheers,

Earl

12

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.

13

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.

14

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.

Cheers,

Earl

16

USS Fitzgerald and ACX Crystal collision: The Fifth Circuit Court of Appeals delineates the reach of personal jurisdiction (gard.no)

quote:
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

NYPE CL 26

image
image953×129 28.8 KB

BOXTIME CP CL 22

image
image951×157 21.3 KB

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

Characteristics

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

Companies

|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||

17

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

19

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.

21

Think there will be any analysis of the Sunshine State not avoiding Ian???

23

What was the outcome? I wound up taking a detour through the Bahamas to get greater separation from Ian’s potential track. Very happy to only deal with residual swell after it passed when I went through the Florida Straits.

26

AUSMARINER
“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.“

I was asked to review this report once. I’m curious to see if you noticed the same things I did.

27

I really don’t know where to start on this report…….there were so many human failures, from all participants, on that bridge. I would generalise and agree that there was a complete breakdown in BRM.

Putting a loaded vessel, proceeding at ten knots, back to DSA whilst fitted with a high cross section CPP is a recipe for disaster. If the vessel has inherently poor directional stability the impeded water flow over the rudder is not going to end well. The course change was also ordered concurrently with the reduction in CPP pitch setting…….not good.

Both the Master and Pilot made mistakes. The entire ship’s bridge team were Croatian nationals so there was little power distance affecting their performance. There would have been a degree of power distance between the Pilot and bridge team.

The issue with directional stability should have been noted on the Pilot Card and this should have been pointed out to the Pilot during the MPX.

Being mindful of this issue, all parties should have been glued to the Rudder Angle Indicator and the helmsman should have been instructed from the outset to pass on any problems with his task.

In short……this was a complete clusterf…ck!

28

The only vessel I have ever been master of with a Becker rudder and CPP was a small container vessel. As an exempt master for most of the ports I called at I did not experience any sheer but my reductions in speed were probably more measured when berthing without tugs.
At stop it was possible to move the vessel bodily sideways with the rudder and bow thruster. Power for the bow thruster was from the shaft generator.