Accidents and investigations Archives

Oct 23 2018

MAIB reports lack of pilot and Master communication on CMA CGM Centaurus Jebel Ali berth collision

By ALL Academy Accidents and investigations, Bridge Resource Management, Maritime Resource Management (MRM), Master/Pilot No Comments

The recent release of MAIB’s report on the collision that occurred on 04 May 2017 involving containership CMA CGM Centaurus and the berth at Jebel Ali port in Dubai highlighted a few important MRM principles. The lack of Master and Pilot communication was just one of them. In the report, it also stated that the pilot-bridge interaction was kept to minimum therefore making it difficult for the master to actively engage in the act of pilotage. There was no shared mental picture for both the pilot and the bridge staff giving no chance for a healthy challenge and response environment.

MAIB remarked: “It is imperative that pilots and ships’ bridge teams work together and implement the best practices of Bridge Resource Management to ensure the safety of both ships and ports.”

Here is the link to read more about the report: https://www.gov.uk/maib-reports/heavy-contact-made-by-container-vessel-cma-cgm-centaurus-with-quay-and-shore-cranes

Dec 14 2017

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Challenge and Response? The El Faro Case

By ALL Academy Accidents and investigations, Bridge Resource Management, Maritime Resource Management (MRM) No Comments

The latest findings of the US National Transportation Safety Board (NTSB) on the EL FARO case which was recently published highlighted one of the important concepts of MRM which is Challenge and Response. Despite the suggestions of other officers on three occasions that the ship should change course, the Captain ignored these suggestions.

“We may never understand why the captain failed to heed his crew’s concerns about sailing into the path of a hurricane, or why he refused to chart a safer course away from such dangerous weather,” said NTSB Chairman Robert L. Sumwalt. “But we know all too well the devastating consequences of those decisions.”

To read the NTSB text, click here.

Jan 20 2017

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“The Deadly Dozen”

By ALL Academy Accidents and investigations No Comments

The “Deadly Dozen” based on CHIRP near-miss reports 2003-2015. (Click to enlarge)

Analysis of CHIRP* near-miss reports for the period 2003-2015 reveals important facts. Described as the “Deadly Dozen”, and published in the UK MCA’s Marine Guidance Note MGN 520 (M) in December 2016, the analysis has identified twelve important factors in maritime safety. Situation Awareness is found at the top of the list. 22.5% of the reported incidents are attributed to lack of Situation Awareness according to the analysis. Alerting ends up in second place followed by Communication as number three. This is the complete list:

Situation Awareness – 22.5%
Alerting – 15.3%
Communication – 13.4%
Complacency – 12.6%
Culture – 11.4%
Local practices – 7.4%
Teamwork – 6.8%
Capability – 4.9%
Pressure – 1.9%
Distractions – 1.8%
Fatigue – 1.2%
Fit for duty – 0.8%

The results of the analysis come as no surprise to MRM training providers. These areas have been key priority areas in the MRM training programme ever since resource management training was introduced in the maritime industry in the early 1990s. The list of factors is in fact very similar to the MRM course syllabus, even if the term ‘Challenge and Response’ is used instead of ‘Alerting’. Flag States’ recognition of human and organizational factors in maritime safety is very welcomed indeed. This has taken a long, long time and we are still not where we would like to be in the maritime industry. Accidents still take place at a higher frequency than needed but we are slowly moving in the right direction. The statistics produced by CHIRP and UK MCA is helpful.

More information about the “Deadly Dozen” is found in the UK’s Maritime & Coastguard Agency’s Marine Guidance Note MGN 520 (M). The document is definitely worthwhile reading for MRM training providers and MRM trainees and contains also some ‘DOs and DON’Ts’ for each identified factor. Click the picture below for the full document.

MGN 520 (M)

* CHIRP is an abbreviation of Confidential Hazardous Incident Reporting Programme. CHIRP has its own website.

Nov 07 2016

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Maritime Safety Seminar for Shipping Companies in Singapore

By ALL Academy Accidents and investigations, ALL Academy, Bridge Resource Management, Maritime Resource Management (MRM), Seminars/Conferences No Comments

We were not surprised that a “maritime safety seminar for shipping companies aiming at zero insurance claims” should attract a large number of safety-oriented people in Singapore. We spent half a day at the Furama RiverFront hotel on November 7, 2016 discussing contributing factors in accidents, the impact of national and company culture, pilotage issues and how we best increase safety, efficiency and job satisfaction in our shipping companies. Many good ideas and comments came from the highly experienced participants, many of them in top management positions.

At the venue during the MRM Safety Seminar in Singapore on 07 November 2016.

Feb 13 2015

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The Swedish Club identifies lack of MRM behind navigational claims

By ALL Academy Accidents and investigations, Maritime Resource Management (MRM), P&I Clubs and marine insurers 2 Comments

In a report just published by the mutual hull insurer and P&I club The Swedish Club, lack of MRM has been identified as a common contributing factor in navigational accidents. The report is based on hull and machinery claims between 2004 and 2013 and the navigational claims – collisions, contacts and groundings – have been analyzed in more detail. The report lists a number of contributing factors behind these claims. The most important being:

Non-adherence to procedures
Ineffective communication
Poor lookout
Lack of situation awareness
Complacency

The report confirms the picture that we have seen for a long time – accidents are caused by “non-technical” factors rather than lack of technical skills. The non-technical factors are the focus area of Maritime Resource Management (MRM) training and the report also concludes that shipping companies need to better implement MRM in their organizations for substantial improvements to be seen.

Click here or the picture below for the report (1.5 MB, pdf-format).

The Swedish Club, Navigational Claims Report 2014

Mar 18 2014

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Allianz Safety and Shipping Review 2014

By ALL Academy Accidents and investigations, P&I Clubs and marine insurers No Comments

Published by Allianz Global Corporate & Specialty at www.agcs.allianz.com
(Click picture for full report)

“Following the Safety and Shipping Review 2013, this annual release by Allianz Global Corporate & Specialty analyzes the shipping losses (of over 100 gross tons) which occurred in 2013 and focuses simultaneously on key maritime developments over the same period of time.

More than two years after the Costa Concordia disaster, improving passenger ship safety continues to be a priority. With more than 90% of global trade estimated to be carried by sea, the safety of international shipping vessels and routes is critical to the health of the global economy.

For the first time, the AGCS Safety and Shipping Review 2014 also includes the total number of shipping casualties/incidents by region. There were 2,596 casualties during 2013 with the East Mediterranean & Black Sea region the top hotspot (464), and the British Isles has been the scene of the most casualties over the past decade (see page13).

During 2013 there were 94 losses reported worldwide, ensuring the annual total dropped under 100 for only the second time in 12 years, continuing the recent downward trend. These losses are a 20% decline from 2012, which reported 117 losses.

The Safety and Shipping Review 2014 also focuses on safety concerns ranging across topics, from hazardous cargo to passenger ship safety to pollution control. Recent accidents, such as the sinking of the MOL Comfort (an overweight container ship) or the St Thomas of Aquinas (Philippine-registered 1972-built ferry), signal experts as to where standards need to be more closely examined.

According to the report, more than a third of 2013’s total losses were concentrated in two maritime regions. As in 2012, the South China, Indo China, Indonesia and the Philippines region saw the highest number of losses (18 ships), closely followed by the seas around Japan, Korea and North China (17 ships).

Emerging Risks
While the report offers details on topics that have historically challenged marine safety, it also looks at the rising trends and emerging risks that seafarers will need to regard. An increasingly difficult operating climate for ship operators has forced a number of innovations, including larger ship sizes to capitalize on economies of scale, the use of alternative fuels and changes in ship designs. At the same time, more economical trading routes are fast appearing in Arctic regions during the summer months, but these present their own set of challenges.”

Nov 27 2013

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Media release: ALL Academy offers Maritime Resource Management licences to combat maritime accidents

By ALL Academy Accidents and investigations, Maritime Resource Management (MRM), Media releases, P&I Clubs and marine insurers No Comments

An initiative to increase Maritime Resource Management (MRM) training in the maritime industry has been taken by ALL Academy International AB who now offers MRM training licences. “Lack of MRM continues to be a key factor in maritime accidents and there is an urgent need to do something about it. More shipping companies need to implement MRM”, says Martin Hernqvist, managing director of ALL Academy International AB, or ALL Academy for short.

Hernqvist, who parallel to his job at ALL Academy is the managing director of The Swedish Club Academy, continued: “The main promoter of resource management training in the maritime industry in the past has been the hull and P&I insurer The Swedish Club and MRM training licences have so far only been available through The Swedish Club Academy. A challenge has been to reach out to the shipping companies who have their insurances placed with other P&I clubs and insurance providers.”

Protection and indemnity insurance claims exceeding US$ 9 million are shared between the clubs in the International Group of P&I Clubs, Hernqvist explains. Any claim exceeding US$ 9 million will therefore have an impact on all clubs. Hernqvist said that major P&I claims may involve loss of lives and may have severe environmental consequences. The costs of these claims are escalating and many of these claims are also MRM-related, according to Hernqvist. “From a financial perspective, the grounding of the Costa Concordia stands out. It is by far the most expensive P&I claim ever. When the costs exceed the level ‘for own account’, all P&I clubs get involved and eventually all their respective members will have to contribute to cover the losses,” he added.

Martin Hernqvist said: “It is of the interest to all P&I clubs – and to their members – that everyone do whatever possible to reduce the likelihood of incidents. We are firm believers since 20 years now that MRM is the most effective tool available to increase safety and efficiency in our industry. However, it may have been difficult for other P&I clubs and insurers to promote a concept that has only been available through The Swedish Club Academy. The clubs are close colleagues in the international insurance market but at the same time competitors,” he said. “For this reason MRM licenses will now be made available also through ALL Academy. ALL Academy is the development company behind the MRM training programme and completely independent.”

Hernqvist hopes that many parties in the industry, not least other P&I clubs and insurers, through this initiative shall push forward for a greater use of MRM. “We are excited about the new possibilities and we hope that MRM shall reach out to a wider audience. The industry needs it,” he concluded.

-ENDS-

Further information

Martin Hernqvist, managing director, ALL Academy International AB
Tel: +46 (0)706 313 299
Email: martin.hernqvist@allacademy.com
Website: http://allacademy.com
For photos and logotype, click here.

Notes to Editors

ALL Academy International AB is an independent training development company primarily involved in human factors and resource management training programmes. ALL Academy is the company behind the Maritime Resource Management (MRM) training programme that has become the industry standard for resource management training. Primary users are maritime universities and training centres, ship owners, ship managers, manning agencies, pilot associations, marine insurers and P&I clubs. The MRM network is the maritime industry’s largest network in the human factors area and MRM training is today available in 35 countries worldwide.

Martin Hernqvist is the managing director of ALL Academy International AB and The Swedish Club Academy AB. Hernqvist was 20 years ago involved in the development of the maritime industry’s first ever resource management training programme, at that time called Bridge Resource Management (BRM). Maritime Resource Management (MRM) is a further development of BRM. MRM aims at involving the whole organisation, including shore-side management. In order to establish an effective safety culture within the organisation, a deep understanding and a commitment from the top is of utmost importance.

Nov 08 2013

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Master/Pilot relationship in focus at Nautical Institute seminar

By ALL Academy Accidents and investigations, Maritime Resource Management (MRM), Master/Pilot, Seminars/Conferences 3 Comments

The Cyprus Branch of the Nautical Institue ran a half-day seminar on the topic of “Master + Pilot = Zero Accidents?” on Friday 8 November 2013. The well-attended seminar was held at the Odyssia (Kapetanios) Hotel in Limassol, Cyprus. The event was followed by a gala dinner in the evening to celebrate the Branch’s 20 year anniversary.

Graham Cowling, Chairman of the Nautical Institute’s Cyprus Branch, made an excellent summary of the challenges in the Master/Pilot relationship in his welcome address at the seminar. (See bottom of this post.)

Martin Hernqvist of ALL Academy addressing the Master/Pilot relationship

Martin Hernqvist of ALL Academy talking about “The Master/Pilot relationship and soft skills”.

Delegates at Nautical Institute's seminar on the Master/Pilot relationship

Nautical Institute’s seminar on the Master/Pilot relationship attracted a large number of people and discussions were lively.

Captain Sivaraman Krishnamurthi, President of the Nautical Institute, responding to questions from the audience.

The speakers at the seminar, from left to right: Graham Cowling, Operations Manager at Marlow Navigation, Sivaraman Krishnamurthi, President of the Nautical Institute, Martin Hernqvist, Managing Director of ALL Academy and The Swedish Club Academy, Valentin Mavrinac, Marine Superintendent with Columbia Shipmanagement and Nick Cutmore, Secretary General of International Maritime Pilots’ Association (IMPA).

BRANCH CHAIRMAN’S WELCOME ADDRESS

The Master-Pilot relationship is a complex one. This ‘specialist’ navigator must be quickly integrated into the Bridge team as soon as he arrives onboard and needs its full support. On the other hand, ‘To Master’s orders and Pilot’s advice’ still holds good and the consequences of any navigational mishap always stay with the ship. So how do we make sure the Pilot is fit for the task, gets the full support he needs and brings the ship in and out of port with ‘zero accidents’? This seminar will focus on the main issues from the Pilot and Master’s points of view and then provide some answers.

When our Branch Committee first met earlier this year to discuss the topic for a half-day seminar, we wanted to raise an important topic for our 20th year anniversary. By some estimates, the shipping industry is paying US$ 50 million a year on navigational accidents in pilotage waters. Pilots are expected to take care of the interests of the local port, waterway and infrastructure as well as report on navigational deficiencies noted on board so the traditional role as ‘advisor to the Master’ is becoming increasingly unclear. For example, a ship may manoeuvre into a new port every day but the tug masters may not speak English and traffic flow in the port is in the hands of the Vessel Traffic Service (VTS) – how much control on their port manoeuvres do the Bridge Team really have?

Pilots are an invaluable addition to the Bridge for their local knowledge and for their coordination with tugs / linesmen etc. The accidents during harbour manoeuvring may not necessarily be due to faults in the Master-Pilot relationship itself (which is but one component of the Pilotage operation). There are other factors to consider, such as inadequate planning, poor attitude, multi-tasking / multiple demands on the individuals, inadequate infrastructure / planning in ports, actual or imagined time constraints, role of the VTS, technical-failure and lack of contingency plans.

The topic has been the subject of several articles but has yet to be extensively debated in the Nautical Institute forums. Is radical reorganization of Master-Pilot responsibilities possible? While the competency standards of Masters are regulated by IMO STCW, Pilots and Tugs usually operate under national competency requirements and perhaps international ‘recommendations’, which might not be binding. In some countries, the Pilot is obligated to remove himself from the Bridge after an incident in order not to prejudice possible liability. These are issues requiring careful consideration.

It is noteworthy that there are several ports of the world where fewer accidents occur than in other places. There are obviously best-practices to be shared. There is enormous potential for ship-shore interchange of passage planning in ports. Two very experienced navigators – the Master and the Pilot on the Bridge should ideally result in ‘Zero Accidents’ – but we are all painfully aware that this is currently not the case.

Does the industry require a quantum leap in managing navigation with the Pilot onboard?

Graham Cowling, FNI, Chairman, Nautical Institute, Cyprus Branch

Sep 09 2013

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ALL Academy joined EMAIIF conference in Interlaken

By ALL Academy Accidents and investigations, Maritime Resource Management (MRM), Seminars/Conferences No Comments

Interlaken, Switzerland, on 9 September 2013

For the second week in a row, ALL Academy had the pleasure of delivering the opening speech at an important maritime conference. This time it was the European Marine Accident Investigators International Forum (EMAIIF) that had gathered for their EMAIIF 9 conference in beautiful Interlaken, Switzerland. Also this time, Maritime Resource Management (MRM) was the primary topic of our presentation.

“Accident investigations are of no use if they are not used, and they are not used if the quality and standards of the reports are not good enough.” These are obvious truths discussed at the conference but the maritime industry still has some work to do in this respect. There are flag States who take their responsibility seriously but there are also those who act slowly, fail to adequately address the human and organizational factors involved and there are also those who do not publish their reports when completed. Then all the learning opportunities get lost.

Flag States around the world should use the best ones as their benchmark and shipping companies and training providers should also show their appreciation and make better use of the reports when flag States have managed to produce useful reports. It is not an easy task to dig down to the root causes and provide a reasonably clear picture of all the factors contributing to the accident.

Despite being a European conference, there were representatives also from a number of flag States outside Europe. The following flag States were participating at the conference: Antigua and Barbuda, Bahamas, Canada, China, Denmark, Estonia, France, Germany, Hungary, Italy, Japan, Luxembourg, Marshall Islands, Netherlands, Norway, Sweden, Switzerland, Turkey, United Kingdom and USA.
The European Maritime Safety Agency (EMSA) and the Marine Accident Investigators’ International Forum (MAIIF) also had representatives attending the conference.

The EMAIIF 9 conference took place on 8-10 September 2013 and was organised by the Swiss Maritime Navigation Office (SMNO).

Participants at EMAIIF 9 gathered for the Maritime Resource Management speech

Participants at EMAIIF 9 held on 8-10 September 2013