JAPAN P& I CLUBVol.50 February 2021

P&I Loss Prevention Bulletin
The Japan Ship Owners'Mutual Protection & Indemnity Association Loss Prevention and Ship Inspection Department

4M4(5 ) E
AnalysisAnalysis of Accident Cases

P&I Loss Prevention Bulletin

Contents§1 Introduction: Safety and Casualty Mechanism & Maritime Accident Prevention
1-1

What Is Safety? ………………………………………………………………………………… 2

1-3

Prevention of Maritime Accidents ………………………………………………………… 11

1-2

As a Mechanism behind Maritime Accidents Caused by Human Error …………… 4

2-1

Errors Made by an Involved Party and Organizational Errors ……………………… 17

2-3

4M4(5)E Analysis Plus Why Why Analysis: Investigation, Analysis and4M4(5)E Analysis ……………………………………………………………………………… 20

Countermeasures…………………………………………………………………………… 22

the QR code below or by downloading them from the follow URL:

https://piclub.box.com/s/qkc4c4w88m9izvmkegymyunpe7m93yd6

ExamplesAttachment 1

4M4(5)E Analysis ……………………………………………………………… 93

Attachment 2-1

Causes behind Maritime Accidents 4M Classiﬁcation List …………… 94

Attachment 2-2

Maritime Accidents 4M Classiﬁcation List ……………………………… 95

Accident Summary (See Attachment 8）………………………………………………… 32

Attachment 3

Maritime Accident Summary of Related Facts ………………………… 98

Causes behind Maritime Accidents ……………………………………………………… 41§3 Case Study = Collision Accident =3-1

Attachments
Please use the following attachments and blank form of the 4M4(5)E Analysis List using

Please note that the attached documents and data are provided by an external service andthat publication may be suspended without prior notice.

§2 4M4(5)E Analysis
2-2JAPAN P& I CLUB

3-2

Events that Led to the Accident（See Attachments 8 and 9) ……………………… 39

Attachment 4

Maritime Accident Accident Causes (Unsafe Behaviour) …………… 99

Attachment 5

Maritime Accident Accident Causes (Unsafe Conditions)

3-4

Accident Causes ……………………………………………………………………………… 44

Attachment 6

Maritime Accident Analysis using 4M5E and

3-3
3-5

Transport Safety Board Report ＝ Recurrence Preventive Measures ＝ ………… 45§4 4M4(5)E Analysis of a Case Study = Collision Accident =4-1

Summary of Related Facts（See Attachment 10）……………………………………… 47

4-3

Analysis on Unsafe Behaviour for Master A and Master B (See Attachment 12) … 49

4-2
4-4
4-5

4-6

Analysis of Unsafe Behaviour for Pilot A（See Attachment 11) ………………… 48

Countermeasures for Unsafe Behaviour for Pilot A（See Attachment 13) …… 51
Countermeasures for Unsafe Behaviour for Masters A and B（See Attachment 14) … 56
Accident Analysis from the Perspective of Human Factors and Human Error(See Attachment 15) ………………………………………………………………………… 64§5 = Case Study = Bridge Collision Accident
5-1

5-2
5-3

5-4
5-5

Accident Summary (See Figure 36） ……………………………………………………… 68

Summary and Damage Sustained to a Vessel (Cargo ship E）……………………… 70

Summary of Ōshima Bridge（Figure 40）and the Damage Sustained（Photograph 41）……………………………………………………………………………… 72
Events and Sailing Route that Led to the Accident …………………………………… 74

Accident Causes ……………………………………………………………………………… 76§6 4M4(5)E Analysis of Bridge Collision = Accident =
6-1

6-2
6-3

6-4

Human Characteristics (Human Error) and Psychological Factors（See Attachment 16） ……………………………………………………………………… 80

the Countermeasure List (Unsafe behaviour) ………………………… 105
Attachment 7

Attachment 8

Table of Events Leading up to the Accident ………………………… 109

Attachment 10

Vessel A and Vessel B Collision Accident Summary of Related Facts … 112

Attachment 11
Attachment 12

Vessel A and B Collision Accident Accident Cause(Unsafe Behaviour): Master A and Master B ………………………… 116

Attachment 13

Vessel A and Vessel B Collision Accident Analysis using 4M5E andCountermeasure List (Unsafe behaviour): Pilot A …………………… 119

Attachment 14

Vessel A and B Collision Accident Analysis using 4M5E andCountermeasure List (Unsafe Behaviour): Master A and Master B ……120

Attachment 15

Vessel A and B Collision Accident Human Behavioural Traits andHuman Error (Psychological Analysis) …………………………………… 122

Vessel E: Collision Accident with Bridge

Attachment 17……………………………………………………………………………………………… 92

Vessel A and B Collision Accident Maritime Accident Cause(Unsafe Behaviour): Pilot A ………………………………………………… 113（See Attachment 18） ……………………………………………………………………… 84

References

Movements of Vessel A and Vessel B with Map for Reference … 107

Attachment 9

Attachment 16§7 Conclusion ………………………………………………………………………………………… 92……………………… 106

Vessel A and Vessel B: Collision accident oﬀ the port of Kobe

Vessel E Ōshima Bridge Collision Accident: Human Characteristics,
Human Error and Psychology …………………………………………… 124

Analysis Related to Unsafe Behaviour for Master E and 2/O E

Management Company E（See Attachment 19）……………………………………… 85

Maritime Accident Analysis using 4M5E andthe Countermeasure List (Unsafe Conditions)

Summary of Related Facts（See Attachment 17) ……………………………………… 82

Countermeasures Related to Unsafe Behaviour for Master E, 2/O E and Ship……… 102

Maritime Accident Summary of Related Facts(Collision with Ōshima Bridge) …………………………………………… 126

Attachment 18

Maritime Accident Accident Cause (Unsafe Behaviour)
Collision with Ōshima Bridge……………………………………………… 127

Attachment 19

Maritime Accident Analysis using 4M5E and Countermeasure List
(Unsafe Behaviour) Collision with Ōshima Bridge …………………… 130

1

P&I Loss Prevention BulletinJAPAN P& I CLUBunderwriting at the beginning of the term was 171.7% for oceangoing vessels and 9.5%

§1 Introduction:

Safety and Casualty Mechanism& Maritime Accident Prevention

for coaster vessels. This means that, with regards to some P&I accidents, oceangoingvessels caused 1.8 accidents per vessel per year, while this amounted to less than one inten coaster vessels per year. （See Graphs 1 and 2）
Ocean going vessels
Number of
Accidents

7,000

In our previous Loss Prevention seminars and Loss Prevention Bulletins, we introduced
the definition of “safety”, mechanisms behind maritime accidents, how to prevent
maritime accidents and so on. (Please see our Loss Prevention Guides “Thinking Safety(Vol.35)” published in 2015 and “A Psychological Approach to Safety Behaviour” (Vols.
46 and 47) published in 2020.

The number of insurance accidents and accident rate ﬂuctuation
197.5%

187.0%

175.6%

5,000

5,046
4,492

329

226

257

Harbour & Fishery Facilities：2,335

156.3%
4,736

4,454

284

4,000

173.1%

182.2%

6,000

10 Years Total：
41,393 Cases Accident rate (%) 177.2

195.6%

144.1%

147.4%

4,609
4,107

213

153.6%

209

3,647
202

3,000

3,411
201

Accident
rate %

200.0%
180.0%
160.0%
140.0%

3,567
205

120.0%

3,324

100.0%

209

80.0%
60.0%

2,000

40.0%

１−１

What Is Safety?

1,000

0

20.0%

2010PY

2011PY

Cargo Damage

Crew

In the world, absolute safety does not exist, and we are always exposed to all hazards.

2012PY

2013PY“Quality is not a synonym for safety and consequently the respective roles of quality

2017PY

Others2018PY

2019PY

Number of
Accidents

Accident Rate(%)

The number of insurance accidents and accident rate ﬂuctuation
10 Years Total：2,200 / Cases Accidents rate(%)：9.5%

300

Harbour & Fishery Facilities：1,267

269
224

246
210

200

200

202

219

198

8.3%
100

137

8.0%

9.3%

131
8.6%

8.6%

122

12.6%

180

163

them up, “Safety can be deﬁned as the result or evaluation of all danger being avoided.”

10.7%

9.3%
8.6%

105

133

reported to us, the accident rate which was calculated by dividing the total numberof accidents that occurred over the last 10 years by the number of entered ship
2

Accident
rate %

16.0%

252
13.2%

14.0%

12.0%

128
10.0%

112
8.0%

107

129

6.0%

the oﬃces on land, is always in pursuit of safe operation, unfortunately, “zero marine
accidents” have not been achieved yet. Looking at the statistics of P&I accidents

0.0%

Domestic vessels

is no freedom from unacceptable risk.”

Although each related person, not only those on the vessel but those also working in

2016PY

Graph 1and safety should not be confused.” “There can be no absolute safety.” and “ThereAlso, thinking of “Safety” has been discussed in various diﬀerent ﬁelds, but, in summing

2015PY

Harbour & Fishery Facilities

According to the International Basic Safety Standards 1st Edition (ISO/IEC GUIDE 51:
1990） published in 1990, safety is deﬁned as:

2014PY…
0

2010PY

Crew

2011PY

2012PY

Cargo Damage

2013PY

2014PY

2015PY

2016PY

Harbour & Fishery Facilities

2017PY

Others2018PY

2019PY

0.0%

Accident Rate(%)

Graph 2

3

P&I Loss Prevention BulletinJAPAN P& I CLUBIt is concerning that the number of accidents have been increasing since 2017/18 Policy

In addition, those which are caused by Force Majeure (unforeseeable circumstances)Year for oceangoing vessels and 2016/17 Policy Year for for coaster vessels.

are also almost all related to human errors. Then, it may be presumed that 94% of all
maritime accidents are caused by human factors.
Therefore, it follows that if there were no human errors, most maritime accidents should

１−２

As a Mechanism behind Maritime Accidents
Caused by Human Error

not occur. However, unfortunately, it is not possible to realize zero human errors, as thefollowing four aspects are behind the main root cause.

Why then do marine accidents still occur, even though we are aiming to eradicate

Causes behind Human Error

them every day by taking all possible safety measures? It is necessary to consider the

1 Common characteristics among the people who have acquired

mechanisms that trigger marine accidents.

advanced skills such as Master, Navigation Officer, aeroplane

According to a guidebook called “Facts and countermeasure against maritime accidents

pilot, medical doctor and so on.

in 2017 (provisional translation)” issued by the Japan Coast Guard, the ratio by types of（80th Cultural lecture held by the Japan Captains’ Association: Ensuring safety in acauses as accumulated over the last ﬁve years of total maritime accidents reported to theproud profession ― Why BRM is paramount ― from a person with a proud profession

Japan Coast Guard shows that approximately 74% of the causes were those of Human(provisional translation.）factors. (See Graph 3)

The ratio by type of cause of total accidents
as accumulated over the last ﬁve years
Irresistible forces etc.

20 %Materials and structure

20 %

2,173

Irresistible forces etc.

6%
593

2,148

26 %
2,766

7,826

1,704

Insuﬃcient monitoring of weather
and sea conditions

Human
factors74 %16 %Other human factors

6%
590

8%
883

13 %
1,378

Inappropriate
ship operation

11%

1,123

cause human error.
1.

Pride and confidence in one’s work and skills.

2.

When hearing of an accident, they have astrong sense of conviction that they would
never cause such an accident.

3.

Behind this there is the assumption that safety
comes naturally if one has a high level of skill.

4.

Feel offended by imposition of Safety Management Regulations and SMS manuals etc.
from the management division.

5.

Cover-up: Protect each other, particularly inthe case of an accident.

6.

Mistakes are matters of acute embarrassment,
and are concealed.

Engine handling error
Insuﬃcient maintenance ofhull and equipment

Graph 34

Insuﬃcient lookout

These common characteristics of technicians, which are shown in Figure 4, sometimes

Fig. 4

5

P&I Loss Prevention BulletinJAPAN P& I CLUB

2 Human characteristics（Nihon VM (Visual Motivation) Centre Co., Ltdfrom Anzen-no-komado 18 (Safty Loopholes) dated 30 June, 2002

④ Social loaﬁng
This is when someone does not choose to take the initiative. They may say,“Someone will do it for me.”(Provisional translation）

Figure. 5 shows the “human characteristics that everyone has” which are likely to cause
human error.

4 Human Brain Capacity

Twelve human characteristics
1

Human beings sometimes makemistakes
2
Human beings are sometimes careless3
Human beings sometimes forget4
Human beings sometimes do not notice5
Human beings have moments ofinattention
6 ㅤHuman beings sometimes are able to seeor think about only one thing at a time

7
8

9

10
11
12

Human beings are sometimes in a hurry
Human beings sometimes become
emotional
Human beings sometimes makeassumptions
Human beings are sometimes lazy
Human beings sometimes panic
Human beings sometimes transgress
when no one is looking

Fig. 5

The reason why we can say that the human brain is a very ineﬃcient organ is because
it occupies only 2% body weight, yet consumes 20% of all the energy. Our brains areprogrammed to save as much energy as possible, while aiming to achieve maximum
energy eﬃciency. The following are examples of its energy-saving mode, and it is thesethat are responsible for optical illusions and perceptual errors.
Since Neoanthropic man (Cro-Magnon man) was born 70,000 years ago, human beings
have been making a living from hunting, pasturage and farming. In 1769, which is just
250 years ago, a Scottish mathematician and engineer, James Watt invented the steam
engine, which was epoch making for humanity. In other words, problems in the era offarming and pasturage were mainly only floods, fires, and natural disasters, but now,

3 Psychological Factors

new disasters can be added to this. It is said that human beings inhabited the earth

The following psychological factors mainly induce human error.

approximately 40,000 years ago. If this were compressed into 1 year, and human beings①

Psychological reactance（self-eﬃcacy）

started to inhabit the earth from 00:00 on January 1, the industrial revolution wouldThis is when people do not wish to do something that is not of their own

have begun at 17:15 on December 29. Meaning that only 2 days and 6 hours and 45

volition. They may be inclined to say, “I won’t do what you tell me.”minutes have passed since human beings came into contact with machines. It is true that

② Entrainment, Peer Pressure and Normalcy Bias (justiﬁcation and cognitivetechnological advances in machinery and equipment are becoming more upgradable

dissonance）

and complex, however, we should still think of our DNA and brain capacity as “ﬁrst-

Anyone else would do the same and the psychology of, “What will the neighbours

generation processes that cannot keep up with these changes”.

think?” and “I’m special, nothing can hurt me!”③ Conﬁrmation bias
People are unconsciously prone to believe only “what they want to believe” and“information that supports what they believe” rather than purposefully seeking
information to the contrary. They may say something like, “Stop exaggerating!”■

Avoids thinking deeply (it gets tired)■

Is not good at thinking logically■

Forgets and does not remember easily■

Not able to reject our assumptions■

Tends to believe that our choice is correct■

Tends to make choice based on first impression etc.
Fig. 6

6

7

P&I Loss Prevention BulletinJAPAN P& I CLUB
Optical illusions

Optical illusions
Human beings sometimes make assumptions

Observe the black and white tiles
that are separated by grey lines. The
grey lines appear as though they arecrooked. This is an optical illusion.
Really, each of these grey lines are infact straight and not crooked. This is
one example of a geometric illusion.
The straight lines between the rows ofalternating black and white “bricks”

Fig. ８: Café Wall illusion

appear to be tilting, when they are in fact parallel.
This illusion was ﬁrst described under the name of Kindergarten illusion in 1898, andwas re-discovered in 1973 by Richard Gregory. According to Gregory, this eﬀect wasFig. 7

When looking at the illusion in Figure. 7, we recognize that there are two different
women: one is a young lady who is facing away from us, and the other a proﬁle of anobserved by Steve Simpson, a member of his laboratory, on the wall tiles of a cafe at thefoot of St. Michael’s Hill in Bristol. This is a variant of the “shifted-chessboard illusion”
originated by Hugo Münsterberg.

elderly lady. If you can only see a young lady, try focussing on her ear to then see an eye, andSource from Wikipedia: Cafe wall illusion

her chin to then notice a nose, and then her necklace to see a mouth. On the other hand,
if you can only see an elderly lady, try focussing her eye and you will notice an ear, her nose
to reveal a chin and her mouth to reveal her necklace. Now it is possible to recognize bothladies, but isn't it hard to switch to seeing the other lady, once your mind is set on either ofthem at one time?

Interestingly, there is a strong tendency that someone of a younger generation willrecognize the young lady at first and that someone of a senior generation will rather
recognize the older woman ﬁrst.
It is an old painting from the 19th century, and as of 2016, it is the oldest conﬁrmed
drawing on a German postcard from 1888. The author is unknown, but what is

As a Mechanism behind Maritime Accidents
Unlike traffic accidents that may be caused by a single driver, casualties at sea are
seldom caused by one single human error. In most cases, there is a chain of humanerrors that leads to an accident, and unless the error chain is broken, as a result, an
accident is likely to occur.
An example of a collision accident is shown in Figure 9. It is understood that an accident
occurs when several errors overlap.

known is that this postcard’s illustration was used for a US automobile manufacturer
advertisement for the Anchor Buggy Company at around that time in 1890.
Source from Wikipedia: Trompe l'oeil (deceive the eye) My Wife and My Mother-in-Law

89

P&I Loss Prevention BulletinJAPAN P& I CLUB

１−３

Collision could have been avoided
by breaking the error chain

Prevention of Maritime Accidents

Basic approach
Herbert William Heinrich (1886-1692). When working as an assistant superintendent of
the engineering and inspection division of a non-life insurance company in America, his

Lack of proper look-out

law Heinrich’s Law was derived from his thesis which was published on 19 November,
1929.(Heinrich’s Law: Figure 10)
Behind every serious accident or disaster, it is said that there are 29 minor ones and that

Delay observing the other vessel

there are 300 near misses that fortunately do not lead to any accidents. Hazardous “unsafe
acts” referred to as “unsafe situations” number in their thousands, meaning that evenmore dangers lurk in the background.

Delay taking action to avoid collision

Expects other vessel to take action

Thus, if we are able to decrease the several thousands of unsafe conditions and 300 nearmisses, maritime accidents either minor or major, could deﬁnitely be reduced.



    
Lack of close communication

Collision
Fig. 9
       
Fig. 1010

11

P&I Loss Prevention Bulletin
There can be no “absolute safety” and “Safety can be deﬁned as the result or evaluation

JAPAN P& I CLUBJohari Windowof all danger being avoided”, as explained above in 1-1. Then, how can we achieve

to Self

the safe operation of vessels which are always exposed to a variety of dangers? By



that it is possible to “heighten the level of safety”.











   
     

Open Self

Blind Self

  





         

       
   

Considering the scope of activities in vessel operation, there are many dangers lurking in② Not known to self (Blind spot), ③ Known to others (Hidden area) and ④ Not known
the unknown area is an area that no one knows about (or a danger that no one notices)where safety measures are yet to be taken.
A requirement that would heighten the level of safety would be to enlarge the Open area.
In other words, the Open area speciﬁes that all members within the range of activity,

to others (Unknown area). The most dangerous area is the “Unknown area”. Namely,

to Other

the Johari Window. This consists of four window-panes: ① Known to self (Open area),

understanding the Johari Window (see Figure 11） in the ﬁeld of psychology, we can see

including the vessel and its land management department, are equally aware of the

Hidden Self

Unknown Self

danger, thus proactive measures can be taken.

to Self

The “Blind spot” can be narrowed by learning from each other’s knowledge andexperience, thus expanding the “Open area” of the team. Also, by opening our Hidden







Open area will be expanded, which will in turn bring about improved safety, eventually.






If we remain unaware of the “Unknown” area and its inherent dangers, this will render
However, if we enlarge the Open area, the Unknown area will reduce. At the same time,
the Blind spot and Hidden area will also reduce. This means that the level of safety will
improve.

to Others

us defenceless.



areas (what we know that others don’t) and by being aware of others’ blind spots, the

   
      

Open Self

Blind Self


     
    

Hidden Self  




     
   
 

Unknown Self

Fig. 1112

13

P&I Loss Prevention BulletinJAPAN P& I CLUBBTM and ETM
If there is insuﬃcient communication and cooperation between the person responsible

Bridge/Engine Room Team Management

BTM and ETM have been introduced as methods to prevent maritime accidents fromoccurring by breaking the chain of human errors (error chain). This method seeks to
acknowledge that it is a) impossible not to generate human error, b) that the team unite
and work together so that one person’s mistake does not create a dangerous situation, c)that mistakes be noticed and corrected in a timely manner, and d) that everyone ﬁnd a
way to support each other and break the error chain.
The concept of BTM and ETM is based on communication with the resources
surrounding the subject. （See Figure 12）
  

L Management（managing and utilizing SHELL)

error (L), the resources surrounding him/her will be aware of it and will communicate
this so that L is aware.
BTM and ETM training are effective methods that help us address communication
issues, however, there are many who still say that it is difficult to carry this out inpractice. The main reason has to do with the difficulty of communication. Figure 13
E 
L    

BTM・ETMS 

M

If the squares (H, S, E, L) are well aligned, then even when a person causes a human100％

H 

M

and safety cannot be established when a human error occurs.

illustrates this.

〈 M-SHELL Model 〉

for the accident (L) and each resource, and if the team does not gel, this will create a gap

Does not know, forgets ordoes not understand enough
  those resources such as: （: Hardware ） , (and （: Software） , （is always in a state of change. This situation can be shown in terms of quivering 




Distortion, notenough knowledge

Speculation,
judgement andown experience

40％

0％

Understands only 20% of what Capt. wants to convey

: Environment） ,: Persons other than the person responsible for the accident） . Each resource

60％ …

: Person responsible for the accident） is surrounded by



Gap

Is this common
sense in the world?

0％

Fig. 12The person at the centre （A gap or distortion
during conveyance 100％of instructions

Is this really common
knowledge among crew?

  

Fig. 13


Problems with oral instructions and communication (diﬃculty with communication)

rectangles.
14

15

P&I Loss Prevention BulletinJAPAN P& I CLUBThe yellow coloured area on the extreme left shows what a Master intends to order
or what message he intends to convey (Full understanding is shown as 100%). Even
when the Master tries to relay information to an Ordinary Seaman (O/S), only 20% of§2

the information may be understood due to a misunderstanding, a lack of understanding

4M4(5)E Analysis

or knowledge that the O/S may think is common sense, a lack of communication,
speculation or judgement on the part of the O/S, or he/she may compare what was
relayed to their own experience. Why is this the case?
It seems most likely that the reason why information cannot be conveyed successfully is
down to a diﬀerence in their level of understanding regarding technology. For example,
if the Master tries to convey the same message to another Master, his message will be
conveyed to the full (100%), because their technical backgrounds are almost the same.

One preventive measure that we can use is the 4M4(5)E Analysis. This model takes into
account lessons learned from similar past accidents. This is a countermeasure (method)that seeks to prevent a re-occurrence of the same or a similar accident based on lessons
learned, in the event that such an accident should occur.
“Safety” is management’s top priority
priority. In order to realize this, it is important to correctly
identify “the bud of a potentially new accident” and to prevent a re-occurrence based on thelessons learned. Most accidents at this bud forming stage can be referred to as events that
require attention or risky events and are often due to human error. Thus, it would be vitallynecessary to analyse such phenomenon thoroughly from a human factor perspective.
This method is derived from an accident investigation method adopted by the US National
Transportation Safety Board (NTSB) and has been used in various fields including theindustrial arena. With this method, we can not only look at error factors from multiple
perspectives but also examine preventive measures from a wide range of viewpoints.

２−１

Errors Made by an Involved Party andOrganizational Errors

Although we have established preventive measures for every time an accident occurs,
why then has the 4M4(5)E analysis been the subject of recent interest?

16

17

P&I Loss Prevention BulletinJAPAN P& I CLUB

According to The Hudson Model: Types of Safety Culture (See Figure 14), Safetyor holding the individual to account by punishing him/her (“grave-post type”). The

Culture has been developed as follows:

above Level １ (Pathological) and Level 2 (Reactive) are applicable to this.



But, we have learned that this kind of preventive measure lacks in eﬃcacy. Therefore,
it is a must that we examine the factors behind human error and explore further as towhy an individual causes a human error. Then we can take eﬀective countermeasures

In

fo

rm

ed

Level 5 GENERATIVE(“preventive type”） to prevent future re-occurrence.
ab
ili
t

cr

y

ea

sin

gl

y

Level 4 PROACTIVE
ou
nt
Ac
c

In

Level 3 CALCULATIVE

written by Akira Ishibashi; from Japan Industrial Safety and Health Association (JISHA)）(Provisional translation)

us
t

an

d

Level 2 REACTIVE

Figure 15 illustrates this. （Why are accidents repeated - the analysis of the human factor

Tr

Level 1 PATHOLOGICAL

maneuvering mistake andnon-compliance with COLREGS

In

cr

ea

sin

g

Error made by person involved

Easy to put measures in place

Fig. 14

Level 1 Pathological

Noticeable errors

Technical improvement(Small but easy to see)For example, Enforce use of lookout
and compliance with COLREGS

Safety problems are caused by the workers. Safety concerns
only the Safety department.

Level 2 Reactive

Safety is important, but we activate it only after an incident.
Collision

Mistakes are punished.
Level 3 Calculative

Safety driven by SMS and safety is improved through PDCA.
Emphasis on continuous monitoring using safety measures.

Level 4 Proactive

All staff understand the importance of safety. The

Unnoticeable errorsorganization tries to prevent accidents with proactive(Large but difﬁcult to see)

Organizational problems for
those both on land and on board(Problem is not easily solved)

measures (manpower, equipment and cost to be included).
Level 5 Generative

Safety is an inherent aspect of a sustainable organization.
All staff unconsciously give priority to safety.

In other words, in the past, when an accident occurred, because almost all accident
causes were due to human error, the person who caused the accident was identiﬁed andthe mistakes that led to the accident investigated. Then, the case would have been closed
after having reprimanded the individual by saying something like, “Be careful in future”

18

CHECK
Points to consider
from now on

Organizational error

Inappropriate manual, insufﬁcient training,poor working conditions and excessive paperwork
Fig. 15 Why are accidents repeated - the analysis of the human factor written by Akira Ishibashi
Source: Seminar on Analysis and Countermeasures of Accidents Learned from Case Studies, by Japan
Industrial Safety and Health Association (JISHA) (Provisional translation)

19

P&I Loss Prevention BulletinJAPAN P& I CLUBIn the event that an accident is considered to have been caused by human error, it is easy

4M

４（5）E

ﬁrst glance that the parties involved should be punished and that the technology should

Shows speciﬁc factors

Reveals countermeasures

be improved.

behind an accident

to take remedial measures for visible and technical errors. Moreover, it seems clear at

For example, as for collision accidents, most of their direct causes are related to humanerror such as insufficient lookout and non-compliance with the navigation act. As aresult, compliance with Article 5 of the Act on Preventing Collision at Sea (Lookout)●

Education

●

Man

●

Engineering●

Machine●

Enforcement●

Media（Environment）●

Example●Management●（5）Environment （within company
and on-board ship etc.）

and its 2nd Chapter (Navigation act) are followed, and the party involved is punished,
then the case is closed.
However, each Master and Navigation Officer who has a seaman’s competency
certificate fully understands the importance of lookout and compliance with the
Navigation act. True preventive measures cannot be established unless we analyse indepth as to why professional qualified mariners “neglected appropriate lookout andWhen considering the conditions that cause occupational accidents, it can be said that
85.6% occur as a result of a combination of “unsafe behaviour” and “unsafe conditions”.
(See Figure 16）

could not comply with the navigation act”. For example, as organizational errors that〈  

are not readily apparent manifest themselves, shown in Figure 15, we must construct
recurrence preventive measures by analysing the “Underlying causes”, to establish if
there are errors in the organization or team, such as an inappropriate manual, insuﬃcienttraining, poor working conditions and excessive paperwork.













２−２

4M4(5)E Analysis

As mentioned above, the 4M4(5)E analysis considers the cause of the accident to be a
result of organizational error. A matrix table of speciﬁc causes behind the accident and  〉



enforcement, examples, and environment (organization both within the company andonboard), are added.




   
   


    countermeasures is formulated. The speciﬁc causes behind the accident are described(4M）、 and then countermeasures (5E) in terms of training, technology, reinforcement/Percentage of accidents that occur when the two overlap ⇨85.6％
Fig. 16
Source: Seminar on Analysis and Countermeasures of Accidents Learned from Case Studies, byJapan Industrial Safety and Health Association（JISHA) (Provisional translation)

20

21

P&I Loss Prevention BulletinJAPAN P& I CLUBOn considering the reasons behind “unsafe behaviour” or “unsafe conditions”, theroot cause is often found in an “organization’s safety management deﬁciencies”. （SeeFigure 17） for 4M4(5)E analysis, whereby these “root causes” and “direct causes” areorganized into a table, analysed, and preventive measures formulated.

An outline of the analytic procedure will be explained below. （See Attachment 1 P.93）
1. Site investigation

Carry out investigation in as much detail as possible, ideally by a third party (such asa surveyor or marine consultant etc.) 

2. Analysis of site investigation report
・Clarify accident cause/s (4M), using a classiﬁcation table and so on.

（See Attachments 2-1, 2-2 and example in Figure 19.)

   



・Organize these into a matrix to examine the facts (See Attachment 3).



➊ Facts extracted from the accident investigation report that caused theaccident have been identiﬁed and listed under each factor in the table to
the right.



➋ Classify into Unsafe Behaviour or Unsafe Conditions by factor.
➌ After clarifying the accident cause/s, in order to analyse this, assess

Root Cause

Direct Cause

Accidents➍ Furthermore, clarify which items need to be inspected/investigatedFig. 17

again.

２−３ 4M4(5)E Analysis Plus Why Why Analysis:
Investigation, Analysis and Countermeasures
The 4M4(5)E analysis and countermeasure planning workﬂow is shown in Figure 18.







Man

Direct Cause

Accident Cause＊ Accident Reports
Ship reports, ship management company reports, survey reports,
attorney (maritime auxiliary）reports, transportation security
reports, and as much information as possible, such as accident
investigation reports of all committees and decisions of the Japan
Marine Accident Tribunal, are to be collected.














accident cause by prioritizing according to the scale of the cause.

４(or5)Es

Countermeasure＊Because it is important to check the facts, countermeasures are not to be made based on own speculation.
Conduct a further investigation, if necessary.
Fig. 18

22

23

P&I Loss Prevention Bulletin

ExampleVessel superintendent was aware of the
low visibility weather forecast, but, as heassumed that the Master also knew, he
did not report it.

JAPAN P& I CLUB
2 radars were equipped on board, but the magnetron of
No.1 radar was to be replaced by the manufacturer at thenext port. The Master was requested to navigate using
only No. 2 by the vessel superintendent, and agreed
despite feeling uneasy about it.

Attachment ３

Maritime Accident Summary of Related Facts

Caused by

Check facts and problem areas
Did not report a forecast of low visibility
to the Master

1

Unspeciﬁed
dateApprox. 3 p.m.

Vessel superintendent2

Unspeciﬁed
dateApprox. 4 p.m.

Vessel radar3

Unspeciﬁed
dateApprox. 5 p.m.

Vessel superintendent

Requested the Master to navigate using
only No. 2 radar until next port, because
arrangement to ﬁx No. 1 radar at the port
had been made4

Unspeciﬁed
dateApprox. 5 p.m.

Master5

6

Unspeciﬁed
dateUnspeciﬁed
dateUnspeciﬁed
time

Unspeciﬁedtime

No. 1 radar was out of order〇△

Re-examination necessity

Time

Unsafe conditions

Date

Unsafe behaviour

Reference No.

Identiﬁed problems from survey ﬁndings

Accident cause evaluation

Directcause

3. Once the above have been established, compile this information
into an accident cause/s matrix (unsafe behaviour and unsafe
conditions).

（See Attachments 4 and 5）
Pick out the relevant facts, and compare “unsafe behaviour” and “unsafe conditions”
using the 4M classification table and carry out a “Why Why Analysis”. Circle thecorresponding items.
❶ Enter relevant factors into Analysis Tables 1 to XX, and enter why these occurred in (2)to (6) below.

❷ Then, circle each applicable column.

❸ Enter the sub-item number of each item in the 4M Classification List for Machine,

4
〇

3

〇

〇

5

〇

Approved navigation to the next port using only one radar.

〇

6

2/O

Did not report to the Master, although
there was the low visibility (less than 2
nautical miles) (According to the Safety Management Code, low visibility is deﬁned as less than 3 nautical miles.)

〇

2

2/O

Searched for the other vessel at 6.6 nautical miles via radar, but did not notice
the image captured on ARPA, because hebelieved he could pass starboard to starboard〇

Media, and Management.

❹ For items requiring re-investigation, circle the corresponding column to the right.
4. Once the above 3 has been completed, analyse and devise
countermeasures.

(See Attachments 6 and 7)
1●

Classify the direct cause and indirect/root cause of the accident
referring to the 4M4(5)E table.

●

Devise a countermeasure for every 4(5) item.

❶ Copy over the risk factors from the analysis chart (including the applicable
numbers).

❷ Copy over countermeasures to reduce or improve the risk factors into the 4(5)E
table.

ExampleAccident cause assessment: Prioritized according to the scale of the cause

Why Why Analysis
The Why Why Analysis method is a way of finding and verifying the efficacy of

At XX:XX (unspecified time), the 2/O
knew that there was low visibility ofless than 2 nautical miles, but he did
not report it to the Master.

At XX:XX (unspecified time), Although the 2/O
searched for Vessel △△ at approximately 6.0 degrees
on their starboard bow in the vicinity of <015> 6.5
nautical miles via radar, he believed he could pass
starboard to starboard, but did not notice the image
captured on ARPA.

Fig. 19（P.98

24

solutions to a certain problem. By repeatedly asking the question “Why?”, the methodseeks to identify what caused the problem, what factors led to that cause, and so on andso on. This is a mainstay component of the Toyota Production System.

Attachment 3)

25

P&I Loss Prevention Bulletin
Method (Figure 20)• The first stage is to present the problem in question. In order to make a logicalJAPAN P& I CLUB〈 Analysis Chart for Incident ＆ Cause Factors（Model）〉
TimeSequence①

TimeSequence②

TimeSequence③

TimeSequence
④

Why?

Why?

Why?

Why?

ReasonReasonReasonReason

Why?

Why?

Why?

analyze

ReasonReasonReasonCausecauses. This is the result of the second “Why?” As with the first stage, thereWhy?

analyze

Why?

Conclusion

may be a number of different factors involved, but each must have a logical

ReasonCause

Reasonconnection to the subsequent cause.

analyze

Conclusion

Why?

progression to the next stage, it is helpful at this point to go through a processof elimination of irrelevant causative factors.
• A list of potential causes can then be created. This is the result of the first “Why?”
There may be multiple causes but they must all have a logical connection to theoriginal problem.
• The next stage is to come up with the potential factors which led to those• This process is repeated in the same manner with the 3rd and 4th stage of“Why?s”.

It is difficult to say at what point it is best to suspend this repeated process, but in

Cause
Conclusion

Measures

Measures

Incident

Measures

Reasonanalyze

Cause
Conclusion

practical terms the ultimate goal is to ﬁnd a logically proven solution whereby removalof the causative factors leads to elimination of the original problem.

Measures

During the “Why Why” process, some causative factors, be they a particular
phenomena or something of a more systemic nature, may well be deemed

Fig. 20

unavoidable. In which case, the analytic process should be suspended. Conversely
though, through this same process, it is also possible that factors, which were
thought to be unavoidable, are actually shown to be no more than a preconception.
The Toyota Motor Corporation ﬁrst pioneered this methodology and advocated a 5“Whys” technique. However, this method is now employed in a variety of diﬀerent
ﬁelds and is not restricted to a set number of whys. The important thing is to arrive at
the root cause of the problem.

26

27

P&I Loss Prevention Bulletin
Devise a countermeasure
Devise a countermeasure for each factor below regarding unsafe behaviour andconditions. The following items from ① to ⑤ are to be extracted from Attachment 4.
1

Measures to improve the competency, awarenessand knowledge required to perform the task.
Engineering：Technology and engineering
Technical measures of handling equipment forsafety improvement and improvement of equipment
etc.
3

Enforcement：
Thorough guidance and enforcement
Measures related to thoroughly enhanced regulationin order to ensure the work done and revision of the
SMS etc.

4

ExampleRisk factors（direct cause and indirect/root cause）

It is considered eﬀective to have them attend training programs
such as behavioral psychology to learn awareness.
Risk factors（direct cause and indirect/root cause）
Vessel
１． Why wasn't this captured by ARPA?
（１－③,⑧,⑨,⑩,⑪,4－1－③）

２． Why was the problem of poor visibility not reported to the Master?
（1－②,⑥,⑪,⑫,2－①,3－③）

６． Why did he approve navigating with a single radar?
（1－①,⑤,⑥,⑧,⑨,⑪,4－1－③,4－3－②）

Shipowner and ship management company
５． Why did they request a single radar for navigating?

（1－①,⑥,⑦,⑨,⑪,4－1－①,②,③,④,4－2－①,4－3－②,③）

Examples：Case studies, countermeasures and rules
Measures to show speciﬁc cases such as lead byexample, experience of success, introducing model

5

Figure 21 shows an example of recurrence prevention countermeasures.

Education ：Education and training

2

JAPAN P& I CLUB

Education and training

Knowledge, skills, consciousness,being given information, etc.

ExampleCase studies, countermeasuresand rules

cases etc.

● Training in behaviour psychology⇒ Learn to notice things

Lead by example, experience of success,Environment：● Education to reinforce habitually that(near misses), etc.

optical illusions/errors and assumptions● Gain a sense of experience using navi-

can cause a risky behaviour

gation simulations, for example

Measures related to working environment, oﬃce
internal management, on-board organization, etc.

introduce model cases,“Hiyari-Hatto”

Fig. 21

28

29

P&I Loss Prevention Bulletin
5. Carry out and verify countermeasures based on the devised
example above, and Brush up using a PDCA cycle.

The key is (1) to ensure that the proposed countermeasures are always implemented,(2) that their effectiveness is evaluated and verified and (3) that any defects arecorrected. That is to say, PDCA (Plan ・ Do ・ Check ・ Action （for improvement） shallJAPAN P& I CLUBDo
It is important to carry out the planned schedule with certainty.

Check（evaluation）

be performed. If this is not done, the hard-earned measures to prevent recurrence will

An assessment committee will be held every 3 to 4 months in order to manage

quickly become a mere formality. In the event of a major accident, it will be of value tothe work plan progress and to assess the implementation report. It is important tohave a recurrence prevention campaign annually (so as not to forget).

identify the problems by providing a general overview of the ﬁscal year at the end of
the year.

When considering methods of prevention, for example the PDCA cycle mentioned in
Attachment 7, be sure to carry out the following to ensure that the intended preventive
measures do not become a mere formality.

Action（improvement）
Analyse the problems identified in the evaluation （including the Why Why
Analysis), and formulate measures for improvement.

Enforcement（thorough guidance and enforcement）

Thoroughly clarify procedures for low visibility
in the procedure manual.

This outcome will be the Plan for the following ﬁscal year.

Plan
Here, we will examine how to ensure that the existing procedures are reviewed
and clariﬁed, as well as how to ensure compliance with the revised procedures atsea. In order to achieve this, 4 root causes (Technicians characteristics, Humanbehavioural traits, Psychological factors and Human brain capacity） described in
1-2 As a Mechanism behind Maritime Accidents Caused by Human Error, shall beconsidered. For example, a review of training programmes, internal audit frequency,
the launching of an evaluation committee etc. could be considered. The mostimportant is annual scheduling. If the scheduling is vague, these kinds of tasks will
be easily put oﬀ.

30

31

P&I Loss Prevention BulletinJAPAN P& I CLUBPoint of Occurrence

Near Kobe Rokko Island East Fairway Central FW Buoy

§3 Case Study= Collision Accident =Movement of Both Vessels

Pilot A boards at Tomogashima Channel, and when navigating northeast of Osaka Bay
toward RC-7 (Kobe Rokko Island) for mooring, he was trying to head for south of Kobe
Rokko Island East Waterway and steered to port side while reducing speed （ship speed:
11.3 knots (approx.).

Japan Transport Safety Board Report MA2019-6-02

Vessel B departed Osaka bound for Kobe RC-4 (Kobe Rokko Island) via Kobe Central

Japan Transport Safety Board Report

Fairway. While navigating northwestward and westward, at 13 knots of speed, S/B Full,

http://www.mlit.go.jp/jtsb/ship/rep-acci/2019/MA2019-6-2̲2018tk0004.pdf

The collision accident of the outgoing large size container which occurred oﬀ the port of
Kobe on XX May, 2018 is to be analysed.

３−１Date and time

the starboard bow of Vessel A collided with the accommodation space near the astern
port side of Vessel B. (See Figure 23）

Accident summary（See Attachment 8）

Vsl. B

07:02:49

XX May 2018. at approximately
07:02:49(JST)(See Figure 22）

07:02:44
07:02:34

XX May, 2018 at approximately 07:02:49 (JST)


Rokko Island

07:02:23
Hyogo 


Pref.

Osaka Bayakwater

No. 7 Bre

Osaka

Vsl. APref.

07:02:49

Wakayama Pref.

air

Way

rF
te

en

eC

East Fairb
KoPort Island

Awaji IdW
ay

Anchored Vessel 
   ­

07:02:29
100m

oy

ir Way Bu

Center Fa

Vsl. B

50
50

100m

Anchored Vessel
Vsl. A

Osaka Oﬀshore Landﬁll Site
(Osaka Bay Phoenix Center)Fig. 23

The weather and sea conditions and visibility at that time were as follows, and did notcontribute to the cause of the accident.
05:06

Fig. 2232

Fine SW ～ WSW 3.8 ～ 4.1m/s (wind force 2 ～ 3) Visibility 30km or

more (more than 16 nautical miles)
33

P&I Loss Prevention BulletinJAPAN P& I CLUBContainer Vessel A Summary

Container Vessel B Summary

Photograph 24

Gross tonnage： 97,825GT

L×B×D： 338m×46m×25m

Port of origin： Singapore（Length）（Breadth）（Depth）

34

Port of destination： Kobe RC-7

Cargo

:

Draft

： 12.85m Aft 13.35m

Crew arrangement： 3 Croatian, 2 Russian, 16 Filipino, 2 Indian, 1 Romanian and 2
ChineseSubtotal 26 crewmembers ＋ 3 accompanying passengers(Indian) and 1 Pilot
Total of 30 crewmembers on board

20FT CTNR×1,360
40FT CTNR×2,441

Ship's Bridge on duty
personnel at the timeof the accident： Master A, Pilot A, 3/O A, AB A and Cadet A

Master A： Croatian nationality at the age of 54：Captain since 2003, boarded
the vessel on March 2018 and had 8 times experience of entering
Hanshin Port of Kobe as Master

Pilot A： Japanese nationality at the age of 70 has been an active Pilot
since 2002 (15 times per month)

3/O A： Filipino nationality at the age of 24

Cadet A

： Chinese nationality at the age of 25

Photograph 25

Gross tonnage： 9,566GT

L×B×D： 141m×23m×12m

Port of origin： Osaka

Port of destination： Kobe RC-4

Cargo

:

Draft：： Fore 5.19m

Crew arrangement： Master and 17 other crew members, all Chinese nationals

Ship's Bridge on duty
personnel at the timeof the accident： Master B, Navigation Officer B and AB B

Master B： Master B was at the age of 45 with experience as Mastersince 2002. He boarded the Vessel on November 2017 andhad more than 100 times experience as Master of calling at
Hanshin Port in the Kobe area.

（Length）（Breadth）（Depth）

20FT CTNR×197
40FT CTNR×208
Aft 7.05m

35

P&I Loss Prevention BulletinJAPAN P& I CLUB

Damage■Vessel A was damaged due to a bent and dented bulwark at the starboard bow withscratched shell plating and concave loss on the bulbous bow. (Photograph 26)

F'cle Deck Starboard Side

Photograph 26■As for Vessel B, her accommodation spaces at the astern of port side and the shell
plating on the port side was cracked. （Photograph 27）

Vessel B Damage
covered with a sheet

36

37

P&I Loss Prevention BulletinJAPAN P& I CLUB

３−２ Events that Led to the Accident（See Attachments 8 and 9）
In the table of events leading up to the accident (Attachment 9), items related to theaccident cause are shown in red.

Ship handling to be applied
Although the conclusion is not yet known, as the decision of the Marine Accident
Inquiry is still currently being deliberated (while the author is writing this Guidebook),
relative position which seems to be applicable to a Crossing Situation （Rule 15 of Act
for Preventing Collisions at Sea) would appear to be the case. However, considering
the fact that both Vessel A and B frequently changed headings, increased or decreased
speed, etc., and given the outcome of similar accidents, there is a high possibility that
“Article 39 of the same law: Liability for negligence of caution, etc. (Managing oﬃcer
of a seafarer)” will be applied. For reference, a crossing situation, actions by the giveway vessel and stand-on vessel, text regarding Crew responsibilities related to Act for
Preventing Collisions at Sea and Marine Accidents Inquiry Law Article 1 （Purpose）
will be shown below:

Reference: Extracts from the Act on Preventing Collisions
at Sea and the Marine Accidents Inquiry Law-Sea and the Marine Accidents Inquiry Law■ (Crossing Situation)

Photograph 27

38

Rule 15
When two power-driven vessels are crossing so as to involve risk of collision, the vessel
which has the other on her own starboard side shall keep out of the way and shall, if thecircumstances of the case admit, avoid crossing ahead of the other vessel. In this case,the vessel that must avoid the course of the other vessel shall not cross the bow of theother vessel unless it is unavoidable (Provisional translation).

39

P&I Loss Prevention BulletinJAPAN P& I CLUB■ (Action by give-way vessel)

３−３Rule 16

Causes behind Maritime Accidents

In accordance with the provisions of this Act, every vessel which is directed to keep out of
the way of another vessel (stand-on vessel defined in the following article) shall, as far as
possible, take early and substantial action to keep well clear.

By extracting the accident causes from the Japan Transport Safety Board Report■ (Action by stand-on vessel)

Attachment 9)(MA2019-6-02), the parts considered as the accident cause are highlighted in red. (SeeRule 17(i)Where one of two vessels is to keep out of the way the other shall keep her courseand speed.
(ii) The latter vessel（hereinafter, “stand-on vessel” in this Rule）may however take action
to avoid collision by her manoeuvre alone, as soon as it becomes apparent to herthat the vessel required to keep out of the way is not taking appropriate action incompliance with these Rules. In this case, if the requirements of Rule 15.1 apply tothese vessels, the stand-on vessel shall turn to port unless impossible.
(iii) When, from any cause, the vessel required to keep her course and speed finds herself
so close that collision cannot be avoided by the action of the give-way vessel alone,
she shall take the best possible cooperative action to avoid a collision.
■ (Neglect of duties: Crew responsibilities)

Container Vessel A▶

05:00 (approx.)

Pilot A

Boarded Vessel A at Tomogashima pilot station. After conducting theinformation exchange about Vessel A and its port entry work with Master A,
he started his pilotage of Vessel A. Through his pilotage on various vessels,
he felt that the crew of Vessel A had received thorough training in BRM andassumed them to be trustworthy. Also, he assumed that Master A had ashared understanding of the navigation plan.

▶

06:44 (approx.)

Pilot A

Informed port radio via VHF No. 2 in Japanese as follows:

Article 39
This article stipulates that in the event of any consequences resulting from neglect of anyof the following listed below, neither the vessel structure or materials, or vessel owner, or
Master, or crew will be exempt from responsibility: appropriate navigation, observance ofany lights or shapes displayed, the sending of signals, or any of the duties of the crew, be●

He had arrived outside Hanshin Port of Kobe area, and●planned to pass through the breakwater to RC-7 of Hanshin Port
Kobe at approximately 07:20

they either routine or those required in special circumstances.

The Pilot also heard that a vessel would pass Vessel Aʼs bow from port radio;that Vessel B would enter Kobe Central Fairway at approximately 07:15.
The Pilot visually conﬁrmed Vessel B, but did not inform the Master.

Marine Accidents Inquiry Law
Article 1 (Purpose)
This article stipulates that in the event of any marine accidents caused either in the courseof duties or through negligence, disciplinary proceedings against either maritime officers,
or small vessel operators, or pilots, shall be determined at a maritime tribunal establishedby the Ministry of Land, Infrastructure, Transport and Tourism. The main purpose of which
will be to help prevent further accidents from happening again.

▶

06:53 (approx.)

Master A

After visually confirming Vessel B on starboard bow at a distance ofapproximately 3.0 nautical miles, he also conﬁrmed Closest Point of Approach(CPA)（hereinafter, DCPA) with Vessel B via No.1 Electronic Chart Display andInformation System at 0.84 nautical miles (approx. 1,556 meters). Because
Vessel B was heading in a southwest direction, and his Vessel was going tosteer to port, the Master thought he could pass starboard to starboard with
ample distance.
But, he did not mention the movement of Vessel B to Pilot A. Also, because

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P&I Loss Prevention BulletinJAPAN P& I CLUB

Pilot A did not mention the movement of Vessel B as well, near the sea chart
table, he started discussing port entry work with C/O A.

▶

▶

06:55 (approx.)

Note: Cocktail-party effect (psychology terminology)

Pilot A

Please imagine a situation such as

across the room, because they can

Because Master A appeared to be keeping lookout via radar, Pilot A kept abeing at a job-well-done party or

focus on the talk that interests themvisual lookout for Vessel Bʼs movements. At approximately 06:55, althoughwedding after party. An example

most. Thus, it is thought that humans

he felt that there was no change of bearing between Vessel A and Vessel B,of this would be the way in whichhave the ability to segregate different

he assumed that the crew of Vessel A were paying attention to the movement

a person at a lively par ty is ablesounds and re-arrange them in orderof Vessel B, because Master A and 3/O A were watching the radar (ARPA)

to filter out all of the surroundingof priority. In psychology, this is known

and ECDIS. Also, because he visually pointed to Vessel B. Then he instructedbackground noise and still hear theiras the “cocktail-party effect”
ect”. It may be

the vessel to steer to port side in order to head for Kobe Rokko Island Eastown conversation. They will eventhat he did not pay attention to Cadet

Waterway (hereinafter East Fairway).

notice if their name is called out fromA’s reporting on a routain basis.

06: 57 (approx.)

Pilot A▶

risk of collision with Vessel B.

Pilot A, Master A and 3/O A

Did not respond to Vessel Bʼs VHF call. He might have got into a panic as

Cadet A reported to Pilot A, Master A and3/O A, because he was worried about a

07:02 (approx.)

the Vessel was about to collide.

Container Vessel B▶

06:50 (approx.)

Master B

Confirmed Vessel A (at bow and distance of approximately 4.0 nautical
Although he could not predict where Vessel B was heading immediately after

miles) and started lookout both via radar and visually. Then, at 06:52

she steered to starboard, he visually conﬁrmed Vessel Bʼs relative position.

(approx.), he steered to starboard heading for Kobe Central Fairway.
Fairway

Vessel B would pass the bow of Vessel A, and he continued to steer to portside while reducing speed. Therefore, he kept manoeuvring, believing that his
instruction regarding navigation in preparation for port entry work had been
approved by Master A. In addition, Cadet A conﬁrmed the risk of collision with
Vessel B via radar and reported it to Pilot A（by saying “Closer!! Closer!!”), but
the Pilot did not notice Cadet Aʼs report.

▶

06:57 (approx.)

Master A and 3/O A▶

06:54 (approx.)

Master B

Recognized crossing point with Vessel A

and that Vessel B was the stand-on vessel. He was concerned about the decreasing DCPA of approximately
06:57, but assumed that vessel B could pass the bow of Vessel A without
trouble, according to Vesselʼs A predicted course on the radar (ARPA). Also,
if the speed had been increased to Nav. Full, he assumed that the vessel
would reach port too quickly.

Did not notice the Cadet reporting. * Cocktail-party effect

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P&I Loss Prevention Bulletin

３− 4JAPAN P& I CLUB

Accident Causes

on vessel at the crossing point with Vessel A. This is why he completely believed that
Vessel B could pass the bow of Vessel A without the need to conﬁrm visually.

Taking the above 9 factors into account, the Japan Transport Safety Board summarised
the accident causes as follows:

Information exchange via VHF

Another cause behind the accident could be that neither communicated one another’sContainer Vessel A
Headed for the entrance of Kobe Rokko Island East Waterway and started steering toport side while reducing speed, Pilot A thought that Vessel A could pass the bow ofVessel B, which became the direct cause.

sailing route at an early stage using VHF.
Although Vessel A obtained the other vessel’s information from port radio, neither
paid attention to each other’s Vessel’s movements. Mutual communication might have
prevented the accident.

Although Pilot A continued to steer to port side along with reducing speed gradually in

３−５ Transport Safety Board Report＝ Recurrence Preventive Measures ＝preparation for port entry, he assumed his vessel could pass the bow in relation to Vessel
B which was visually conﬁrmed, but apparently he did not realize there was a risk ofcollision with Vessel B.
Furthermore, Master A visually confirmed Vessel B at the point of 3.5 nautical miles

The Japan Transport Safety Board Report (MA2019-6-02) summarises preventive

in the distance, without confirming the movement of Vessel B with Pilot A. Judging

measures to be taken as follows:by his vessel’s relative position, before Vessel B steered to starboard side (had alreadypassed Vessel B’s bow), there is the possibility that he assumed that Vessel B would pass
starboard to starboard and that there would be no risk of collision.

Pilot
A constant watch must be kept both visually, and by means of radar

Container Vessel B
While heading for the entrance of Kobe Central Fairway, he continued manoeuvringand ECDIS navigation instruments.
When another ship is passing in close proximity, the risk of collisionmust be considered. VHF contact should be made to the other vessel

believing that he could pass the bow （front） of Vessel A, which we consider to be thewith a request for their co-operation to avoid such an outcome.

direct cause.

The respective oﬃcers of the watch of the two vessels should verbally

From Vessel A’s sailing route and predicted course via radar (ARPA data), Masterclarify each other's manoeuvres and headings.

B assumed that Vessel A would follow her original course. (In fact, Vessel A started

Communication should be in the local language (Japanese), and thesteering to port side).

contents relayed to the Ship's Master.

He confirmed the ARPA data via radar （vector diagram and DCPA and TCPA digital
display), but there is a possibility that he believed that Vessel B was to be the stand44

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P&I Loss Prevention BulletinJAPAN P& I CLUB

§4 4M4(5)E Analysis of a Case Study＝ Collision Accident ＝
Photograph 28 courtesy of the Japan Captains Association, DVD

Master A and Master B: Common characteristics of both vessels
Together with the pilot, the respective oﬃcers of the watch should verbally
clarify each others manoeuvres and headings.

４−１

Summary of Related Facts (See Attachment 10)

Related facts from the previous chapter “3-2 Events That Led to the Accident weresummarised in the “Maritime Accident Summary of Related Facts.” This brings us to thefollowing:

Even when there is a pilot on board, both the crew and the Master himself

There is nothing applicable to Unsafe conditions.

must be aware that navigation is ultimately the responsibility of the Master

Rather a number of unsafe behaviours of Pilot A are examined.

and that constant surveillance must be maintained.
When coming into close proximity to another vessel, both the Master andMaster must ensure that the crew are fully competent with operating the
VDR.
Vessel A switched off its VDR immediately
after the accident in order to preserve the data,
however the vessel set off on its next voyage
before the data could be extracted (Kobe to
Nagoya). The VDR was again switched on andthe previous data overwritten and deleted.
Photograph 29

1

XX MayTime

05：00 Approx.

Caused by

Check facts and problem areas

Pilot A

Felt that the crew of Vessel A had received
thorough training in BRM and assumed them
to be trustworthy. Also, assumed that Master A
had a shared understanding of the navigation
plan.

〇

4

2

XX May06：44 Approx.

Pilot A

Visually conﬁrmed Vessel B, but did not informthe Master of port radio information (Vessel B
bound for RC-7).

〇

3

3

XX May06：53 Approx.

Master A

Assumed that Vessel B would keep its distancewhen passing the starboard side of Vessel A.

〇

5

4

XX May06：53 Approx.

Master A

Did not mention the movement of Vessel B to
Pilot A. Also, as Pilot did not talk to him about
Vessel B, he started discussing port entry worknear the sea chart table with 1/O A.

〇

6

〇

1

5

XX May06：55 Approx.

Pilot A

Although he felt that there was no changeof bearing between Vessel A and Vessel B,
he assumed crew of Vessel A were paying
attention to the movement of Vessel B, because
Master A and 3/O A were watching the radarand ECDIS. Pilot A himself conﬁrmed Vessel B
visually by pointing.

6

XX May06：57 Approx.

Pilot A

Assumed that Vessel B would pass their bow,and continued to steer to port side.

〇

2

7

XX May06：57 Approx.

Pilot ADid not notice the Cadet reporting.

〇7

Did not notice the Cadet reporting earlier.

〇

8

8

XX May06：57 Approx.

Master A and 3/O
A

9

XX May07：02 Approx.

Pilot A, Master A
and 3/O A

Did not respond to Vessel Bʼs VHF call.

〇

9

10

XX May06：57 Approx.

Master B

Was concerned about decreasing DCPA, but
assumed that vessel B could pass the bow
Vessel A, according to the predicted course
Vessel A on the radar.

〇

10

11

XX May06：57 Approx.

Re-examination necessity

To safeguard the storage of objective data in the event of any accident, theDate

Unsafe behaviour

be maintained for both vessels to safely pass each other.

Identiﬁed problems from survey ﬁndings

Unsafe conditions

into account the length and width of either vessel. Suﬃcient separation must

Vessel A and Vessel B Collision Accident Summary of Related Facts
Directcause

Reference No.

which is based on the location of each vessel's GPS antenna, does not takeAttachment 10

Accident cause evaluation

the Pilot must be aware that the distance of closest approach (DCPA),

Bias and assumptions are particularly noticeable.

Master B

Assumed that the vessel would reach port
quicker if speed was increased to Nav. Full.

〇

11

12

Master B andship managementcompany B

Did not instruct navigation ofﬁcer to reportand lookout thoroughly.（BRM is was not
implemented）

〇

12

13

Pilotsʼ Associations

Were the pilots obliged to take BRM training
periodically?

〇

13

14

Master A

Non-compliance with Safety Management Code

〇

14

〇

15

Ship managementcompany A

Non-compliance with Safety Management Code

〇

15

〇

〇

Accident cause assessment: Prioritized according to the scale of the cause

Fig. 30 (Attachment P. 112）

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P&I Loss Prevention BulletinJAPAN P& I CLUBRegarding the examined behaviours in the list of related facts, each unsafe behaviour
will be summarised while carrying out a Why Why Analysis.

It is understandable that it may be diﬃcult to exchange information with other membersof the Bridge including the Master of the vessel because of such pilotage conditions
in Osaka Bay where traffic is congested. However, ⑪ Habituation phenomenon and

４−２⑤ Unconscious acts and Judgement based on speculation and so on, and each item

Analysis of Unsafe Behaviour for Pilot A

applicable to the list here all contribute to the chain of human errors.

（See Attachment 11)

In addition, Cadet A reported the movement of Vessel B shortly before the collision, but
After carrying out the Why Why Analysis regarding Pilot A’s unsafe behaviour which

they did not notice. “People are unconsciously prone to believe only what they want

was extracted from the “Maritime Accident Summary of Related Facts”, we can see

to believe” and “information that supports what they believe rather than purposefully

that the causes of the unsafe behaviour are mostly associated with “Man” of the 4M.

seeking information to the contrary” from ③ Psychological factors on “P.6 1-2 As a

(Figure 31)

Mechanism behind Maritime Accidents Caused by Human Error” of which Conﬁrmation

In addition, in this situation, Management （Management factors and organization）

bias (psychology terminology) might have contributed as well.

stipulates that Pilot A, as a member of the BTM structure, should exchange information,
but this was not adhered to. Thus, there is a necessity to investigate as to whether the

４−３

Pilots associations have such policies and operation manuals, and if so, ascertain as towhy Pilot A could not follow them.
P&I

Loss Prevention BulletinJAPAN P& I CLUBMan

MachineHuman factor (The vessel, shipowner and ship management company）
4 Individual skills

Cause (Unsafe behaviour)
2 Emotional

3 Organizational

4-1 Inadequate knowledge

4-2 Inadequate
4-3 Poor work ethic
skillsMediaManagement

Mechanical factors such as machinery not working properly or
being out of orderMedia connecting Man with
Machinery

Mainly on the vessel

The vessel, shipowner andship management company

5 Managementof health andworking environment

Management factors and organization

Shipowner and Ship managementcompany

On the vessel
⑥

①

②

③

④

⑤

⑥

Lack of education and training

Inadequate layout arrangement

Inadequate supervision of his/her
subordinates

Inadequate management/
organization

Inadequate/incomplete regulations
and procedure manual

Inadequate safety management
planning

Lack of education and training

Inadequate layout arrangement

Inadequate supervision of his/her
subordinates

Work preparedness/inadequate
working conditions

Inadequate safety management
planning

Lack of information regarding work
to be carried out⑤

Lack of machinery and facility
maintenance, etc.

Inadequate/incomplete regulations
and procedure manual②

Lack of standardization④①

Lack of consideration regarding
ergonomic factors

Inadequate management/
organization⑥

Lack of fundamental safety (designand ergonomic arrangement)③⑤

Defective protection against hazards②④

Design ﬂaw in the machinery

Inadequate work space③

Tool box meeting was not
implemented①②

Inappropriate work method①

Health check not implemented prior
to working

Poor working environment conditions②

Protective wear not worn⑤①

Covers up or tolerates dishonest
work

④

④

③

③

Communication②

Leadership and teamwork

Not enough training

Desire and willingness

The belief that the work done is satisfactory,
when objectively it is inadequate③

AgeingIntentionally dishonest regarding
work, and breaks the rules②

Physical ability

Not “ready” to work①

Alcohol, medicine or disease①⑤

Lack of sleep

Unaccustomed to work,
inexperienced, inadequate skills④

Fatigue③③

Personality

Lacks basic knowledge of the work②

Habituation phenomenon②①

Judgement based on speculation

Mistakes and perceptual illusion

Mistakes regarding work procedure/
forgetfulness⑫

Cuts corners①⑪

Mental shortcuts

Lack of a sense of urgency andawareness⑩

Sense of urgency and sensitively⑤⑨

Unconscious acts

Work content not understood or
misunderstood⑧

Personal problems④⑦

Habituation behaviour③⑥

Forgetful

Commitment (responsible
intervention)⑤

Impulsive action

②

④

①

③

Inadequate or inappropriate knowledge
about the work to be carried out

②

④

①

Necessity of re-investigation

1 Psychological

In ① , write down a direct cause
which was investigated basedon the facts After ② , write
down the root cause using the
Why Why Analysis. Then, circle
each applicable cause. Regarding items other than Man (Human factors), enter the sub-item
number of each item in the 4M
Classiﬁcation List.

Analysis on Unsafe Behaviour for Master A
and Master B (See Attachment 12)

In the same way as Pilot A, the Why Why Analysis will be carried out here regarding theunsafe behaviour of Master A and Master B.
P&I

Loss Prevention BulletinJAPAN P& I CLUB

Pilot A
1. Why was it assumed
that the crew of vessel A
had been thoroughly trainedin BRM and that Master A
had a shared understandingof the Passage Plan?

1

Was there not enough time
to conﬁrm?

③

Was it because the vessel
belonged to his afﬁliatedshipping company?

〇

Management

Mechanical factors such as machinery not working properly or
being out of orderMedia connecting Man with
Machinery

Mainly on the vessel

The vessel, shipowner andship management company

5 Managementof health andworking environment

Management factors and organization

Shipowner and Ship managementcompany

On the vessel

Inadequate layout arrangement

Inadequate safety management
planning

Lack of education and training

Inadequate/incomplete regulations
and procedure manual

Inadequate supervision of his/her
subordinates

③

⑥

②

Inadequate layout arrangement

Inadequate management/
organization

⑤

①

④

⑥

Inadequate safety management
planning

Lack of education and training

Inadequate/incomplete regulations
and procedure manual

Inadequate supervision of his/her
subordinates

③

⑤

②

④

①

Inadequate work space

Inadequate management/
organization

Inappropriate work method

Poor working environment conditions

Work preparedness/inadequate
working conditions⑤②

Lack of information regarding work
to be carried out④①

Lack of standardization

Lack of machinery and facility
maintenance, etc.

③⑥

Defective protection against hazards

Lack of consideration regarding
ergonomic factors⑤④

Lack of fundamental safety (designand ergonomic arrangement)

Design ﬂaw in the machinery③

Tool box meeting was not
implemented②②

Protective wear not worn

Health check not implemented prior
to working①①

Covers up or tolerates dishonestwork

Mistakes regarding work procedure/
forgetfulness

Intentionally dishonest regarding
work, and breaks the rules

Lack of a sense of urgency andawareness④

Work content not understood or
misunderstood

③

④

②

③

Communication

Not enough training②

Leadership and teamwork

Inadequate or inappropriate knowledge
about the work to be carried out

The belief that the work done is satisfactory,
when objectively it is inadequate①

Desire and willingness

Commitment (responsible
intervention)

Not “ready” to work④

Ageing③③

Physical ability①②

Alcohol, medicine or disease

Lacks basic knowledge of the work①

Lack of sleep

4

6

2

1

1

Fig. 31（Attachment P. 113）

3. Why did he assume
that Vessel B would
pass the starboardbow?

②

Why did he not continue
monitoring Vessel B?

〇

4

4. Why did he not ask
the pilot about the
movement of Vessel B,
and instead discuss port
entry with C/O A?

〇〇

speculation. In addition, there are many issues related to ② Leadership and teamwork
and ③ Communication, in 3 Organizational factors.

〇〇

8. Why did he not pay
attention to Cadet Aʼsreporting?

8

〇

〇

〇

2

10

10. Why did he thinkthat Vessel B could
pass the bow of VesselA, even though he wasconcerned about thedecreasing DCPA?

〇②

Why did he only not
conﬁrm the ARPA?

2

①

③

2

1

1

〇

〇

①

③

1

1

1

1

〇

〇

〇

〇

Total number ofcircled items

Looking at Human factors, it is possible to see that there is a concentration of factorsthat fall under 1 Psychological Factors ⑧ Cutting corners and ⑨ Judgement based on〇

Why did he not re-con② ﬁrm the movement ofVessel B?

Why did believe that
② Cadet Aʼs skills were insufﬁcient?

48

Unaccustomed to work,
inexperienced, inadequate skills

⑤

〇

②

④

Fatigue〇①③

Personality

3

⑤

②

2

Habituation phenomenon

10

①

7

Mistakes and perceptual illusion

3

〇

3

〇

2

⑫

4

⑪

4

Cuts corners〇⑩

9. Why did he not respondto Vessel Bʼs VHF call?

4-2 Inadequate
4-3 Poor work ethic
skillsMedia

Master A(Master of Vessel A)〇〇

Total number of circled items

〇

〇

〇

〇

Mental shortcuts〇

Judgement based on speculation

〇

〇

⑨

〇

Sense of urgency and sensitively

〇

〇

〇

⑧

〇
〇

〇

Unconscious acts

〇

〇

⑦

〇

Personal problems〇

In ① , write down a directcause which was investigated based on the facts After② , write down the root
cause using the Why Why
Analysis. Then, circle eachapplicable cause. Regarding
items other than Man (Human factors), enter the subitem number of each item inthe 4M Classiﬁcation List.

〇⑥

Why did believe that CadetAʼs skills were insufﬁcient?

〇

〇

〇

〇

Habituation behaviour

③

〇

〇

〇

⑤

Why did he not pay attention to Cadet A as well?

〇〇

Forgetful

②

〇

〇

〇

7. Why did he not notice
Cadet A reporting?

7

〇

〇

4-1 Inadequate knowledge

④

〇

〇
〇

3 Organizational

Impulsive action②

Why did he not check thechange of relative bearingor DCPA?

4 Individual skills
2 Emotional〇③

Why did he assume conﬁrmation was not needed because the crew weremonitoring the ECDIS?
6. Why did he assume that
Vessel B would pass theirbow, and continued tosteer to port side?

6

Human factor (The vessel, shipowner and ship management company）

1 Psychological

Assumed that the Master
understood because he also checked Vessel B.

Machine

②

②

Man

①

Cause (Unsafe behaviour)〇

5. Why did he think thecrew were paying attention
to Vessel B?

5

①

①

②

〇

〇

2. Why was information on
Vessel B not reported to
Master A?

2

9

〇

〇

Necessity of re-investigation

②

〇

〇

〇

2

〇
1

2

3

3

1

1

〇

〇

〇

〇

〇

〇

〇

〇

2

2

3

2

Master B(Master of Vessel B)

Why did he not havethe Navigation Ofﬁcer③ report on the change ofrelative bearing and so
on?

〇

〇

11. Why did he believethat the vessel would
reach port quicker ifspeed was increased toNav. Full?

〇〇

Total number of circled items

2

2

11

〇

1

〇

Fig. 32（Attachment P. 116）

49

P&I Loss Prevention Bulletin
Master A
We can see that the causes of unsafe behaviour are mostly associated with “Man” of
the 4M. As shown in Figure 31 and on close examination, we can see that there is atendency for ⑦ Mental shortcuts, ⑧ Cutting corners and ⑨ Speculation and judgementin 1 Psychological factors. Also, similarly to Pilot A, problems can be identified in ②

JAPAN P& I CLUBcorners and ⑨ Judgement based on speculation. In particular, he was distracted inorder to not be delayed for the port arrival time which caused him to neglect monitoring
Vessel A. Also, another reason as to why he did not pay attention to the movements ofVessel A was because he neglected to conﬁrm visually as a result of solely relying on the
ARPA （CPA/TCPA) system.

Leadership and teamwork and ③ Communication in 3 Organizational factors.
Vessel B’s movement was confirmed only once. However, it was before Vessel B
changed her direction bound for Kobe RC-4 (Kobe Rokko Island) and, at that point,
the stem of the Vessel B was facing a southwesterly direction （Tomogashima Channel
direction). This is why he believed Vessel B was an outgoing ship from Osaka Bay andthat he could pass starboard to starboard.
As introduced in “ 4 Human Brain Capacity ” in “P.7 1-2 As a Mechanism
behind Maritime Accidents Caused by Human Error”, once he/she may have had a bias,
we understand the diﬃculty in thinking diﬀerently about something once it set in one’s
mind.

４−４

Countermeasures for Unsafe Behaviour for
Pilot A (See Attachment 13）

As there were no related facts applicable to unsafe conditions, regarding the unsafe
behaviour of Pilot A and the pilots’ association, we are going to consider measures with
“Analysis using 4M5E and Countermeasure List (Unsafe behaviour)”.
3-4-4 Analysis using ４M５E and Countermeasure List for Pilot Attachment 13
On listing up the examined factors, it is possible to ascertain countermeasures.

He let Pilot A take care of the manoeuvring, and started discussing port entry workwith C/O A. It must be said that he neglected his top priority of keeping lookout, whichshows that the prioritizing of work proved to be challenging.
We presume that the importance of BTM is stated in the SMS manual at the ship
management company. But as this is still unknown, we circled the column Re-

The root causes can be identified in the following:● Human beings face difficulty thinking differently about something once
they have it set in their mind.
● Lack of awareness that the pilot is also a member of the BTM structure.

examination necessary regarding: 1. Inadequate management/organization, 2.
Inadequate/incomplete regulations and procedure manual, 3. Inadequate safety
management planning, and 6. Inadequate supervision of his/her subordinates, in theitems under Management.

Master B

Recurrence Prevention Countermeasures● BTM re-training● Training in psychology (mental stateof mind)

The Pilots’ Associations, as organizations,also need to take preventative measures● Creation or review of the procedure
manual● Introduce BTM training and trainingthat covers mental state of mind

Similarly to Master A, it is possible to see that there is a concentration of factors that fallunder Man (Human factors) in 1 Psychological Factors ⑦ Mental shortcuts, ⑧ Cutting

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P&I Loss Prevention Bulletin

Attachment 13

JAPAN P& I CLUB

Vessel A and Vessel B Collision Accident Analysis using 4M5E andCountermeasure List (Unsafe behaviour): Pilot A
ManMachineMedia

The vessel, shipowner and ship managementcompany

Mainly on thevessel

The vessel,
shipowner andship management company

1 Psychological
1. Why was it assumed that the crew ofvessel A had been thoroughly trained in
BTM and that Master A had a shared understanding of the Passage Plan?（1- ① ,③ and ⑧〜⑪）
2. Why was information on Vessel B not reported to Master A?（1- ⑦〜⑨）

Risk factors（Direct cause and indirect/
root cause）

Management
On the vessel

13. Incomplete BRM
includingpilot（2①）

13. Incomplete BRM including pilot（2- ①）
13. Not enough training
about psychologicalfactors invites human error（2- ①）

6. Why did he assume that Vessel B would
pass their bow, and continued to steer toport side?（1- ③ , ⑤ , ⑧ and ⑨）

operation and ship management were both managed by the shipping company from
where Pilot A belonged.

9. Why did he not respond to Vessel Bʼs
VHF call? (1- ①）
3 Organizational Related Facts 1, 2, 5, 5,
7 and 9② Why could he not exert leadership as aconning ofﬁcer?
③ Why could he not communicate with the
Master?

This would partly explain as to why he assumed that the BTM training had beenthoroughly carried out.

Cause・Human beings face difﬁculty thinking differently about something once they haveit set in their mind.
・The pilot is also a member of the Bridge.
It would have been naive not to haveconsidered him part of the BTM structure.

06:45 (approx.) He visually conﬁrmed Vessel B and checked the movement

2 of Vessel B with port radio, but he did not report this to Master A.

Recurrence Prevention Countermeasures
・BTM re-training
・Training in psychology (mental state ofmind)

Resource management via communication with resources surrounding the subject

Engineering
Technology and engineering
Engineering countermeasure
Enforcement
Thorough guidance and enforcement
Standardization, proceduralization, alerting, rewardand punishment KYT, Campagnes etc..

Recurrence Prevention
Countermeasures・Thorough guidanceand creation of procedure manual for pilotage regarding BRM（Pilotsʼ associations)

ExamplesCase studies, countermeasures and rules
Lead by example, experienceof success, introduce model cases, “Hiyari-Hatto” (nearmisses), etc.

Recurrence Prevention
Countermeasures
・Introduce model cases, BRM training andtraining that covers mental state ofmind(Pilotsʼ associations)

Environment
Working environment, ofﬁce
internal management, onboard organization, etc.

Each item number (bold and red coloured) corresponds to the Summary of Related Facts No. in the Attachment 3
The number applies to the number in Attachment 2-2 (Maritime Accidents 4M Classification List)

Fig. 33 (Attachment P. 119)（P.14 See Figure 12), which is based on the concept of BTM, was not sufﬁcient. This
generated a gap between the subject and other people except the subject which is
the most important resource where human error would be caused.
Not informing the movement of Vessel B to Master A, 3/O A, Cadet A and A/B A
is applicable to the Hidden area: risk factors which only one knows, that others do
not in the Johari Window（P.13 See Figure 11). Had such information been sharedappropriately, this would have been changed to an Open area, which would haveallow the shipʼs bridge on duty personnel of Vessel A to have kept paying attention

After transcribing the results of the analysis in 4-2 “Analysis of Unsafe Behaviour” forto the movement of Vessel B and to report it to Pilot A. This exchange of information

Pilot A into the risk factors column （in the column of Direct and indirect/root causes

might have made it possible to make a give-way manoeuvre prior to being in a（coloured in pale yellow） of “Analysis using 4M5E and Countermeasure List (Unsafe

dangerous situation.

behaviour)”, the Why Why Analysis will be carried out here regarding each risk factor.
The root causes can be identiﬁed in the following two points:

Human beings face difficulty thinking differently about something
once they have it set in their mind.
Lack of awareness that the pilot is also a member of the BTM structure.
The following numbers correspond with each Summary of Related Facts No.
52

Pilot A assumed that the crew of vessel A had been thoroughly trained

1 and that Master A had a shared understanding of the manoeuvring.

Although not stated in the report by the Japan Transport Safety Board, Vessel Aʼs

5. Why did he think the crew were paying
attention to Vessel B?（1- ① , ⑤ and ⑦〜⑨）

7. Why did he not notice Cadet A reporting?
(1- ③ and ⑨）

Education
Education and training
Knowledge, skills, consciousness, being given information, etc..

Psychological Factors： Man

Shipowner and ship management company

5 He thought that the crew were paying attention to Vessel B.
06:55 (approx.) Assumed crew of Vessel A were paying attention to the movementof Vessel B, because Master A and 1/O A were watching the ECDIS（Electronic Chart
Display Information System). They also conﬁrmed Vessel B visually by pointing.
However, Master A and C/O A moved away from the ECDIS just prior to this, and53

P&I Loss Prevention Bulletin
they started discussing port entry work beside the sea chart table. Lookout wasneglected.
06:55 (approx.) Headed for the entrance of the East Fairway and

6 continued to steer to port, assuming that Vessel B would pass their bow
He instructed the vessel to reduce speed in preparation for port entry and docking
work, but he did not allow the crew to report the actual speed, and did not checkit himself. He assumed that the vessel could pass the bow of Vessel B owing to his
pilotage experience.

7 Did not notice Cadet A reporting
06:57 (approx.) Cadet A reported Closer to mean that Vessel B was too close. The
timing of the report was a little too late, however, since it was around ﬁve minutes
prior to the collision, this would have been the crucial moment to have given way. It
cannot be denied that not enough attention was paid to the report that was made by
the cadet.

9 Did not respond to Vessel B's VHF callJAPAN P& I CLUBRecurrence Prevention Countermeasures
Pilot A felt deeply responsible for causing the accident. However, as mentioned above,
the root cause behind the chain of human errors was caused by Psychological factors.
Even though there were several chances to break such a chain of errors after having
boarded Vessel A until the accident occurred, resource management (the foundationof BTM) was ineffective and the error chain could not be broken as a result, which
inevitably lead to the collision accident. Because it was unknown as to what kind ofsafety measures had been implemented by the Pilots' Associations, we raised the issue
that a Re-examination was necessary.

Recurrence Prevention Countermeasures through Education(education and training) in 4(5)E for Pilot A
After removing the above risk factors, the following two preventive measures remain.

BTM re-training
Training in psychology (mental state of mind)
After Pilot A took above mentioned training and lecture, had he have taken actions such

Shortly before the collision, VHF calls were made twice by Vessel B, but non wereas Self-analysis and told other pilots around him about his experiences, this may havereturned. This presumably was not noticed because a collision was imminent and hebeen helpful in preventing a recurrence.

panicked.

Management（Pilots Associations）：
Preventive measures by Management

Workplace Factors: Man and Management
The root causes were (1) both Master A and Pilot A did not adequately perform theirleadership duties as conning officers and (2) could not communicate with Vessel A’s
bridge on duty personnel. Pilot A well understood the importance of BTM, but it ispresumed that he could not carry it out in reality.

According to the Japan Transport Safety Board’s report, Pilot A took BTM training
3 years prior to the accident (in 2015). We naturally assume that accident prevention
activities are appropriately implemented by Pilots' Associations. However, it is still
unknown if such accident prevention measures pertaining to Management were
sufficient or not, therefore, it would be necessary to review the accident prevention
measures through Re-examination. Thus, we have identiﬁed Re-examination necessary
in the countermeasure list.

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P&I Loss Prevention Bulletin

４−５JAPAN P& I CLUBCountermeasures for Unsafe Behaviour for
Masters A and B（See Attachment14）

Psychological Factors Regarding Master A: Man
The root causes can be identified in the following three points: Each number
corresponds with a Summary of Related Facts No.

The root causes can be identified in the following two points:● Human beings face difficulty thinking differently about something once they have it set
He assumed that Vessel B would pass the starboard bow,in their mind.
● Lack of awareness that pilot is also a member of the BTM structure. Collapse of communication (the foundation of BTM) Master A starts discussing port entry work with C/O● Mistakes regarding work prioritization.

3 without continuously monitoring Vessel B.

06:53 (approx.) Master A visually confirmed Vessel B, but Master A did
not watch continuously.
At this moment, Vessel Bʼs bearing was <068> and her distance at approx.

Recurrence Prevention Countermeasures● BTM re-training● Re-training of Safety Management
System (SMS）
Attachment 14

The Company, as organizations, alsoneed to take preventive measures.
● Reviewand make the work procedure.
● Introduce BTM training and traing thatcovers mental state of mind.

Vessel A and B Collision Accident Analysis using 4M5E and Countermeasure
List (Unsafe behaviour): Master A and Master B
Man

The vessel, shipowner and ship management company

MachineMedia

Mainly on
the vessel

The vessel,
shipownerand shipmanagementcompany

Master A
1. Psychological
3. Why did he assume that Vessel B
would pass the starboard bow, without
continuously monitoring Vessel B?
4. Why did he start discussing port entry workwith C/O A?
8. Why did he not pay attention to Cadet Aʼsreporting?（１- ① , ③ , ⑤ and ⑦〜⑪）
3. Organizational factors（Related Facts No. 3,4, 8 and 9)② Why could he not exert leadership as a
Master A?
Master B
1. Psychological10

Fig. 34 (Attachment P. 120)

Management

On the vessel

Shipowner andship managementcompany

Vessel A
Ship management
14. Why did he not company A
comply with the 15. Why did he not
Safety Managecomply with thement Code?（2Safety Manage①）
ment Code?（1③）
4. Why did he interrupt lookout duty 4. Why did he interto start discussrupt lookout duty
ing port entry
to start discussing
work with C/O A
port entry workin the middle ofwith C/O A in theS/B?（2- ①）
middle of S/B?
（1- ③）
Vessel B
12

Ship managementcompany B
12

3.4 nautical miles and steering to starboard, but she would have beenheading in a southwest direction. Also, the ARPA showed Closest Point ofApproach (CPA) to be 0.22 nautical miles on the starboard side and TCPA
displayed 6.5 minutes later. Together with those and the vector, MasterA assumed that Vessel B was an outgoing vessel from Osaka Bay andcompletely believed that he could pass starboard to starboard.
However, Pilot A was in contact with port radio via VHF at approx. 06:45
and understood that Vessel B was a shifting ship between Osaka Bay andKobe RC-4.
Port radio communications with Pilot A was conducted in Japanese andMaster A did not understand the contents. But, he would have noticed
that Pilot A was using VHF to relay information. At that point, if he had
conﬁrmed with Pilot A what he was talking about, the chain of errors could
have been broken at this stage.

4 He started discussing port entry work with C/O A.

Let’s take a closer look at the preventive measures for unsafe behaviour of both Master

06:53 (approx.), he let 3/O A man the bridge to take over from 1/O A and

A and Master B. Just as with Pilot A, Analysis using 4M4(5)E and Countermeasure List

started discussing port entry work with C/O A beside the sea chart table.

10(Unsafe behaviour) will be used here. It is clear to see that the root cause underlying

It is important that discussion immediately prior to work be conducted, so

Psychological factors and Organizational factors has to do with Man on both sides.

it is also known that the most important work to be done during S/B in a

11

3. Organizational（Related Facts No. 10 and
11)

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57

P&I Loss Prevention Bulletincongested area like this is lookout. Errors regarding work prioritization.

JAPAN P& I CLUB10

He thought that Vessel B could pass the bow of Vessel A,
even though he was concerned about the decreasing DCPA.
In addition, he checked ARPA data only and did not conﬁrm

8 Did not notice Cadet A reporting
Similarly to Pilot A, it cannot be denied that not enough attention was paid
to the report that was made by the cadet. As usual, and not just on thisoccasion, he did not notice the Cadet reporting.

Workplace Factors Regarding Master A: Manit visually.
Furthermore, whilst Master B did appear to pay attention to the
movements of Vessel A, he neglected to make a visual confirmation andbelieved blindly in the ARPA（CPA/TCPA) data alone. In addition, 3/O B
on the bridge did not give the order to monitor the movements of Vessel
A. When focusing on ship handling in congested sea areas, it is possible
to lose sight of the surrounding circumstances, because it is very difﬁcult

Even when a Pilot is on board, the Master is ultimately responsible as navigator.

for crew to perform 3 or 4 different tasks simultaneously. To deal with

But, just as with Pilot A, (1) leadership duties were not adequately performed, (2)this problem, the bridge personnel need to form a team which can exert

communication with the vessel’s bridge on duty personnel including Pilot A was

efﬁcient BTM and raise the level of safety. However, this did not happen

insuﬃcient. These underlay the root cause. It is considered that BTM was infeasible.

on this occasion.

Risk Factors Regarding Management of Master A andShip Management company A
The ship management company of A’s SMS Manual clariﬁes the procedures during port
entry work. Why was this not adhered to? Also, as mentioned earlier, why did he neglect
to carry out important lookout work and management of the ship’s bridge on duty
personnel to start discussing port entry work with C/O A?
It is apparent that both Master A and the Safety management company are fully awarethat compliance with the Safety Management Code is a top priority. However, why were
they unable to realize this? As further examination and analysis to clarify the reason isnecessary, we have designated this as Re-examination necessary.

Assumed that the vessel would reach port delayed or quicker

11 if speed was decreased or increased

Although he believed that the vessel could have just passed the bowof Vessel A, based on the relative bearing of A, and if the speed wasmaintained, it would have been problematic to do such a manoeuvre using
only ARPA data in such close quarters.
In addition, the Master steered to starboard while increasing speed justprior to the collision. The author understands that DCPA will increase
when speed is increased, but it is impossible to rapidly increase speed for alarge-sized vessel.
The author believes that Master B did his very best given the somewhat
stressful circumstances and understands that he may have used thePsychological Factors Regarding Master B: Man
The root causes can be identiﬁed in the following two points:

engine for better rudder effect due to there being more than 1 nauticalmile to Kobe Central Fairway, but believes that his testimony regarding his
concern as whether speed should have been increased (or decreased) to bequestionable.

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P&I Loss Prevention BulletinJAPAN P& I CLUB
Although he knew that Vessel B was communicating in Japanese and that

Recurrence Prevention Countermeasures
Recurrence Prevention Countermeasures through Education(education and training) using 4E for Master A

was communicating via VHF. At the time once they had finished speaking,he should have proactively asked the pilot if there was any information thatneeded to be shared with him.
Also, when he started discussing port entry work with C/O A, he let 3/O A

The Master is expected to handle the ship in congested areas until the Pilot arrives

take over from 1/O A immediately after he ascended and started manning theon board. However, there is a tendency due to language difficulties to just hand overbridge. Was he really aware of the surrounding situation when he took over?

responsibility to the pilot upon their arrival.

Although he took BTM training, he was unable to practise it in reality, which

This author has also experienced entry into Kobe port on many occasions. Typicallyis the root cause behind the accident. Thus, he is required to take BTM re-

we would pick up the pilot at 04.00 in the morning, which would require some timetraining.

rescheduling from around 23.00 the previous night at Cape Muroto or oﬀ the coast of・ Re-training of Safety Management System (SMS）

Cape Shiono (adjustment of engine speed, change of course etc.). At this point I would

Details including the importance of BTM regarding duties on departure

take command of the bridge. However, it is said that the average human concentrationand entry, congested areas, reduced visibility would be written in the

span is around 40-50 minutes, with 90 minutes being an absolute maximum. Under

Safety Management System (SMS). Master A had also seemingly received

busy continuous working conditions, that span begins to fade and become even shorter.

training in the Safety Management System (SMS）several times. Still, it is

The tendency to leave it all up to the Pilot when he comes on board is therefore

necessary to analyse as to why he could not practice this on board and tounderstandable given the level of mental and physical fatigue of the crew.

recommend re-training.

That said though, the command of ship handling is not something which should be

Recurrence Prevention Countermeasures through Management

simply handed over to the Pilot. The Master must retain responsibility until safely(management and organization) Applying 4E to Ship Management

docked at port. Exercising good BTM, including management of the Pilot, is one of theCompany A

duties of the Master.
With this in mind, the measures needed to be taken by Master A, to prevent recurrenceof this danger, can be summarised in the following two points.

The ship management company proactively provided the crew with BTM training andseminars on the Safety Management System(SMS). We have identified this as Reexamination necessary, because we do not know the contents of the program.
In other words, crew (those who attended lectures and training) vary in levels of・ BTM re-training

competency, and, consequently, may not be able to apply such training to actual

When the pilot boards, is enough information exchanged, or would there havecircumstances, thus leading to an accident.

been enough information exchanged regarding a head-on situation like this?

This is the reason why there needs to be further investigation as to why the Safety

The pilot checked port radio for the movement of Vessel B via VHF.

60

he could not understand what was being said, he could see that the pilot

Management System (SMS) was not adhered to and, furthermore, the following
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P&I Loss Prevention Bulletincountermeasures need to be examined and implemented if necessary.

Countermeasure through Guidance and Enforcement (Enforcement）
Review, disseminate, and carry out training of Safety Management

JAPAN P& I CLUB・Re-training of Safety Management System (SMS）
It appears that the vessel was not able to carry out port departure and entry
work in accordance with Safety Management System(SMS), and similarly to
Master A, re-training will be necessary.

System (SMS) procedures for Pilot duty when the Pilot is on board.
Also, VDR data was overwritten, thus data at the time of the accident
is not available. VDR operation skills and a review of the procedure
manual may be required.
In addition, for the time being, it will be of value to continuously carryout internal audits and hold collision recurrence prevention campaigns.
Moreover, the Master must realize that he is in charge even whena pilot is on board. However, he must also understand that it may

Recurrence Prevention Countermeasures throughManagement (management and organization) Applying 4E toShip Management Company B
As in the case of Company A, the following recurrence prevention countermeasures
could be considered: (1) to analyse why the Safety Management System(SMS） was

be difficult to supervise a pilot as intended. The ship management

not adequately performed at sea, and if necessary, (2) to review the Safety Managementcompany should check with the Pilots' Associations for any relevant

Code regarding duties on departure and entry, narrow channels, reduced visibility and so

improvements.

on, and (3) to disseminate and carry out training for improvement.

Recurrence Prevention Countermeasures through Education(education and training) Applying 4E to Master B
Similarly to Master A, one of the contributing root causes Psychological factors: Humanbeings face diﬃculty thinking diﬀerently about something once they have it set in theirmind. Another contributing root cause would be the collapse in communication, suchas bridge on duty personnel management and the exchange of information externally,
which are the foundations of BTM. Therefore, the following have been identified asrecurrence prevention countermeasures:
・ BTM re-training
Similarly to Master A, although Master B appears to have taken BTM
training, he was unable to practise this in reality. BTM re-training is one
recurrence prevention countermeasure that could prove to be effective forthose not ready to carry it out in practice.

6263

⑨ Human beings sometimes
make assumptions

P&I Loss Prevention Bulletin④ Social loaﬁng⑩ Human beings are sometimes
lazy.

JAPAN P& I CLUBnotice
4-6 Accident Analysis notfrom
the Perspective of
Human Factors and Human
Error (See Attachment 15)⑤ Human beings have moments ② Normalcy bias
④ Human beings sometimes do ③ Conﬁrmation biasof inattention

Attachment 15
Time

Movement

06：10 Vessel A
After passing
Tomogashima
Channel, changed
course to thenortheast for Kobe
Rokko Island Berth.

Who?
Pilot A

Pilot A

Vessel A and B Collision Accident Human Behavioural Traits and Human Error(Psychological Analysis)
Behaviour⑨ Human beings sometimes
make assumptions
Human characteristics

From past experience as a
⑨ Human beings sometimes
pilot, he assumed the crew ofmake assumptions⑨ Human beings sometimes
Vessel A to be trustworthy.
make assumptions

Ｐ sychology③ Conﬁrmation bias
People unconsciously collect② Normalcy
informationbias
that supports what they
believe.

Pilot A
Vessel B
MasterB
Steered northwesterly heading forthe entrance of Kobe
Central Fairway⑨ Human beings sometimes make assumptions, and⑩ Human beings are sometimes lazy
He did not explain the procedure sufficiently enough to the Master after
boarding, as he assumed it would not be necessary, despite the fact that thecircumstances at that time were unknown. As a result, he probably simpliﬁed
his usual explanationtion.

Assumed that Master A had⑨ Human beings sometimes② Normalcy bias
make assumptionsa shared understanding of theAssumed everything would be ﬁne,navigation plan.
⑩ Human beings are sometimes
because this method had been ﬁnelazy.
up until now.
Did not explain procedure③ Conﬁrmation bias
④ Humanbeingssometimes
reactance
sufﬁciently
enoughto the do ① Psychological
Only collected information that
notnoticeMasterafter boarding.
supported what what he/she believed.

06：45
Approx.

Human characteristics

Informed port radio via VHF
of the approximate time he③ Human beings sometimes
forget④ Social loaﬁng

Concerned about decreasing
CPA, but assumed that thevessel could pass the bow,according to the vector
indicated on ARPA.

⑨ Human beings sometimes
make assumptions② Normalcy bias

⑤ Human beings have moments
inattention
⑩ of
Human
beings are sometimes

Thought
he need not explain and thatparty
effect.
People ignore negative information
and underestimate phenomena saying“Iʼm special, nothing can hurt me!”②

Only
conﬁrmed information via
not notice
ARPA⑤ ECDIS
Humanandbeingshave moments

Normalcy bias

Psychologically, he assumed that everything would be fine, because thismethod had been ﬁne up until now.
Did he not underestimate the importance of exchanging information?

⑩ Humanlazy. beings are sometimeslazy.

⑥ Human beings are sometimes
only able to see one thing attime beings sometimes do ② Normalcy bias
④ aHuman

MasterB

Psychological factors

Psychological factors③

Conﬁrmation bias

According to human behavioural characteristics, could it be that when heof inattention

Fig. 35 (Attachment P. 122)

quickly observed Master A and other bridge personnel, that he may have had⑥ Human beings are sometimes
only able to see one thing at
a timeEach item number printed in the “Human⑦Characteristics”
and “Psychology” in the list
Human beings are sometimes

the bias that the crewmembers were all conversant in BTM?

in a hurrycorresponds with those numbers of “(2) Human characteristics （Nihon VM (Visual
Motivation) Centre Co., Ltd from Anzen-no-komado 18 (Safety Loopholes) dated 30
June, 2002 (Provisional translation） （Figure 5）” which explains what causes humanerrors in “P.4 1-2 AsMastera Mechanism behind ⑤Maritime
Accidents Caused by Human Error”
Human beings have moments ② Normalcy biasof A

and “(3) Psychological Factors”.

of inattention⑨ Human beings sometimes
make assumptions⑩ Human beings are sometimes ③ Conﬁrmation bias
lazy.

For example, at 06:10 (approx.) Pilot A thought that he had shared his understandingof manoeuvring with Master A, but they never actually communicated with each other

Although mentioned earlier above, Master A visually conﬁrmed Vessel B at approximately
25.0 degrees on its starboard bow at approx. 06:53. However, because Master A did nothear from the Pilot that Vessel B would head for Kobe Central Fairway, he assumed that
there would be no risk of collision judging by his vessel’s relative position with the othership: that it would be heading in a southwest direction (Outgoing Osaka Bay). He also
neglected paying attention to the movement of Vessel B afterwards. This, too, can beapplied to human characteristics and psychological factors as follows:④ Social loaﬁng

in reality. We can assume that information exchange using the Pilot Card in accordance⑥ Human beings are sometimes ③ Conﬁrmation bias

with the procedure manual was all but a formality.
as follows:
only able toThis
see one canthing atbe④analysed
Social loaﬁng
a time64

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P&I Loss Prevention Bulletin

Human Characteristics⑤ Human beings have moments of inattention,⑨ Human beings sometimes make assumptions andJAPAN P& I CLUBstarboard, but he was concerned about entering port late if he was to follow
the originally scheduled course, and neglected to keep visual conﬁrmation ofVessel A.

⑩ Human beings are sometimes lazy.
Tracing the chain of human errors, it is possible to see that he neglected tokeep monitoring the movement of Vessel B.
Psychological factors②

Normalcy bias

People unconsciously collect information that supports what they believe.
Psychological factors③

Conﬁrmation bias

He only collected information that supported what he believed by thinking
everything was ﬁne because she crossed the stem of Vessel B.
Psychological factors④

Social loaﬁng

Assumed that Pilot A would take care of the entire procedure.

In addition, as for Master B, at 06:52 (approx.), he steered to starboard for Kobe Central
Fairway without checking the movement of Vessel A visually. This was also the result of
the following human characteristics and psychological factors which contributed to thechain of errors.
Human Characteristics④ Human beings sometimes do not notice,⑤ Human beings have moments of inattention,

Psychological factors②

Normalcy bias

People ignore negative information and underestimate phenomena saying :Iʼm special, nothing can hurt me!
He simply conﬁrmed the ARPA only.

As compiled in Attachment 15, when looking chronologically at the course of events, it
is possible to see how each factor contributes to the chain of human errors. This accident
might have been prevented had the chain been broken at some point. It can be said that
BTM was not operational.
When analysing other collision accidents, it is possible to observe “accident analysis
from the perspective of human factors and human error”. These are almost identical to“4M4(5)E Analysis”. In other words, the root causes that led to the collision accident
can be found in the following Human Characteristics: ⑨ Human beings sometimes
make assumptions, ⑤ Human beings have moments of inattention, ⑩ Human beings
are sometimes lazy and ⑦ Human beings are sometimes in a hurry. There are also 4
psychological factors that are connected which make it impossible to eradicate humanerror.
Thus, even if the person “L”, who is the centre of the M-Shell Model (P. 14 Figure12) makes a mistake, the surrounding resources will notice and point it out via
communication without hesitation. This is important, because it will break the chain oferrors to prevent an accident, namely: practising BTM eﬀectively.

⑥ Human beings are sometimes only able to see one thing at a time,⑦ Human beings are sometimes in a hurry.
He understood that the relative position would be risky, if he steered to66

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P&I Loss Prevention BulletinJAPAN P& I CLUB§5 ＝ Case Study ＝Bridge Collision Accident

Hiroshima Pref.

Actual Sailing Route taken

Kure

Recommended Route

Edajima

Yamaguchi Pref.
Yanai City

Japan Transport Safety Board Report (MA2019-10-2)
Modiﬁed from the Japan Transport Safety Board Report:
http://www.mlit.go.jp/jtsb/ship/rep-acci/2019/MA2019-10- 2̲2018tk0020.pdf

Ohshima Bridge
Suoh Oshima Town
Yshiro Isl.

Let’s analyse the Ōshima Bridge Damage in Yamaguchi Prefecture that occurred on
October 22, 2018.

Heigun ISl.

5-1 Accident Summary（See Figure 36）
On the 22nd of October 2018, at approximately 00:27 (JST), Cargo ship E (25,431 G/T）

Yamaguchi Pref.
Yanai City

collided with Ōshima Bridge while navigating Obatake-Seto channel, heading from theport of Onsan (South Korea) to Etajima of Hiroshima Prefecture (navigating to the east).
3 cranes out of 4 on the vessel sustained damage. On the other hand, Ōshima Bridge
sustained cracks and depressions in the bridge girders, and a water mains pipe ruptured

Ohshima Bridge

Point Accident Occurs(22 October 2018, atapproximately 00:27.00 (JST))oetNo.3 Pier

S
ke

ta

ba

Oh

el

nn

a
Ch

as a result of the inspection corridor dropping down on it. Consequently, all areas of
Oshima Town suffered approximately 40 days without water, and in addition, power

No.4 Pier

cables and communications cables were also damaged.
Ohiso LH

Suoh Oshima Town
Yashiro Isl.
Fig. 36

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P&I Loss Prevention Bulletin

５−２JAPAN P& I CLUB

Summary and Damage Sustained to a Vessel(Cargo ship E）

Air Draft （Fig. 38） and Damage （Photograph 39）

Aft. Mast
Abt. 42m

AirDraft
No.4

Abt. 35m

No.３

No.２

No.１

Abt. 34m(Fore 5.95m Aft 6.97m)

Fig. 38

Photograph 37

Gross tonnage： 25,431 G/T

L×B×D： 180m×30m×15m

Port of origin： The port of Onsan (Korea)
on October 19, departed at 08:30

Port of destination： Etajima, Hiroshima Prefecture Private berth

Cargo

:

Draft

： Fore 5.95m

Crew arrangement： Total number of 21（12 Indonesian, 4 Filipino, 2 Russian,
1 Turkish, 1 Indian and 1 Ghanaian)

Ship's Bridge on duty
personnel at the time of
the accident.

： Master E, 2/O and AB E

Master E： Indonesian national at the age of 44 joined as crew in1998 and became Master in 2016 with a crew change
at Qingdao (port before last) on October 16. He had
a great deal of experience manoeuvring in the Seto
Inland Sea area as a Master, but it was his first time tomanoeuvre in the Obatake-Seto channel.

2/O E： Indonesian national at the age of 26 joined as crew in2012 and boarded Vessel E from July, 2018. It was his
first time to serve on board as 2/O.

（Length）（Breadth）（Depth）

70

No.1, No.2, No.3 cranes and the aft mast sustained damage. Air Draft （height from thewater surface) is as shown in Figure 38.
Figure 39 illustrates damage sustained.

⬅ ForeBroken Aft Mast

Oxidized aluminium Approximately 6,300KT
Aft 6.97m

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P&I Loss Prevention BulletinJAPAN P& I CLUBŌshima Bridge Damage
Bridge sustained cracks and depressions in the bridge girders, and an inspection corridor
which was situated under the girders dropped down damaging a water mains pipe,
power and communications cables etc.
No.1 Crane

No.3 Crane

In almost all parts of Suo-Oshima Town, 9,046 houses and 4,590 residents and local
industry suffered approximately 40 days without water. In addition, in a part of SuoOshima Town, there were problems such as a temporary power outage, interruption ofInternet connections and mobile phones, and electrical equipment such as bridge lights
and so on.

No.2 Crane

No.4 Crane
Inspection passage debris dropped from Oshima bridge
Photograph 39

Center of Bridge

５−３ Summary of Ōshima Bridge（Figure 40）
and the Damage Sustained（Photograph 41）
Pasage Length 290ｍ

← Yanai City

Damaged Location

Suoh Ohshima Town →← Yanai City

Water Pipe
No.3 Pier

No.4 Pier

Ship's Heading

TP+31.9m

24m

No.3 Pier

Suoh Ohshima Town →24m
Created from the generallayout provided by
Yamaguchi Prefecture

Height of General Drawing :TP（Ave. Sea Level in Tokyo Bay) + 31.90m
Estimated Tide Level : 22nd Oct., 2018 00:30 JST
TP-0.69m← Yanai City

No.4 Pier

約１ｍ
Water Pipe

Water Pipe

Iwakuni City →Cross Section Drawing:
Prepared using General Drawing(Yamaguchi Pref., Japan)

Inspection Passage

Cross Section Drawings of Ohshima Ohashi(Image)Height from water
surface at the timeof accident :about 33.0m

Photograph taken from under the bridge

Ship's Heading
Yanai City

Photograph privided : Yamaguchi Civil Engineering Ofﬁce

Photograph 41

Fig. 40

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５− 4 Events and Sailing Routethat Led to the Accident
Timelines and sailing route that led to the accident are summarised in Figure 42 andJAPAN P& I CLUB❼Recommended RouteYamaguchi Pref.
Yanai City

Hiroshima Pref.

Actual Sailing Route taken

Kure

Etajima❻Ohshima Bridge❹❸ Kasasa Isl.

Yamaguchi Pref.
Yanai City

Suoh Oshima Town

Table 43.

Yashiro Isl.
Suoh Oshima Town
Yashiro Isl.

▶

The passage plan was created just 1 week before the accident by the❶

2/O E.
▶

Heigun ISl. Kudako Channel:

Point of Accident Occurence(22 October 2018, at approximately 00:27.00 (JST))No.3 Pier❺

At 00:00 on October 22, the duty was taken over by 2/O E at theNo.4 Pier

point of 1 nautical mile south of Kasasa-jima.
As Master E felt uneasy about the height of the Ōshima Bridge, he

Ohiso LH

ordered 2/O E to confirm it. But he continued navigating. 2/O E tried
Fig. 42

beam using pilot directions and the ECDIS.
ECDIS
Date・TimeNo.

Occurrence of Events According to an Interview
and Questionnaire

9/24 〜 10/19―

9/24 Departed Kwinana Quay (Australia) and arrived at theport of Onsan (Korea)via Isabela (Philippines) and Qingdao(China) on 10/19.

10/13 Approx.

―

2/O E made the Voyage Plan for Onsan - Etajima.

10:27 (approx.) On Octorber 27, the Vessel collided with Ōshima
Bridge. Master E tried to make a call to the agency but no one
answered at all. Master E kept navigating because it seemed that
there was no appropriate point of anchor in the vicinity and at 04:00(approx.) he finally anchored off the Port of Kure.

10/21

74

Suoh Oshima Town
Yashiro Isl.

in vain to ascertain information, regarding the height of the bridge

▶

to

Se

a
Ch

t

ba

Oh

e
ak

el

nn

Ohshima Bridgefor navigating the Obatake-Seto channel, and commenced ship▶

Water depth at 20m
Yamaguchi Pref.
Yanai City

E ascended the bridge in the vicinity of Figure 42 ① in preparation▶

Water depth at 10m

This route is morecommon for large ships

On the day of the accident, at around 22:00 on October 21, Master

handling command.

❷

10/16

Master E took over from previous Master at Qingdao.

10/20

Master E and 2/O E confirmed the Passage Plan between
Onsan and Etajima.

08：30

Departed the port of Onsan.

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P&I Loss Prevention Bulletin

Date・Time
10/21

22：00
Approx.

00：00

No.

Occurrence of Events According to an Interview
and Questionnaire❶

In preparation for navigating the narrow channel the Mastermanned the bridge (Master, 3/O E and A/B E).

❷

Duty Officer 3/O E was relieved by 2/O E.
As Master E felt uneasy about the height of the bridge, heordered 2/O E to confirm it.
2/O E tried in vain to ascertain information regarding theheight of the bridge beam using BA edition sailing directions.

❸

Although 2/O E tried to check the height of the bridge beam
operating the ECDIS, he did not notice how high the bridge
was.

Steered to
starboard to thewest of Kasasajima.

❹

Ship's Bridge on duty checked for bridge lights, but wereunable to see them due to it being too dark.
Master E worried about being pressed by the westerly
current.

00：26❺

2/O E instructed hard to starboard and A/B E responded tothe order.

00：09

10/22

JAPAN P& I CLUB

00：27

Shortly after Master E ordered midships, the No.1, No.2 andNo.3 cranes and the aft mast collided with the bridge insuccession.

00：36

❻

Although Master E made a call to the agency requesting themto report this to the Japan Coast Guard, the person in charge
at the agency could not hear what was being explained well,thus it did not get reported.
Master E kept navigating because it seemed that there was
no appropriate point of anchor in the vicinity and it would besafe to continue to the destination.

04：00

❼

Anchored off the Port of Kure.
Table 43

５− 5Accident Causes2), summarise statements in Table 44 (2/O E) and Table 45 (Master E), so that we may
compare their respective statements with the ship management company’s procedure
manual (SMS manual).

Passage Plan of 2/O E
Ship Management Co. E Procedures(SMS Manual: ISM Code)Actual Passage Plan made by 2/O E
2/O E did not confirm the information regarding
Obatake-Seto using Sailing Directions.
⇒ According to the Sailing Directions
published by the Japan Coast Guard, theheight of the bridge over the narrowest
point of the Obatake-Seto is said to be 24
to 30 meters.
⇒ It is shown as 24 meters in the Sailing
Directions of the BA edition.

Both the Master and duty officer(s) shallcarefully review Sailing Directions anytime
prior to and during the voyage, especiallywhen operating ocean-going vessels.

When making the route plan from Onsan toEtajima, 2/O of E used software installed in the
PC on board in order to operate the electronic
chart and to place orders. At this point the route,from Onsan to Etajima via Obatake-Seto, that thesoftware had automatically created was copied
to the ECDIS to be used.

For small, medium and large scale electronic
charts, the route is to be refined in stages.

2/O E used the route check function and noticed
that there were several warnings, including
shallows on this particular route, but, he missed
the warning for Ōshima Bridge.
⇒ The registered height in the ECDIS was
24 meters. As the vessel’s draft and air
draft had not been input, when using theroute check function, it showed up as“Unidentified”. Later on, when inputting thedraft and air draft, it had been verified as“Not Passed”.

The duty navigation officer and the Master are
to visually check the route that has been input
into the ECDIS and must very carefully checkthis during the entire sailing route on theelectronic chart using the appropriate scale.
This is to be then reconfirmed using the route
check function of the ECDIS.

Table 44

2/O E made the Voyage Plan with ECDIS and it was signed by the previous Masterand Master E. Excerpts from the Japan Transport Safety Board Report (MA2019-1076

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P&I Loss Prevention BulletinJAPAN P& I CLUB

2/O E created the Passage Plan one week before the accident occurred. However, theThe following deviations from the procedures are also found for both Master E andfollowing deviations from the procedure manual were identiﬁed:

Management Company E.

▶
▶

▶

2/O E did not confirm the information regarding Obatake-Seto using
pilot directions.
According to the SMS procedure manual for creating Passage Plans,
it is specified that it be created by confirming each item of data before
inputting it into the electronic chart. However, he created the Passage
Plan using nautical chart ordering software and copied the data over tothe ECDIS.
When creating a Passage Plan, it is necessary to input the draft, safety
isobaths and air draft information of the vessel to begin with, but heneglected to do this. As a result, he could not use the route check
function of ECDIS successfully.

▶

Master E boarded at Qingdao on 16 October (which was 5 days before theaccident occurred). As the previous Master mentioned to Master E that
the Voyage Plan for Onsan - Etajima had been created, Master E assumed
that the previous Master had checked and confirmed the plan, meaningthat Master E did not check it himself.

▶

The Master checked the Voyage Plan to Etajima with 2/O E using the
ECDIS when mooring at the port of Onsan. However, this was not carriedout in detail.

▶

Master E and 2/O E were not used to using the check-bridge-heightfunction on the ECDIS.

▶

Ship Management Company E would not usually intervene during thecreation of a Passage Plan which are created on board each vessel. At the

Master E

time of the accident, they had no information about any of the Passage
Ship Management Co. E Procedures(SMS Manual: ISM Code)

Checks carried out by Master E

Plans, including the Passage Plan from Onsan to Etajima, in advance.

The previous Master had checked and signed
Passage Plan document for Qingdao. The
Master was relieved by another master at
Qingdao. (Checked only the summary anddid not sign for it)
Master E believed that the former Master had
confirmed this because the Passage Plan had
already been made when he boarded on 16
October.
Master E checked the Passage Plan to Etajima
with 2/O E using the ECDIS when staying
at the port of Onsan. However, this was not
carried out in detail.
Master E’s signature was found dated 20
October (one day before departure) on the
Voyage Plan for Onsan - Etajima.

The Master is to confirm the Passage Plan
first-hand by himself/herself in order toensure that there are no errors. When the
Master signs a Passage Plan document thismeans that it has been officially approved.

Table 45

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P&I Loss Prevention BulletinJAPAN P& I CLUB
2/O E's Creation of the Passage Plan
While he may be versed in the Safety Management System (SMS)’s procedure manual,§6 4M4(5)E Analysis of
Bridge Collision ＝ Accident ＝

he was unable demonstrate this. When applying this with human characteristics, thefollowing emerge. (Numbered Figure 5 on P. 6）
1

Human beings sometimes make mistakes and

10 Human beings are sometimes lazy

Created Passage Plan using nautical chart ordering software and copied the data over to

６−１ Human characteristics（Human error ）and
Psychological factors (See Attachment 16)

the ECDIS as is.
2

Human beings are sometimes careless and3

Human beings sometimes forget

Before starting a speciﬁc 4M4(5)E Analysis, let’s look at the relationship between human

Before inputting speciﬁc data of sailing route, it is a requirement that basic information

characteristics (human error) andsuch as Draft, Air Draft、 Safety isobaths of the vessel, be input. This was neglected.

psychological factors.

Attachment 16
Date
and
time

Movement

Who?

Vessel E Ōshima Bridge Collision Accident:
Human Characteristics, Human Error and Psychology
Behaviour

In the same manner as theprevious chapter, Attachment 16

・2/O E did not conﬁrm information
regarding Obatake-Seto (including
bridge beam height) using pilot
directions

was summarized with the results・Worked according to the following
procedure when creating a Passage Plan

used in “(2) Human characteristics（Nihon VM (Visual Motivation)

13 Oct.
approx.

Navigating
en route to
Qingdao.

dated 30 June, 2002 (Provisional

Copied the data over to the ECDIS⑩ Human beings are sometimes
lazy: Knew the procedure, but cut
corners３）Did not input Draft and Air Draft
data into the ECDIS② Human beings are sometimes
careless, ③ Human beings
sometimes forget

16 Oct.
approxWhen mooredat Qingdao

・The previous Master had checked andsigned the Passage Plan document for
Qingdao under his command. He only checked a summary of the Passage
Master E
Plan between Qingdao-Onsan, andOnsan-Etajima, and did not sign for it.

Error in “P.4 1-2 As a Mechanism

・Master E believed that the previous
Master had conﬁrmed this because
the Passage Plan had already beencreated.

behind Maritime Accidents
20
Oct.
approxWhen mooredat the port of
Onsan

Master E

The Master E checked the Passage Planbetween Onsan-Etajima with 2/O E
using the ECDIS. However, this was not
carried out in detail.

Normalcy bias
Human beings have thecharacteristic to underestimate
or ignore information regarding
him or herself.

Peer pressure
・Human beings are prone
to make a judgement or
decision inﬂuenced bysomebody elseʼs ideas andthoughts.

⑩ Human beings are sometimes
lazy: Neglected to take overproperly

Normalcy bias
Human beings have thecharacteristic to underestimate
or ignore information regarding
him or herself.

⑨ Human beings sometimes makeassumptions: It was assumed thatthe previous Master had approved
the Passage Plan up until
completion of voyage discharge

Social loaﬁng
There is the psychologicaltendency to cut corners in the
belief that someone else willtake care of it⑨ Human beings sometimes makeassumptions: Based on theabove, he assumed that the
Passage Plan had been enteredinto the ECDIS correctly

Departed theport of Onsan.

22:00

The west of
Heigun Island

Master E

Manned the bridge in preparation for
navigating the narrow channel

22 Oct.

copying of data into the ECDIS from the Passage Plan using software for ordering charts
by superiors and predecessors contributed to the above mentioned actions.

Master E
We can conclude that the following human characteristics invited human error.

9

Human beings sometimes make assumptions

The previous Master checked and signed the Passage Plan up until Qingdao Port where
the takeover Master boarded. The Master assumed that the Passage Plan created forand signed it.

⑩ Human beings are sometimes lazy:Knew the procedure, but cut corners

No speciﬁc problem

Management System (SMS） is time consuming, etc.,) and Peer pressure such as the

Qingdao-Onsan-Kure (Etajima) was complete and that the previous Master had checked

21 Oct.
08:30

In addition, as for psychological factors, overlaps of Normalcy Bias which is to ignore
information that is inconvenient （e.g. following the procedure manual in the Safety

While it may be easy to use
・When normalcy bias andconvenient software for orderingpeer pressure are combined,
charts, if ECDIS is not used correctly
a deviation from what wasthen it will return incorrect results
the standard occurs. Then,
as a result, and in no timeat all, this then becomes the
new standard.

The next Master E took over from theprevious Mastertranslation） （Figure 5)” which

Psychological Factors”.

⑩ Human beings are sometimes
lazy: Knew the procedure, but cut
corners① Human beings sometimes makemistakes: The software was notfor creating Passage Plans

As a result, although some warnings
were detected by the route check
function of ECDIS, as the vesselʼs Draft
and Air Draft had not been input, thewarning for Óshima Bridge showed
up as “Unconﬁrmed” and was thus
overlooked.

komado 18 (Safety Loopholes)

Caused by Human Error” and “(3)Psychology③ Human beings sometimes forget:
Forgot the procedures of the
Safety Management Code

１）Created using software forordering charts ｈ
2/O E

Centre Co., Ltd from Anzen-no-

explains Causes behind Human

Human characteristics

Created Passage Plan: Onsan - Etajima

No speciﬁc problem

10 Human beings are sometimes lazy

The Safety Management System (SMS） speciﬁes that the Master is to check the details

Table 46 (Attachment P. 124)

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P&I Loss Prevention Bulletinof the Passage Plan and sign for it. However, he neglected this duty because of hisJAPAN P& I CLUBAttachment 17

Maritime Accident Summary of Related Facts（Collision with Ōshima Bridge)

assumption.

Caused by1

13 Oct.
approx.

2/O E

2

16 Oct.

Master E

Believed that the previous Master had
checked and signed the Passage Plan
both between Qingdao-Onsan andbetween Onsan-Etajima.

〇

5

3

20 Oct.

Master E
and 2/O E

Passage Plan between Onsan-Etajima
were not conﬁrmed in detail on the
ECDIS.

〇

2

4

22 Oct.

Master E

As Master E felt uneasy about the heightof the Ōshima Bridge, he ordered his 2/O
E to conﬁrm it.

〇

4

2/O E

2/O E did not conﬁrm bridge beam heightusing pilot directions and the ECDIS〇

3Master E

Continued navigating without conﬁrming
the height of the bridge beam

〇

6

Ship
managementcompany E

No intervention was taken into accountwhatsoever, regarding the vesselʼs
Passage Plan〇

6

As Master E felt uneasy about the height of the bridge, he ordered 2/O E who justunderlying root causes.

5
6

22 Oct.
22 Oct.

7

６−２Summary of Related Facts (See Attachment 17）〇

Created Passage Plan using nautical chartordering software and copied the dataover to the ECDIS as is

the previous Master) was supposed to do it.

was too late. Let’s proceed to the following 4M4(5)E analysis, while considering these1

Did not input Draft, Air Draft and Safety
isobaths data into the ECDIS

Simply assuming that someone（in this case,ascended the bridge to conﬁrm it. But, it must be said that this was in vain, because it〇

Check facts and problem areas
Created Passage Plan: Onsan - Etajima
without checking the bridge beam heightof Ōshima Bridge. Abort Point procedure
was unclear

Similarly for 2/O E, he conveniently interprets
the burdensome task at hand.

● Social loafing：Time

Re-examination necessity● Normalcy bias：

Date

Unsafe conditions

characteristics.

Identiﬁed problems from survey ﬁndings

Unsafe behaviour

Reference No.

The following psychological factors underlay the root cause behind these human

Accident cause evaluation

Direct cause

00:00
00:00
00:11

Accident cause assessment: Prioritized according to the scale of the cause

Table 47 (Attachment P. 126）

It is possible to list up the following related facts from the main accident causes

Master E

summarised in 5-5.

▶

Believed that the previous Master had checked and signed the
Passage Plan from Qingdao-Onsan-Kure (Etajima).

Creation of Passage Plan by 2/O E

Passage Plan conﬁrmation between Master E and 2/O E▶

Did not research the waterway enough.

▶

▶

Did not input basic information such as draft, Air draft and safety
isobaths of the Vessel into the ECDIS.

▶

the port of Onsan.
▶

Immediately before the accident, Master E ordered his 2/O E toconﬁrm the height of the Ōshima bridge, but 2/O E could not conﬁrm

Saved to the ECDIS only by copying the Passage Plan data which
was created using nautical chart ordering software.

Both did not do a ﬁnal check of the passage plan before departing

this with pilot directions and the ECDIS.
▶

Continued navigating without conﬁrming the height of the Ōshima
Bridge.

We can understand that the accident occurred, because the chain of human errors was
not broken.
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P&I Loss Prevention BulletinJAPAN P& I CLUBBefore departing the Port of Onsan, Master E and 2/O E conﬁrmed the ﬁnal

Ship Management Company E▶

No intervention was taken regarding the creation and conﬁrmation of
the management of the vessel's Passage Plan

６−３

P&I Loss Prevention Bulletin

4 Individual skills

Cause (Unsafe behaviour)

The Safety Management System (SMS) specifies the creation procedure manual of

2 Emotional

3 Organizational

4-1 Inadequate knowledge

4-2 Inadequate
4-3 Poor work ethic
skills

MachineMediaManagement

Mechanical factors such asmachinery not working properly or being out of orderMedia connecting Manwith Machinery

Management factors and organization

Mainly on the vessel

The vessel, shipowner andship management company

5 Managementof health andworking environment

Shipowner and Ship managementcompany

On the vessel

Lack of education and training

Inadequate layout arrangement

Inadequate safety management
planning①⑥

Inadequate/incomplete regulations
and procedure manual①

Inadequate supervision of his/her
subordinates

③

②

⑤

②

④

①

Inadequate layout arrangement

Lack of education and training

Inadequate management/
organization

Inadequate safety management
planning

Inadequate supervision of his/her
subordinates

Inadequate/incomplete regulations
and procedure manual

②

⑥

③

③

⑤

②

Inadequate work space

Inadequate management/
organization④①

Work preparedness/inadequate
working conditions

Inappropriate work method

Lack of information regarding work
to be carried out

Poor working environment conditions②

Lack of standardization

Lack of machinery and facility
maintenance, etc.

⑤

①

④

⑥

③

⑤

Defective protection against hazards④

Design ﬂaw in the machinery

Lack of fundamental safety (designand ergonomic arrangement)

Lack of consideration regarding
ergonomic factors③

Tool box meeting was not
implemented

②

①

②

Protective wear not worn

Health check not implemented prior
to working

Covers up or tolerates dishonest
work
Intentionally dishonest regarding
work, and breaks the rules

①

②

④

③

The belief that the work done is satisfactory,
when objectively it is inadequate

Not “ready” to work

Not enough training③①

Desire and willingness①

Ageing⑤

Physical ability④①

Alcohol, medicine or disease②⑤

Lack of sleep③④

Fatigue②③

Personality

Communication②

Habituation phenomenon①①

Mistakes and perceptual illusion

Leadership and teamwork⑫

Unaccustomed to work, inexperienced, inadequate skills
Lacks basic knowledge of thework
Mistakes regarding work procedure/ forgetfulness
Lack of a sense of urgency andawareness
Work content not understood or
misunderstood
Inadequate or inappropriate knowledge about the work to be carried out
Commitment (responsible
intervention)⑪

Judgement based on speculation④⑩

Mental shortcuts

Cuts corners

③

⑨

②

⑧

Unconscious acts⑦

Habituation behaviour

Personal problems

Forgetful

Sense of urgency and sensitively

Impulsive action

⑥

③

⑤

②

④

①

①

Necessity of re-investigation

1 Psychological

In ① , write down a direct cause
which was investigated basedon the facts After ② , write
down the root cause using the
Why Why Analysis. Then, circle
each applicable cause. Regarding items other than Man (Human factors), enter the sub-item
number of each item in the 4M
Classiﬁcation List.

Ship Management Company E

JAPAN P& I CLUBMan

2/O E and Ship managementcompany E

2/O E created the Passage
Plan between Onsan andEtajima without conﬁrming the height of the Ōshima
Bridge

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

Why was the Passage Plan
② created using nautical chartordering software?

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

What was the data copied
over to the ECDIS?

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

Why was Draft and Air Draft④ data not input into the ECDIS?

〇

〇

〇

〇

〇

〇

〇

〇

〇

1

③

〇

〇

Abort Point had not been identiﬁed, it was also not input into the ECDIS. ⑥
Sense of urgency and sensitivity and to ⑧ Cut corners are applicable.

Analysis Related to Unsafe Behaviour for
Master E and 2/O E (See Attachment 18)

Human factor (The vessel, shipowner and ship management company）

Passage Plan, but without checking the details. In addition, as a planned

①

③

〇

the Passage Plan, and there was no problem with this in itself. However, regarding
management at the oﬃce on land, it is clear that they were not involved in the Vessel
including any other vessels. “2 Inadequate/incomplete regulations and procedure
manual”, “3 Inadequate safety management planning” and “4 Lack of education andtraining” are applicable. As the problem lies in that of the operational method, we havedesignated this as Re-examination necessary.

Regarding the Passage Plan,⑤ why did the managementcompany not intervene?

②

①

①

Master E and 2/O E

Why did the Master E believe that the previous Master had signed the Passage
Plan?

2

Why was the Master E un② able to take over effectively
from the previous Master?

〇Why did the 2/O E create
the Passage Plan between③ Onsan and Etajima without
conﬁrming the height of theŌshima Bridge?

〇

〇

〇

〇

〇

〇

〇

〇

６−４ Countermeasures for Unsafe Behaviour for
Master E, 2/O E and Ship Management Company E

Master E and 2/O E

Why did the Master E continue navigating even though
he felt uneasy about theheight of the bridge?

4

〇

〇

〇

〇

Why did the 2/O E not② re-conﬁrm the height of thebridge beam?

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

6

6

6

7

6

6

6

6

Master E

Why did he continue navigating regardless?

6②〇

Why was an Abort Point notarranged?

Total number of circled items

〇
〇

3

1

〇

〇

3

2

6

4

8

（See Attachment 19）

〇

〇
5

1

3

1

1

1

1

1

2

2

2

1

Table 48（Attachment P. 127）

Attachment 19

There is a tendency that causes are from “1 Psychological factors” and “4 Individual

The vessel, shipowner andship management company

1. 2/O E created the
Passage Plan between
Onsan and Etajima
without conﬁrming thebridge beam height of
the Hakata-Oshima
Bridge（1- ③ and ⑤〜⑪）

skill factors” in Human Factor (Man) of 4M.

Psychological Factors

Risk factors（Direct cause
and indirect/root
cause）

Among the psychological factors, ⑥ Sense of urgency and sensitivity, ⑧ Cutting

copied the data over to the ECDIS as is. ⑧ Cutting corners is applicable.
Did not input Draft, Air Draft and Safety isobaths data into the ECDIS ⑧
Cutting corners is applicable.

2. Regarding the Passage
Plan between OnsanEtajima, Master E did
not receive details fromthe previous Master.（1① , ⑧ and ⑨）

MachineMediaManagement

The vessel,
Mainlyshipowner andon the vessel ship managementcompany

On the vessel

Education

1. Vague setting 3. Vague
7. No intervention
method ofprocedure forwas taken into
ECDIS (inputconﬁrming
account whatsoeverting basic daand approving
regarding theta) (1- ③ , ⑤
the Passage
vesselʼs Passage〜⑧ and ⑪） Plan（1- ①
Plan (Management
and ⑦〜⑨） 2- ②，3- ① and
4- ①）
2. What the
Master did
receive fromthe previous
Master wasvague (1- ① ,⑧ and ⑨）

6. Continued navigating
while feeling uneasy
about the height of thebridge,（1- ① , ⑥ , ⑨
and ⑩）

Education andtraining
Knowledge, skills,
consciousness,being given
information, etc.

・Re-training for the
personnel in charge ofcreating the Passage Plan
(2/O E)・Re-training regarding
handling of Abort Point
procedureMan

Shipowner andship managementcompany

The vessel, shipowner andship management company

・Re-training for taking
over from previous
Master・In particular, procedure
manual compliance
Thorough guidance
regarding the approvaland enforcement
procedure of Passage
Standardization,
Plans.
proceduralization,
・Formulationof handlingalerting, reward andmethod (procedure)
punishment KYT,
regarding the route checkcampagnes etc.
function of ECDISEnforcement

MachineMedia

The vessel,
Mainlyshipowner andon the vessel ship managementcompany

Management
On the vessel

・Creation
・Thoroughof Passage
compliance
Plans usingwith theECDIS andreviseda procedure
procedure
manual on
manualhow to utilize
the routefunction

Shipowner andship managementcompany

・Review of SMS
procedure manual
regarding creation,
conﬁrmation andapproval of Passage
Plans. (To include
basic setting methodof ECDIS)
・Guidance andcompleteness ofrevised procedure
manual for all ships
under management
・Enforcement ofinternal auditing

ExamplesCase studies,countermeasuresand rules
Lead by example,
experience of
success, introduce
model cases,“Hiyari-Hatto” (nearmisses), etc.

1. Abort Point: Was there aclear plan if the Passage
Plan got interrupted
or if there were nonreturnable points?（Reexamination necessary)（1- ① , ② and ⑥〜⑨）

corners and ⑨ Judgement based on speculation, are the main causes.
Created a Passage Plan using nautical chart ordering software andMaritime Accident Analysis using 4M5E and Countermeasure List
(Unsafe behaviour) Collision with Ōshima Bridge
Man・Formulation ofcontinued training
and education for
Crew

Environment
Workingenvironment,ofﬁce internalmanagement, onboard organization,
etc.

・Re-training on how tohandle feeling uneasinessregarding navigation
・Re-training for MasterE regarding Safety
Management CodeEngineering
Technology andengineering
Technologicalcountermeasures

Table 49 (Attachment P. 130)

84

85

P&I Loss Prevention BulletinJAPAN P& I CLUBWhen listing risk factors derived from a direct cause and indirect/root cause,

each ship under management, the implementation frequency of internal audits

countermeasures for improvement will emerge.

is to be increased.
▶

review in order to not forget the lessons learned from the accident.

Recurrence Prevention Countermeasures through
Education (education and training) for Master E and 2/O E
It is likely that there were no major deficiencies in the procedure manual on how tocreate the Passage Plan according to the Safety Management System (SMS). The root
cause shows that the creator(s) did not have the foundations necessary to plan the
Passage Plan according to the manual.
Therefore, it will be important for both Master E and 2/O E to receive re-training on
creating a Passage Plan including the utilization of ECDIS.
Also, Master E continued navigating even though he felt uneasy about the height ofŌshima Bridge. Re-training on how to handle feelings of uneasiness while navigating
will also be required.

Specific prevention countermeasures will be summarized here by adding therecurrence prevention countermeasures compiled in Japan Transport Safety Board’s
report (MA2019-10-2). （As the (X) numbered items are recurrence prevention
countermeasures which are defined in the Japan Transport Safety Board Report, ourrecurrence prevention countermeasures with 4M4(5)E analysis are almost identical.)
1 When crew create the passage plan regarding a sea area where they areto navigate for the first time, it is a requirement that they carry out an indepth investigation throughout the entire route, using nautical charts, sailinginformation and other oceanographic information in particular.
1

Recurrence Prevention Countermeasures by Ship
Management Company E
Regarding the creation of the Passage Plan, the fact that the management company was
not directly involved poses a problem, since they relied on related parties only. Conﬁrm
if there any problems with regards to the ISM Code or SMS Manual. If there are any
deﬁciencies, they need to be improved. This should include the following:

Recurrence Prevention Countermeasures Specific to (1)When considering why they could not perform their duties, as mentioned
above, psychological factors and individual skill factors of Master E and 2/
O E underlay the root cause. Another direct cause, which is a result of
insufficient knowledge and experience regarding Passage Plan creation by 2/
O E（who firstly conducted the duty as 2/O on this vessel）can be identified.
Thus, the following two points can be regarded as recurrence prevention
countermeasures:▶

● A review of the Passage Plans procedure using the ECDIS and procedure manual. This is
to include how to utilize the route function.
● This should not stop with work completion and an improved procedure manual, butthat ongoing verification be carried out if it is to be practised reliably at sea (PDCA
cycle). Namely, it is important to manage the following:▶

Thoroughly introduce accident summary and guidance and completeness ofrevised procedure manual for all ships under management.

▶

86

Until the management company can confirm that they reliably practice this with

Moreover, it is important to evaluate these operation results and, if necessary,

Re-training for Master E and 2/O E regarding the creation procedure of the
Passage Plan.

▶

Ship Management Company E to systematize crew education and training.

2 When creating the Passage Plan using the ECDIS, crew must not overlook thepotential hazards en route. They must (1) confirm the electronic charts and (2)employ the ECDIS function. The contents of any cautions displayed should bethoroughly inspected.
3 It is sometimes the case that crew are not fully aware of the potential hazards

87

P&I Loss Prevention BulletinJAPAN P& I CLUBen route when using computer generated voyage plans. When using computer

5 When crewmembers feel uneasy during navigation, navigation should continue

software for navigation, crew should pay attention to the aforementioned two

only after confirming satisfactory safety by the taking of necessary steps topoints.

change course, reduce speed, stop manoeuvring and so on asap, depending

4 In order to prevent oversight of any aerial obstacles, crew should make full useof the ECDIS height check function, if so equipped. It is hoped that the shipowner will actively encourage implementation of this function.
One factor is the fact that both Master E and 2/O E had insufficient skill andknowledge to operate the ECDIS route check function. According to the Japan
Transport Safety Board Inquiry, vessel E’s ECDIS displayed the height above sealevel of the Oshima Bridge as 24m. However, neither vessel draft or air draft had been
input and so cautions regarding the bridge were displayed as “Undeﬁned”.

When the route was rechecked following input of the vessel draft, air draft andthe circumstances.
Master E’s continuing to navigate, even while feeling uneasy could be a direct cause.
Because of the inadequate planning for an abort point, the information was not
displayed on screen. At that time when checking the lights at the Ōshima Bridge, it
might be possible to judge if she could keep manoeuvring by stopping navigation atthat point, and take into consideration the manoeuvrability of the vessel (minimum
stop distance, turning etc.).
5 Recurrence Prevention Countermeasures Specific to (5)▶

When approaching port entry and passing narrow channels, it is necessary tosafety isobath data, the display changed to “Not passed”. Before departing Onsan

clarify the location of an Abort Point and determine whether or not to continue

Port, it appears that both Master E and 2/ Ｏ E did check the route with thenavigation at that point.

ECDIS, but failed to notice the “Undeﬁned” display.
From this author’s history of being on board vessels, it can be said that although▶

Ship Management Company E is to prepare the procedure manual and set
up the Abort Point, and systematise further education and training for Masters
and officers.

the route check function is useful, too many alerts are shown on screen (this could
be related to the settings of basic information), and there is a tendency to get

The ship’s Sea Trial Results and the Turning and Stopping performance displayed on thedesensitized to the meaning of the alerts. Regarding this area, we hope to discuss

bridge are as follows:

how to improve this aspect via Machine (out of 4M) in the future. Considering
this background information, the following have been identified as recurrence
prevention countermeasures:
2 〜 4 Recurrence Prevention Countermeasures Speciﬁc to (2) - (4)▶

Re-training for obtaining safe isobaths and vessel information via ECDIS for
not only the parties involved but also all Masters and navigation officers ofcontracted ships（including how to deal with draft, Air Draft and so on.）▶

It is important to carry out not only temporary re-training, but ongoing andperiodic training, also. It is necessary that Ship Management Company E
create and review the education and training programme for crew.

88

89

P&I Loss Prevention BulletinJAPAN P& I CLUB1. Turning performance

90° Turn (Advance)

2. Stopping performance

Right (Starboard) Turn

Left (Port) Turn

(Initial Spd 12.9kts
Rudder Angle 35deg.)(Initial Spd 13.5kts
Rudder Angle 35deg.)

about 543m

the distance forward until stopping the vessel was 2,116 meters and its time taken was 9
minutes and 53 seconds.

about 559m

(Req. Time)(2 min. 10 sec.)(2 min. 02 sec.)

180° Turn Tactical
Diameterabout 441m

about 463m

(Req. Time)

When operating full speed sternway during employing full speed ahead (14.3 knots),(4 min. 22 sec.)(3 min. 52 sec.)

Table 50

At approximately 00:00 (27 miniutes before the accident occurs) on October 21 when
Master E felt uneasy about the height of the Ōshima Bridge, he ordered his 2/O E toconﬁrm it; the vessel was at the point of 1 nautical mile south of Kasasa Island (Kasasajima). Considering this sea area, it would have been possible both to return by turning or
stopping the vessel itself.
In addition, in the case of heading for Kure （Etajima) passing Kanmon Straits, as it isTurnig Circle

not suitable to navigate Obatake-Seto channel for large ships, for example, those that are
more than 180 meters in length, i.e. Vessel E, it is common to pass via Kudako Suido

Original Course
Tactical Diameter（See Figure 42） instead. In the event of being unfamiliar with this sea area, it would benecessary to have a pilot on board.

Transfer

90° Turn

180° Turn
Advance

90

er
et
iam
lD
na
Fi

Kick

91

P&I Loss Prevention BulletinJAPAN P& I CLUBAttachment 1§7

Conclusion









As explained in the Chapter 1, almost 90% of the root causes of all maritime accidents
are said to be caused by a chain of human errors. In terms of accidents such as
collisions, bridge damage and groundings, which were closely examined this time, it is
no exaggeration to say that the root causes were down to human errors (100%). BTM/







accident and using lessons learned from past accidents to reﬂect and prevent the same
type of accident occurring, it is our hope that these methods may serve to prevent similar


   
   


    ETM and the 4M4(5)E analysis can break the error chain and prevent future accidents.
By utilising the PDCA cycle and by analysing why the parties involved caused thePercentage of accidents that occur when the two overlap



accidents from happening in the future.
1 Site investigation
・Carry out investigation in as much detail as possible, ideally by a third party (such as asurveyor or marine consultant etc.)

References• Transport Safety Board Reports• A collection of tribunals by the Marine Accident Inquiry Agency (MAIA) (Provisional translation)• Cultural lectures held by the Japan Captains’ Association：

75th Human Error from a psychological perspective (Provisional translation）
77th What is BRM? (Provisional translation）

80th Cultural lecture：Ensuring safety in a proud profession ＝ Why BRM is required(Provisional translation）＝
81st Accident elimination caused by human factors (Provisional translation）• The Maritime Human Resource Institute, Japan: Engine room resource management (Provisionaltranslation）• Bridge team management published by Seizando• P&P Network: Meaning and object of OJT (Provisional translation）• Japan Industrial Safety & Health Association Training materials from a Cause analysis andprevention seminar through lessons learned from disaster cases (Provisional translation）

JISHA

92

2 Analysis of site investigation report・ Clarify accident cause/s (4M) using a classification table and so on.
・ Organize these into a matrix to examine the facts.
・ Furthermore, clarify which items need to be inspected/investigated again.
3 Once the above have been established, compile this information into an accident
cause/s matrix (unsafe behaviour and unsafe conditions).
・Refine relevant items.
・Carry out a Why Why Analysis.
4 Once the above 3 has been completed
・Classify the direct cause, indirect cause and root cause of the accident referring to the
4M5E table.
・Devise a countermeasure for every 5E item.
5 Carry out and verify countermeasure based on the above⇒ Brush up with PDCA cycle.

93

P&I Loss Prevention BulletinJAPAN P& I CLUBAttachment 2-1

Attachment 2-2

Causes behind Maritime Accidents (4M)
1. Man2. Machine

1 Psychological factors

1 Design ﬂaw in the machinery

2 Emotional factors

2 Defective protection against hazards

3 Organizational factors
4 Individual skill factors

3 Lack of fundamental safety (design andergonomic arrangement)

5 Management of health and working
environment

4 Lack of consideration regarding
ergonomic factors
5 Lack of standardization(Medium connecting Man and Machine)

Vessel, Ship Owner/Ship management company

1 Lack of information regarding work to
be carried out

1 Inadequate management (organizational)

2 Work preparedness. Inadequate
working conditions

94

2 Inadequate/incomplete regulations andprocedure manual
3 Inadequate safety management planning

3 Inappropriate work method

4 Lack of education and training

4 Inadequate working space

5 Inadequate layout arrangement

5 Poor working environment conditions

6 Inadequate supervision of his/her
subordinates

The vessel, shipowner and ship management company

4. Management (Control factors)

Man

3. Media

Human factors that cause errors

6 Lack of machinery and facility maintenance, etc.

1 Psychological① Impulsive action:
・Human instinct: where there
is a tendency to concentrate on
only one thing, unable to see
what is occurring peripherally,
unaware of hazards (Human beings are sometimes only able tosee one thing at a time)② Forgetful:
・Human beings are limited inthat they cannot memorize
everything (Human beings
sometimes forget)③ Habituation behaviour:・Bad habit. Human beings have
moments of inattention④ Personal problems:・Relationship between strength
to resist stress and stress tolerance⑤ Unconscious acts:
・Human beings are sometimes
careless
・Effects of the human mind
that one is unable to control(Carl Gustav Jung)⑥ Sense of urgency and sensitivity:
・High ability to identify differences in sensory stimuli
strength, and can identify factors that impair safety or life
⑦ Mental shortcuts:
・Human beings are sometimes
in a hurry
・Does not properly complete apart of the work procedure inorder to ﬁnish it quickly
・Use of unsafe behaviour tomake haste (cutting corners)⑧ Cuts corners:
・Breaks the rules due to extra
work all of a sudden or fatigue
・Human beings are sometimes
lazy and human beings sometimes transgress when no one
is looking)⑨ Judgement based on speculation: subjective decision andwishful observation (Human beings sometimes make assumptions)・Conﬁrmation bias and experience of success or failureinﬂuence subjective judgement
and wishful observation⑩ Mistakes and perceptual illusions:
・Visual and auditory (Humanbeings sometimes do not notice and occasionally makemistakes)⑪ Habituation phenomenon:
・False success experience (Human beings have moments ofinattention)
・The ability to acquire an experience of success is not only
achieved by the person experiencing something ﬁrst hand,but may also be acquired
through observing anotherʼsexperience⑫ Personality:
・Unsafe behaviour caused byindividual characteristics
・Human beings sometimes become emotional, etc..

Maritime Accidents 4M Classification List
2 Emotional

3 Organizational

4 Individual skills① Fatigue① Desire and willingness

4-1 Inadequate
knowledge② Leadership andteamwork① Inadequate or inappropriate knowledge about thework to be carriedout② Lack of sleep③ Alcohol, medicine
or disease④ Physical ability(sight, forearm
strength, muscle strength andgood reﬂexes)⑤ Ageing③ Communication④ Commitment(responsible intervention)② Work content
not understood or
misunderstood

5 Management ofhealth andworking
environment① Health check not
implemented prior
to working② Tool box meeting
was not implemented③ Lack of a senseof urgency andawareness④ Mistakes regarding work procedureand forgetfulness⑤ Lacks basic
knowledge of thework
4-2 Inadequate
skills
① Unaccustomed
to work, inexperienced, inadequate
skills② Not enoughtraining③ The belief thatthe work done issatisfactory, when
objectively it is inadequate
4-3 Poor work ethic① Not “ready” towork② Intentionally dishonest regarding
work, and breaks
the rules③ Covers-up or
tolerates dishonestwork④ Protective wear
not worn

Example (1/3)
95

P&I Loss Prevention Bulletin

and machinery design② Inadequate protection functions on facilities andmachines③ Lacking in strength, durability and fatigue strength④ Control program defect⑤ Inadequate performance andfunctions⑥ Defect in construction material and work
carried out⑦ Placement of inappropriate
machines(guard, cover, safety fence, insulating
mat, etc.)② Has protection,
but it is easily deactivated③ Has protection,
but it is inadequate④ Protection available, but the durability of this isproblematic⑤ Inadequate ﬁxing(lashing), shielding
or nothing at all⑥ Inadequate indication of dangerous
areas, range andlevels(design and ergonomic arrangement)

4 Lack of consideration regarding
ergonomic
factors① Fool Proof① AffordanceShould function in away so as not to

Intuitive structure orlayoutcause a hazard
even when operated② Usability

incorrectly② Fail-safe
Maintain safety even if it breaks
down③ Fail Tolerancefunction Even during malfunction,

Operability and alayout which is easytoaccess, yet difﬁcult for errors to bemade③ Universal design
Designed so thatanyone can use it

5 Lack of standardization① Facilities violating laws andregulations, ISO/JIS
or standards onboard (company-speciﬁc)② Inadequate safety measures suchas equipment failure(e.g. power cut,
residual pressure
treatment, etc.)③ Danger warningon usage not relayed to the operator

6 Lack of machinery and facility
maintenance, etc.
① Failure or breakdown of equipment, machinery
sensors etc.
② Unrepaired
breakdown or operation during ﬁxing③ Inadequate machinery and facility
maintenance④ Deterioration ofmachinery, equipment etc.
⑤ Periodic maintenance has not been
carried out

the S/B machine
has a back-up⑥ Lack of spareparts and supplies④ Redundancy⑦ Re-using of usedspare parts whichcannot be re-used

To have many
backup systems

1 Inadequate management(organizational)① Inadequate itemized legal
implementation (person responsible, visibly recognizable,inspection, etc.)② Repeating the same or similar accidents③ Risk assessment is not carried out④ “Hiyari-Hatto” (near miss)scenarios not carried out⑤ Violations and oversight of
the rules on a daily basis⑥ Inadequate communication and sharing of information
between supervisors and workcolleagues, among the vessel,
shipowner and ship management company or between shipowner and ship managementcompany(too narrow, high,low etc.)③ Lacking or no information or
instructions regarding necessarywork② Working in thesame position foran④ Information regarding work
(safety) is not understoodextended length oftime⑤ Did not see information
about work

③ Monotonouswork⑥ No or difﬁcult to see displays
and signs④ "Unreasonableness," "waste" and⑦ No signal or warning, or not
audible enough"inconsistency" during work are to⑧ Vague and confusing working
assignment

be eliminatedor personnel allocation⑨ Lack of information regarding work to be carried out⑩ There is no safety standard
on board (company-speciﬁc)⑪ There is no operating manualor literature on safety precautions⑫ Mistakes regarding the work
procedure⑤ Inappropriate
use of machineryandequipment⑥ Inappropriate
use of tools andequipment⑦ Technical andphysical hardship

3 Inappropriate
work method

4 Inadequate
working space① Vital points ofwork not speciﬁed
or not clear① Work space is
too narrow Keeping
the work space neatand tidy while work
is being conducted② Floor condition(obstacles, bumps,
uneven, slopes etc.)③ Inappropriate
placement, stacking
or propping up of
objects④ Inadequate layout arrangement ofmachinery, equipment, containers,
ﬁxtures etc.)⑤ Used beyond
speciﬁcation (use)limits⑥ Inappropriate
working environment management② Dedicated or
maintenance space
not clearly speciﬁed③ Machinery or arrangement of which
may easily cause anerror or an accident④ Working in dangerous proximity(between people or
between man andmachinery)⑤ Safety aisles,
areas and passages
for maintenance notsecured
⑥ Acquisition ofWork Permit andconﬁrmation of Media (working environment)

5 Poor working
environment conditions① Uncomfortabletemperatureor humidity② Inappropriate
lighting(too dark, bright, or
too changeable)

Management① Unsuitable working posture① Inadequate or
inappropriate contents in Safety
Management Codeor SMS Manual. Or,
is there a point ofcontact to report
inadequate adherence to the Safety
Management Codeor SMS manual or non-compliance which may not
be widely known
among the crew?
② Inadequate education and creationof work method andprocedure manual④ Inadequate or noirregular work procedure manual③ Working in bad
weather④ Noise and severvibrations⑤ Not neat and tidy (4S: sort, set inorder, shine andkept spotless⑥ Inappropriate arrangement of local
ventilation and ventilating equipment⑦ Inappropriate
management ofworking environment (Media)⑧ Powdery dust
and harmful rays(e.g. during welding
operations)

Example (2/3)

Shipowner and ship management company

The vessel, shipowner and ship management company② Inadequate or no Safety Management Code or SMS
Manual

2 Inadequate work
preparedness andworking conditions

2 Inadequate/
incomplete regulations and procedure manual③ Inadequate education and review
of work method andprocedure manualManagement factors and organization① Inadequate or no work
method, work procedure orwork standard

Media① No protection

3 Lack of fundamental safety⑤ Safety Interlock

1 Lack of information regarding work to be carried out

Media connecting Man with Machinery

2 Defective protection against
hazards

On the vessel① Inadequate safety consideration regarding facility

On the vessel mainly

MachineMechanical factors such as machinery not working properly or being out of order

1 Design ﬂaw in the machineryJAPAN P& I CLUB

1 Inadequate management(organizational)① Inadequate safety management due to budget
cutting and cost-cuts(Inadequate safety management due
to personnel assignment anddeterioration of machinery)② Excessive quota for crew andunreasonable operations③ Inadequate itemized legal
implementation (person responsible, visibly recognizable, inspection, etc.)④ Repeating the same or similar accidents⑤ Risk assessment is not carried out⑥ “Hiyari-Hatto” (near miss)scenarios not carried out⑦ Violations and oversight of
the rules on a daily basis⑧ Inadequate periodical vessel
inspections⑨ Vague roles, responsibilities and competence regarding
health and safety duty
⑩ Inadequate communication and sharing of information
between supervisors and workcolleagues, among the vessel,
shipowner and ship management company or between shipowner and ship managementcompany.

3 Inadequate
safety management planning① Work schedule isvague② Deviation between PMS (Planned
Maintenance System) and implementation③ Inadequate safety measures andrisk assessment
while working④ Unexpected workor work which was
not planned in theschedule⑤ Unsuitable workthat relies on excessive concentration and an
individualʼs memory① Work plan orschedule is vague① Inadequate or
inappropriate contents② Deviation between PMS (Planned
Maintenance System) and implementation

method without
proper procedure
manual and education③ Inadequate education and review ofwork method manual④ Inadequate or noirregular work
procedure manual① Absence of onsite managers suchas leaders and supervisors② Inadequate guidance and education(including OJT) for
workers③ Inadequate
safety training forsupervisors andmanagers④ Daily safety
guidance (e.g. provision for on-siteinquiries, etc.) is not
carried out② Inadequate consideration of qualiﬁcations (knowledge),
experience (skills)
and physical capacity (good health)③ Inadequate consideration of work
speciﬁcations andcharacteristics, andattitudes and behaviours of individuals④ Lack of consideration and measures for aged oryoung crew

⑧ Inadequate
communication or
meeting prior towork (including between/among departments)

and procedure
manual

② Inadequate understanding of work

① Inadequate
planning of education and training on
board (pre-boarding, annually, every
few years, etc.)

6 Inadequate supervision of his/her subordinates① Inappropriate
work instructions(5W1H)② Lack or shortageof Ho-Ren-So (reporting, contacting,and consultation) on
board and between
vessel and company③ Inadequate communication between
leaders and subordinates④ Information
about hazards is notshared⑤ Inadequate takeover regarding personnel assignment⑦ Prolonged work

3 Inadequate
safety management planning

SMS Manual

5 Inadequate layout arrangement⑥ Inappropriate orinadequate work
time table and personnel assignment

2 Inadequate/incomplete regulationsin Safety Management Code or

4 Lack of education and training③ Inadequate safety measures andrisk assessment
while working④ Inadequate management for unexpected work or
work which was
not planned in theschedule⑤ Unsuitable
management ofwork that relies on
excessive concentration and an
individualʼs memory⑥ Inappropriate orinadequate work
time table and personnel assignment
management at theofﬁce on land

4 Lack of education and training

5 Inadequate layout arrangement① Inadequate planning of educationand training fromcompany departments (pre-boarding, annually, every
few years, etc.)① Inadequate ofon-site managers② Inadequate guidance and education
for workers

qualiﬁcations(knowledge), experience③ Inadequate
safety training forsupervisors andmanagers(skills) and physicalcapacity④ Daily safety guidance (e.g.
provision for onsite inquiries during
vessel visits, etc.) is
not carried out

such as leaders andsupervisors② Inadequate consideration of(good health)③ Inadequate consideration of work

Inadequate supervision of crew
① Inappropriate
work instructions(5W1H)② Lack or shortageof Ho-Ren-So (reporting, contacting,and consultation) on
board and between
vessel and③ Information
about hazards is notshared④ Inadequate explanation for crewprior to boarding

speciﬁcations andcharacteristics,
and attitudes andbehaviours ofindividuals④ Lack of consideration and measures
for aged or youngcrew⑦ Inadequate
communication or
meeting prior towork (including between/among departments)

Example (3/3)
The Japan Ship Owner's Mutual Protection & Indemnity Association, 14 January 2020 (revised)

96

97

P&I Loss Prevention BulletinJAPAN P& I CLUBP&I Loss Prevention Bulletin

Attachment 3

Attachment 4

Maritime Accident Summary of Related Facts

①

②

③

④

⑤

①

②

③

④

Personality

FatigueLack of sleep

Alcohol, medicine or disease

Physical ability

AgeingDesire and willingness

Leadership and teamwork

Communication

Commitment (responsible
intervention)〇〇

Why did he think he could pass②
starboard to starboard?

〇〇③

Why did he think that the bearingof the other vessel was changing?

〇④

Why did he not continue checking?

〇

Why Why Analysis to be conducted according to each
item that was extracted fromthe Summary of Related Facts

〇
〇

⑤

2

⑥
Why was low visibility not reported to the Master2②〇

Habituation phenomenon

2/O⑫

Unspeciﬁedtime

Searched for the other vessel at 6.6 nautical miles via radar, but did not notice
the image captured on ARPA, because hebelieved he could pass starboard to starboard〇⑪

Unspeciﬁed
dateUnspeciﬁed
time

⑩

6

Unspeciﬁed
dateCuts corners

5

6

Mistakes and perceptual illusion
Judgement based on speculation

2/O

Did not report to the Master, although
there was the low visibility (less than 2
nautical miles) (According to the Safety Management Code, low visibility is deﬁned as less than 3 nautical miles.)〇⑨

Approved navigation to the next port using only one radar.

Mental shortcuts

MasterWhy did the 2/O not notice theimage captured on ARPA?

1⑧

Approx. 5 p.m.

〇⑦

Unspeciﬁed
date

5

⑥

4

〇

Unconscious acts

Requested the Master to navigate using
only No. 2 radar until next port, because
arrangement to ﬁx No. 1 radar at the port
had been made3 Organizational

Sense of urgency and sensitively

Vessel superintendent〇

2 Emotional⑤

Approx. 5 p.m.

3

Personal problems

Unspeciﬁed
date

〇

④

3

△

4

Habituation behaviour

Vessel radar〇

Forgetful

Approx. 4 p.m.

No. 1 radar was out of order

In ① , write down a direct cause
which was investigated based on thefacts After ② , write down the root
cause using the Why Why Analysis.
Then, circle each applicable cause.
Regarding items other than Man(Human factors), enter the sub-item
number of each item in the ４M
Classiﬁcation List.

③

2

Unspeciﬁeddate

1 Psychological

Impulsive action

Approx. 3 p.m.

1

Cause (Unsafe behaviour)②

Check facts and problem areas
Did not report a forecast of low visibility
to the Master

Human factor (The vessel, shipowner and ship management company）①

Caused by
Vessel superintendentMan

Re-examination necessity

Time

Unsafe behaviour

Date
Unspeciﬁed
dateUnsafe conditions

Reference No.

Identiﬁed problems from survey ﬁndings

Accident cause evaluation

Directcause

Maritime Accident Accident Causes (Unsafe Behaviour)1〇 〇Why did he not comply with the
Safety Management Code?

〇

〇

〇 〇

〇 〇

〇

〇

③
④
⑤
⑥
Why did the superintendent request that the vessel navigate
with only one radar?

5②〇

Why was the radar not repaired
before port departure?

〇 〇

〇

〇

③
④
⑤
⑥
Why did the Master approve navigation with only one radar?

6

〇

〇 〇

Why did he not request that the② radar be repaired prior to port
departure?

Example

〇
〇 〇

〇

③
④
⑤
⑥
XX

Accident cause assessment: Prioritized according to the scale of the cause

②
③
④
⑤
⑥

Summary of Related Facts No.

XX
②
③
④
⑤
⑥

98

Example (1/3)
99

P&I Loss Prevention BulletinJAPAN P& I CLUBs Prevention
P&I Loss
Bulletin
Prevention Bulletin

P&I& I CLUBBulletin
JAPLoss
AN PPrevention
Media

Management

Media connecting
Man with Machinery

4 Individual skills
4-1 Inadequate knowledge

4-3 Poor work
ethic

Management factors and organization

Cause (Unsafe behaviour)

⑥

⑤

④

③

②

①

⑥

⑤

④

③

②

③

④

④

⑤

⑤

⑥

Why did he not comply with the
Safety Management Code?

①

①

①

③

④

③

⑥
Why did the superintendent request that the vessel navigate
with only one radar?
Why was the radar not repaired
before port departure?

〇

〇 〇 〇

〇

〇

〇

Why did the superintendent request that the vessel navigate
with only one radar?

5

〇

②

③

③

④

④

⑤

⑤

⑥

①

Why was the radar not repaired
before port departure?

⑤④⑥
Why did the Master approve navigation with only one radar?

Why did he not request that the② radar be repaired prior to port
departure?

〇〇〇

Why did the Master approve navigation with only one radar?

6

Why did he not request that the② radar be repaired prior to port
departure?

③

③

④

④

⑤

⑤

⑥

⑥

XX

XX

②

②

③

③

④

④

⑤

⑤

⑥

⑥

XX

XX

②

②

③

③

⑥

①

②

③

⑤

Inadequate supervision of
his/her subordinates
Inadequate layout arrangement
Lack of education and training
Inadequate safety management planning
Inadequate/incomplete regulations and procedure manual
Inadequate management/
organization
Inadequate supervision of
his/her subordinates
Inadequate layout arrangement
Lack of education and training
Inadequate safety management planning
Inadequate/incomplete regulations and procedure manual
Inadequate management/
organization
Poor working environment
conditions

Why was low visibility not reported to the Master2

Why did he not comply with the②
Safety Management Code?

④⑤⑥
Why was low visibility not reported to the Master

6

Inadequate work space

Why did he not continue checking?

⑤②

Inappropriate work method

④

⑤

5

④

Why did he think that the bearingof the other vessel was changing?

⑥

100

Why did he think he could pass
starboard to starboard?

③

2

③

Lack of machinery and facility maintenance, etc.

Lack of standardization

Lack of consideration regarding ergonomic factors

Lack of fundamental safety(design and ergonomic arrangement)
Defective protection against
hazards

Why did he think that the bearingof the other vessel was changing?

②

Why did he not continue check④
ing?

③

Shipowner and Ship management company

On the vessel

Why did the 2/O not notice theimage captured on ARPA?

1

Why did he think he could pass②
starboard to starboard?

②

①

⑥

⑤

④

③

②

Design ﬂaw in the machinery

Tool box meeting was not
implemented

Health check not implemented prior to working

Protective wear not worn
Covers up or tolerates dishonest work
Intentionally dishonest regarding work, and breaks
the rules

Not “ready” to work

The belief that the work
done is satisfactory, when
objectively it is inadequate

Not enough training〇

In ① , write down a direct cause
which was investigated based on thefacts After ② , write down the root
cause using the Why Why Analysis.
Then, circle each applicable cause.
Regarding items other than Man(Human factors), enter the sub-item
number of each item in the ４M
Classiﬁcation List.

Work preparedness/inadequate working conditions
Lack of information regarding work to be carried out

The vessel, shipownerand ship managementcompany

Mainly on the vessel
①

②

①

④
③

②

①

③

②

①

⑤

④

③

Unaccustomed to work,
inexperienced, inadequate
skillsLacks basic knowledge of
the work
Mistakes regarding work
procedure/ forgetfulness
Lack of a sense of urgency
and awarenessWork content not understood or misunderstood
Inadequate or inappropriate
knowledge about the work
to be carried out

Why did the 2/O not notice theimage captured on ARPA?

1

②

①

In ① , write down a direct cause
which was investigated based on thefacts After ② , write down the root
cause using the Why Why Analysis.
Then, circle each applicable cause.
Regarding items other than Man(Human factors), enter the sub-item
number of each item in the ４M
Classiﬁcation List.

4-2 Inadequate
skills5 Management ofhealth andworking environment

Necessity of re-investigation

MachineMechanical factors such as machinery not working properly or
being out of order

Man

Cause (Unsafe behaviour)

JAPAN P& IJAPCLUB
AN P& I CLUB

Example (2/3)

④
⑤
⑥

①
③

④

③

The number in the circle applies to the number in Attachment 2-2 (Maritime Accidents 4M Classification List) e.g. : Vessel 2
Inadequate/incomplete regulations and procedure manual →① Inadequate or inappropriate contents in ISM Code or SMS Manual

Example (3/3)
The Japan Ship Owner's Mutual Protection & Indemnity Association, 14 January 2020 (revised)101

P&I Loss Prevention Bulletin
P&I Loss Prevention Bulletin
Attachment 5

P&I Loss Prevention BulletinJAPAN P& I CLUBJAPAN

P&I Loss Prevention Bulletin

Maritime Accident Accident Causes (Unsafe Conditions)Man

MachineHuman factor (The vessel, shipowner and ship management company）
Cause (Unsafe behaviour)
2 Emotional

3 Organizational

Mainly on the vessel⑤⑥

Lack of standardization

Lack of machinery and facility
maintenance, etc.

Lack of consideration regarding
ergonomic factors

Design ﬂaw in the machinery④①

Tool box meeting was not
implemented③②

Health check not implemented prior
to working

Defective protection against hazards①

Protective wear not worn

Lack of fundamental safety (designand ergonomic arrangement)④

Covers up or tolerates dishonest
work

②

③

②

Not “ready” to work

Intentionally dishonest regarding
work, and breaks the rules③

Not enough training

The belief that the work done is satisfactory,
when objectively it is inadequate

①

②

①

Lacks basic knowledge of the work

Unaccustomed to work,
inexperienced, inadequate skills

Mistakes regarding work procedure/
forgetfulness

⑤

④

④

⑤

⑤
⑥
①

②

②

③

③

④

④

⑤

⑤
⑥
①

②

②

③

③

④

④

⑤

⑤

①
〇

〇

①

The number in the circle applies to the number in Attachment 2-2 (Maritime Accidents 4M Classification
List)
e.g. : Vessel 2 Inadequate/incomplete regulations
and procedure manual→① Inadequate or inappropriate Education in ISM
Code or SMS Manual

⑥

①

①
②

②

③

③

④

④

⑤

⑤

⑥

⑥

①

①
②

②

③

③

④

④

⑤

⑤

⑥

⑥

①

①
②

②

③

③

④
⑤
⑥

102

Lack of a sense of urgency andawareness

③

④

⑥

③

③

①

Work content not understood or
misunderstood

Why was there no time
② to place a repair orderwhile in port?

⑥

Inadequate or inappropriate knowledge
about the work to be carried out

Why was there no time
② to place a repair orderwhile in port?

①

5 Managementof health andworking environment

Why was No. 1 radarout of order?

2

⑥

②

①

Communication

In ① , write down a directcause which was investigated based on the facts After② , write down the root
cause using the Why Why
Analysis. Then, circle eachapplicable cause. Regarding
items other than Man (Human factors), enter the subitem number of each item inthe 4M Classiﬁcation List.

Commitment (responsible
intervention)

Leadership and teamwork

Desire and willingness

AgeingPhysical ability

Alcohol, medicine or disease

Lack of sleep

Fatigue

Personality

Habituation phenomenon

Mistakes and perceptual illusion

Judgement based on speculation

Cuts corners

Mental shortcuts

Sense of urgency and sensitively

Unconscious acts

Personal problems

Habituation behaviour

Forgetful

Impulsive action

Why was No. 1 radarout of order?

2

4-2 Inadequate
4-1 Inadequate knowledge
4-3 Poor work ethic
skills
④

③

②

①

⑤

④

③

②

①

⑫

⑪

⑩

⑨

⑧

⑦

⑥

⑤

④

③

②

①
In ① , write down a directcause which was investigated based on the facts After② , write down the root
cause using the Why Why
Analysis. Then, circle eachapplicable cause. Regarding
items other than Man (Human factors), enter the subitem number of each item inthe 4M Classiﬁcation List.

4 Individual skills

Cause (Unsafe behaviour)
1 Psychological

Mechanical factors such as machinery not working properly or
being out of order

Example (1/3)④⑤⑥

Example (2/3)
103

P&I Loss Prevention Bulletin
P&I Loss Prevention Bulletin JAPAN P& I CLUBJAPAN P& I CLUBJAPANAttachment 6

Media

Management

Media connecting Man with
Machinery

Management factors and organization

Man

Cause (Unsafe behaviour)
On the vessel

③

③

③

⑥

③

Inadequate layout arrangement③

Why was there no time
② to place a repair orderwhile in port?

Inadequate supervision of his/her
subordinates

Lack of education and training③

Why was No. 1 radarout of order?

2

⑤

④

Inadequate safety management
planning

Lack of education and training③④

Inadequate safety management
planning

Inadequate/incomplete regulations
and procedure manual③

Inadequate/incomplete regulations
and procedure manual②②

Inadequate management/
organization

Inadequate management/
organization①

Poor working environment conditions①⑤

Inadequate work space⑥④

Inappropriate work method

Inadequate layout arrangement③

Work preparedness/inadequate
working conditions③

Inadequate supervision of his/her
subordinates②

Lack of information regarding work
to be carried out

③

⑤

①

In ① , write down a directcause which was investigated based on the facts After② , write down the root
cause using the Why Why
Analysis. Then, circle eachapplicable cause. Regarding
items other than Man (Human factors), enter the subitem number of each item inthe 4M Classiﬁcation List.

Shipowner and Ship managementcompany

The vessel, shipowner and ship
management company

Necessity of re-investigation

The vessel, shipowner andship management company

⑥
①
②
③
④
⑤
⑥
②
③
④
⑤
⑥
①
②
③

⑥
①
②
③
④
⑤
⑥
①
②
③
④
⑤

Mainly on thevessel

Risk factors（Direct cause and indirect/root cause）

2. △ Why was No.
1 radar left out oforder? (Re-ex1. Why the did 2/O not notice theamination necesimage captured on ARPA? (1- ③ ,sary)⑧ , ⑨ , ⑩ , ⑪ and 4-1- ③）
2. Why was low visibility notreported to the Master?
（1- ② , ⑥ , ⑪ , ⑫ , 2- ① and
3- ③）
6. Why was navigation approved
using only one radar?
（1- ① , ⑥ , ⑦ , ⑨ , ⑪ , 4 − 1① , ② , ③ , ④ , 4-2- ① and4-3- ② )Shipowner and ship managementcompany
5. Why was it requested that thevessel navigate with only one
radar?

Example (3/3)

Thorough guidanceand enforcement
Standardization, proceduralization, alerting,reward and punishment KYT, campagnes
etc.

Case studies, countermeasures and rules
Lead by example, experience of success,introduce model cases,“Hiyari-Hatto” (nearmisses), etc.
Environment
Working environment,ofﬁce internal management, on-board
organization, etc.

On the vessel

Shipowner andship managementcompany

1. Why was low vis- 1. Why was low visibility not reportibility not reported to the Master?
ed to the Master?
(2- ① and 6- ① ) （2- ① and 6- ①）
4. Why was navi3. Why was it regation approved
quested that theusing only one
vessel navigate
radar? (1- ③ , 2with only one ra① , 3- ④ and ⑥
dar?
-3)

・Thorough compliance with work
procedure・Thorough compliance with work
procedure・Thoroughly clari- ・Thoroughly clarify procedures forfy procedures forlow visibility in the
low visibility in theprocedure manual
procedure manual

Enforcement

ExamplesManagement

・Pursue the cause
behind the failureand formulate
measures（Re-examination necessary)

Engineering
Technology and engineering
Engineering countermeasure

・Create a procedure ・An important naumanual that states tical auxiliary inthat a vessel isstrument was also
not to leave portout of orderwhile an importantnautical auxiliary
instrument is outof order

④
⑤

Media
The vessel,
shipowner andship managementcompany

Education
・Training in behaviour psychology
Education and training ⇒ Learn to notice things
Knowledge, skills, con- ・Education to reinforce habitually that
sciousness, being giv- optical illusions/errors and assumptions can cause a risky behaviour
en information, etc.

⑤①

Machine

The vessel, shipowner and ship
management company③④

Maritime Accident Analysis using 4M5E and Countermeasure List
(Unsafe behaviour)・Gain a sense of experience using
navigation simulations, for example

・Implementation ofnavigational simulation training

・Formulate a pro- ・Formulate a procedure for internal
cedure for internal
company reporting company reporting

Maritime Accident Analysis using 4M5E and Countermeasure List (Unsafe behaviour)

⑥

104

105

P&I Loss Prevention Bulletin
Attachment 7

Maritime Accident Analysis using 4M5E and Countermeasure List
(Unsafe condition)Man
The vessel, shipownerand ship managementcompany

Risk factors（Direct cause and indirect/root cause）

JAPAN P& I CLUB

MachineMedia

Mainly on thevessel

The vessel,
shipowner andship management company

2. △ Why was
No. 1 radar
left out oforder?

Education and training
Knowledge, skills, consciousness, being given
information, etc..

Engineering
Technology and engineering
Engineering countermeasure
Enforcement
Thorough guidance andenforcement
Standardization, proceduralization, alerting,reward and punishment
KYT, Campagnes etc..

Management
On the vessel

Shipowner andship managementcompany

2. Why was there no
2. Why was theretime to place a repair
no time to placeorder while in port?
a repair orderwhile in port?
・Lack of risk awareness regarding thedanger of navigatingwith a radar left outof order
Education about
important nautical
instruments

Education

Attachment 8

・Lack of risk
awareness regarding the danger of navigatingwith a radar left
out of order
Education about
important nautical
instruments

・Pursue thecause behindthe failure andformulatemeasures（Re-examination necessary)Time

06:45:00

06:50:00

06:53:00

AIS

Position of Vessel A・
06:55:00

Case studies, countermeasures and rules
Lead by example,
experience of success,introduce model cases,“Hiyari-Hatto” (nearmisses), etc.

East longitude

North latitude

East longitude

135 15 min.
34.3 sec.

34 37 min.
56.5 sec.

135 22 min.
44.50 sec.

Shipʼs course <040>
reducing speed at 15.1 kts
Pilot A Visually conﬁrmed Vessel B
34 35min.
02.2 sec.135 16min.
33.4 sec.

Environment
Working environment,ofﬁce internal management, on-board
organization, etc.

--

<068.0>

3.35

1.07
6.64
NauticalNautical
mins.
miles
miles

<069.1>

2.53

0.22
NauticalNautical
miles
miles

6.51
mins.

<068.1>

2.13

0.22
NauticalNautical
miles
miles

5.69
mins.

-

-

Shipʼs course <297>
at a speed of 13.8 kts<056.8>0.49

Called Vessel A twice via VHF
Instructed Nav. Full-

135 20min.
8.90 sec.

34 36min.
53.5 sec.

135 20min.
21.00 sec.

Shipʼs course <293>at a speed of 13.8 kts

34 37min.
02.5 sec.

135 19min.
49.60 sec.

Shipʼs course <294> at a speed of
13.8 kts

Instructed vessel to starboard at anangle of 10 as he felt there was adanger of collision
34 37min.
08.5 sec.

135 18min.
17.5 sec.

Shipʼs course <006>
reducing speed at 12.3 kts

34 37min.
24.6 sec.

135 18min.
47.80 sec.

Pilot A Half Ah'd Instructed HardPort
07:02:10
07:02:49

106

Nauticalmiles

Started steering to starboard side
while heading for Kobe Central
Fairway

07:00:45

Each item number (bold and red coloured) corresponds to the Summary of Related Facts No. in the Attachment 3
The number in the circle applies to the number in Attachment 2-2 (Maritime Accidents ４M Classification List)

4.69

135 21min.
33.80 sec.

Master A Visually conﬁrmed Vessel
B

Pilot A Started steering to port side
while heading for Kobe Rokko Island
East Waterway

07:01:00<061.7>34 37min.
14.9 sec.

Shipʼs course <253>at a speed of 14.0 kts

Shipʼs course <032> reducing speed
at 13.8 kts

34 37min.
29.9 sec.

135 18min.
21.0 sec.

TCPA−

Shipʼs course <041>
reducing speed at 14.8 kts

135 17min.
51.5 sec.

CPA−

34 36min.
55.4 sec.

Shipʼs course <041>
reducing speed at 14.6 kts

Distance

Nauticalmiles

34 35min.
35.6 sec.

135 17min.
29.8 sec.

Bearing

7.08

Shipʼs course <040>
reducing speed at 14.9 kts
135 17min.
06.8 sec.

Vessel Bʼs bearing, distance, CPA andTCPA as observed from Vessel A<056.6>

Shipʼs course <235>at a speed of 14.1 kts

Shipʼs course <235>at a speed of 14.2 kts
Visually conﬁrmed Vessel A

34 36min.
20.6 sec.
06:57:00

Position of Vessel B

34 34 min.
03.5 sec.

Pilot A Instructed vessel to steer toport side in order to head for Kobe
Rokko Island East Waterway

Examples

AIS

North latitude

34 35min.
58.4 sec.
・Review Safety
Management Code(handling importantequipment)

Movements of Vessel A and Vessel B

34 37min.
29.9 sec.

135 18min.
21.00 sec.

-

0.08
NauticalNautical
miles
miles

-

Collisions

-

-

1.81
mins.

-

0.00
0.00
Nautical
mins.
miles

107

P&I Loss Prevention BulletinJAPAN P& I CLUBAttachment 9
Vessel Bʼs bearing anddistance as observedTimefrom Vessel A（hrs：mins）

Vsl. B

07:02:49

XX May 2018. at approximately
07:02:49(JST)

Table of Events Leading up to the Accident

Bearing

07:02:44

Distance

05：00
Approx.

07:02:34
07:02:23

Vessel A
Pilot A

Master A, C/O A, 3/O A and
Cadet A

Boarded south of
Tomogashima Channel.
Started discussing pilotage
plan with Master A.
Instructed Nav. Full up to
18.0 kts.

Master A
Received pilotage plan
instructions from Pilot A.

Vsl. A

07:02:49

Bridge: Master A, Pilot A, C/O A, Cadet A and AB A
06：10
Approx.

07:02:29

From past experience
as a pilot, he assumed
the crew of Vessel tobe trustworthy.

100m

06：31
Approx.

50
50

100m




Rokko Island

ay

air

rF

te

n
Ce

ay

W

108

W
East Fairbe
Ko

06:53 Master A Visuallyconﬁrmed Vessel B
Bearing＜067＞
Distance 3.49 nautical miles

Vsl. B

ir
Center Fa
Way Buoy

06:57 Pilot A Continued tosteer to port side while reducing
speed Bearing＜067＞
Distance 1.77 nautical miles 

Vsl. A

Informed port radio via VHF of theapproximate time
he would be passing through the
breakwater to RC4. Obtained information (e.g. vessel
anchorage) from
Vessel B.

Assumed that MasterA had a sharedunderstanding of thenavigation plan.

Pref.

Osaka Oﬀshore Landﬁll Site
(Osaka Bay Phoenix Center) 
  

 


Anchored 







 
Vessel
 

 
 







 


















Departed Osaka bound for Kobe
RC-4 (Kobe Rokko Island)

Osaka

Wakayama Pref.

Anchored
VesselAccident occured
May,2018 at approximately
07:02:49(JST)06:55 Pilot A Instructed
vessel to steer to port side
while reducing speed

Awaji Id

06：35
Approx.
06：44〜 45
Approx.

Instructed to gradually
reduce the speed to S/B
Full in the port
<057>

7.08
nautical
miles

06:50
Visually conﬁrmed Vessel A
Bearing ＜242＞ Distance
4.69 nautical miles

06:52 Master B Steered to
starboard heading for Kobe
Central Fairway

06:45 Pilot A Visually conﬁrmed Vessel B
Co. ＜057＞ Distance 7.08 nautical miles

Navigation Ofﬁcer B

Bridge: Master B, Navigation
Ofﬁcer B and AB B

Pref.

Osaka Bayakwater

07:01 Pilot A
Hard Port
Half Ah'd

Master B

Hyogo 


No. 7 BrePort Island

Vessel B

Informed port radio via
VHF of the approximate
time he would be passing
through the breakwaterto RC-7. Obtained
information from Vessel B.
Did not report it to MasterA.
Visually conﬁrmed Vessel
B

06：50
Approx.

<062>

4.69
nauticalmiles

Confirmed the
Vessel A (at bow
and distance approximately at 4.0
nautical miles)
and started lookout of the movement via radarand visually.

109

P&I Loss Prevention Bulletin
Vessel Bʼs bearing anddistance as observedTimefrom Vessel A（hrs：mins）
Bearing

Distance

06：52
Approx.

JAPAN P& I CLUB

Vessel A
Pilot A

Master A, C/O A, 3/O A and
Cadet A

3/O A ascended and manned the bridge to take over from C/O A
3/O A ascended and manned the bridge to take over from C/O A

06：53
Approx.

<067>

3.49
nauticalmiles

Master A visually confirmed
Vessel B at approximately
25.0 degrees on its starboard
bow. Because Master A did
not hear from the Pilot that
Vessel B would head for
Kobe Central Fairway, heassumed that there would
be no risk of collision judging
by the his vesselʼs relative
position with the other ship
and that it would be heading
in a southwest direction(Outgoing Osaka Bay）.
Started discussing port entry
work with the C/O. A

Vessel B
Master B
Steered to starboard headingfor Kobe Central
Fairway.

Vessel Bʼs bearing anddistance as observedTimefrom Vessel A（hrs：mins）

Navigation Ofﬁcer B
06：57
Approx.

06：55
Approx.

Bearing

Distance

Pilot A

<067>

1.77
nauticalmiles

Because Vessel A was in
the middle of reducing
speed in relation to Vessel
B, it was assumed that
Vessel B could pass
the bow, and Vessel A
continued to steer to portside along with reducing
speed.

While steering
to starboard,
instructed acourse of <290>

2.53
nauticalmiles

Assumed crew of Vessel
A were paying attention to
the movement of Vessel
B, because Master A andC/O A were watching the
ECDIS. He also conﬁrmed
Vessel B visually bypointing.
After that, he did not
notice when Master A andC/O A were discussing
port entry work at the sea
chart table.
Instructed vessel to steer
to port side in order tohead for Kobe Rokko
Island East Waterway.

Master B

Navigation Ofﬁcer B

Cadet A
Reported to Pilot A and 3/
O A, because he was worried
about a risk of collision with
Vessel B
Master A, 1/O A and 3/O
Did not pay attention to
Cadet A reporting.

Visually conﬁrmedthat Vessel A
started steering
to port side, felt
there was a riskof collision, andinstructed Nav.
Full and hard to
starboard 10 .
<057>

0.49
nauticalmiles

Concerned about
decreasing CPA,
but assumed thatthe vessel could
pass the bow,according to thevector indicatedon ARPA.

Sailing close to East
Fairway, instructed to themain engine Half Ahead.
Visually conﬁrmed theirposition in relation to
Vessel B. Ordered hard
to starboard, because hefelt there was a risk ofcollision with Vessel B.

07：02
Approx.

Dangerously
close

Master A
Heard Pilot Aʼs instructions
hard to port, but whenlooking in the direction of thebow, felt there was a dangerof collision.

Master A
Instructed 3/O A D.Slow
Ahead.
3/O A
According to the Masterʼso r d e r, o p e r a t e d e n g i n etelegraph for D.Slow Ahead

Assumed thatthe vessel would
reach port
quicker if speed
was increased toNav. Full.

Blew a whistle

Blew a whistle

Called Vessel A by
VHF.

Called Vessel A by
VHF.

Did not respond to Vessel Bʼs VHF call
Master A
Operated engine telegraphfor full speed sternway byhimself

07：02：49 Approx.

110

Master A, C/O A, 3/O A and
Cadet A

07：00
Approx.

Instructed acourse of <293>.
Recognizedcrossing pointwith Vessel A<069>

Vessel B

Did not notice Cadet A
reporting.

07：01
Approx.
06：54
Approx.

Vessel A

Collision

111

P&I Loss Prevention BulletinJAPAN P& I CLUBP&I Loss Prevention Bulletin

Attachment 10

②

③

④

Desire and willingness

Leadership and teamwork

Communication

Commitment (responsible
intervention)

7

〇

8

07：02 Approx.

Pilot A, Master A
and 3/O A

Did not respond to Vessel Bʼs VHF call.

Master B

Was concerned about decreasing DCPA, but
assumed that vessel B could pass the bow
Vessel A, according to the predicted course
Vessel A on the radar.

〇

Master B

Assumed that the vessel would reach port
quicker if speed was increased to Nav. Full.

〇

11

Master B andship managementcompany B

Did not instruct navigation ofﬁcer to reportand lookout thoroughly.（BRM is was not
implemented）

〇

12

13

Pilotsʼ Associations

Were the pilots obliged to take BRM training
periodically?

〇

13

14

Master A

Non-compliance with Safety Management Code

〇

14

〇

15

Ship managementcompany A

Non-compliance with Safety Management Code

〇

15

〇

12

Ageing〇Did not notice the Cadet reporting earlier.

06：57 Approx.

①

Did not notice the Cadet reporting.

Master A and 3/O
A

XX May⑤

Pilot A

11

〇

9
②

10

Why did he not check the② change of relative bearingor DCPA?

〇②

Why did he not pay attention to Cadet A as well?

③

Why did believe that CadetAʼs skills were insufﬁcient?

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

〇

4

6

〇

〇

〇

〇

7. Why did he not notice
Cadet A reporting?

7

9

〇

6. Why did he assume that
Vessel B would pass theirbow, and continued tosteer to port side?

6

Accident cause assessment: Prioritized according to the scale of the cause

Why did he assume conﬁrmation was not needed because the crew weremonitoring the ECDIS?

〇

〇
〇

〇

〇

Example (1/3)

5. Why did he think thecrew were paying attention
to Vessel B?

5

〇

〇
〇

Assumed that the Master② understood because he also checked Vessel B.

06：57 Approx.

06：57 Approx.

〇

2. Why was information on
Vessel B not reported to
Master A?

2

2

06：57 Approx.

XX MayWas there not enough time
to conﬁrm?

〇

Was it because the vessel③ belonged to his afﬁliatedshipping company?

XX May〇Physical ability②

XX May10

1. Why was it assumed
that the crew of vessel A
had been thoroughly trainedin BRM and that Master A
had a shared understandingof the Passage Plan?

1

8

XX May④

Pilot A

7

9

Alcohol, medicine or disease

Pilot A③

06：57 Approx.

Lack of sleep〇

XX May②

Assumed that Vessel B would pass their bow,and continued to steer to port side.

6

06：55 Approx.

Fatigue1

XX MayPersonality

〇

5

①

Pilot A

Although he felt that there was no changeof bearing between Vessel A and Vessel B,
he assumed crew of Vessel A were paying
attention to the movement of Vessel B, because
Master A and 3/O A were watching the radarand ECDIS. Pilot A himself conﬁrmed Vessel B
visually by pointing.

06：53 Approx.

Habituation phenomenon

6

XX May⑫〇4⑪Master A

Did not mention the movement of Vessel B to
Pilot A. Also, as Pilot did not talk to him about
Vessel B, he started discussing port entry worknear the sea chart table with 1/O A.

Mistakes and perceptual illusion

5

⑩

〇

Judgement based on speculation

Assumed that Vessel B would keep its distancewhen passing the starboard side of Vessel A.

⑨

Master A

Cuts corners

06：53 Approx.

Mental shortcuts

XX May⑧3Sense of urgency and sensitively

3

⑦

〇

⑥

Visually conﬁrmed Vessel B, but did not informthe Master of port radio information (Vessel B
bound for RC-7).

Unconscious acts

Pilot A⑤

06：44 Approx.

Personal problems

XX May4④

2〇Habituation behaviour

Pilot A

3 Organizational

Forgetful

05：00 Approx.

In ① , write down a direct cause
which was investigated basedon the facts After ② , write
down the root cause using the
Why Why Analysis. Then, circle
each applicable cause. Regarding items other than Man (Human factors), enter the sub-item
number of each item in the 4M
Classiﬁcation List.

2 Emotional③

XX May1 Psychological

Impulsive action

1

Cause (Unsafe behaviour)②

Check facts and problem areas
Felt that the crew of Vessel A had received
thorough training in BRM and assumed them
to be trustworthy. Also, assumed that Master A
had a shared understanding of the navigation
plan.

Human factor (The vessel, shipowner and ship management company）①

Caused byMan

Re-examination necessity

Time

Unsafe conditions

Date

Unsafe behaviour

Reference No.

Identiﬁed problems from survey ﬁndings

Accident cause evaluation

Directcause

Vessel A and B Collision Accident Maritime Accident Cause(Unsafe Behaviour): Pilot A

Attachment 11

Vessel A and Vessel B Collision Accident Summary of Related Facts

〇

〇

〇
〇

〇

〇

〇
〇

〇
〇

〇

9. Why did he not respondto Vessel Bʼs VHF call?

〇

Total number of circled items

4

4

〇

2

3

7

10

2

3

2

Summary of Related Facts No.

112

113

P&I Loss Prevention Bulletin
P&I Loss PreventionP&I
Bulletin
Loss Prevention BulletinJAPAN P& I CLUB
P&IP&
Loss
Prevention Bulletin JAPAN P& I CLUBJAPAN P
JAPANI CLUB
MachineMan

Mechanical factors such as machinery not working properly or
being out of order

4 Individual skills

Cause (Unsafe behaviour)

⑤

⑥

①

②

③

④

⑤

⑥
②

Lack of education and training

Inadequate layout arrangement

Inadequate supervision of his/her
subordinates

Inadequate management/
organization

Inadequate/incomplete regulations
and procedure manual

Inadequate safety management
planning

Lack of education and training

Inadequate layout arrangement

Inadequateof his/her
Leadershipsupervisionand teamwork
subordinates

Cuts corners
Inadequate/incomplete
regulations
and procedure manual④⑧②Inadequate management/
organization

Inadequate safety
Judgement
basedmanagementon speculation
planning

①

③
⑨

⑤

Inadequate work space

Poor working environment conditions

Inappropriate work method

④

③

114

Was there not enough time
to conﬁrm?

Assumed that the Master② understood because he also checked Vessel B.

Example (2/3)

Example (3/3)

5. Why did he think thecrew were paying attention
to Vessel B?

5

Why did he assume conﬁrmation was not needed because the crew weremonitoring the ECDIS?

②

Why did he assume conﬁrmation was not needed because the crew weremonitoring the ECDIS?

The number in the circle applies to thenumber in Attachment 2-2 (Maritime Accidents 4M Classification List)

6. Why did he assume that
Vessel B would pass theirbow, and continued tosteer to port side?

6

Why did he not check the② change of relative bearingor DCPA?

7. Why did he not notice
Cadet A reporting?

7. Why did he not notice
Cadet A reporting?

7②

Why did he not pay attention to Cadet A as well?

②

Why did he not pay attention to Cadet A as well?

③

Why did believe that CadetAʼs skills were insufﬁcient?

③

Why did believe that CadetAʼs skills were insufﬁcient?

9. Why did he not respondto Vessel Bʼs VHF call?
Total
4 number 2of circled
4
6 items
3 2 7

Work preparedness/inadequate
working conditions

4①

2. Why was information on
Vessel B not reported to
Master A?

2

Why did he not check the② change of relative bearingor DCPA?

9①

Was it because the vessel③ belonged to his afﬁliatedshipping company?

6. Why did he assume that
Vessel B would pass theirbow, and continued tosteer to port side?

7

②

②

5. Why did he think thecrew were paying attention
to Vessel B?

6

Lack of information regarding work
to be carried out

Lack of machinery and facility
maintenance, etc.

Lack of standardization

Communication
Lack of consideration regarding
ergonomic factors
Leadership and teamwork
Lack of fundamental safety (designand ergonomic arrangement)

Defective protection against hazards

Was there not enough time
to conﬁrm?

Assumed that the Master② understood because he also checked Vessel B.

②

1. Why was it assumed
that the crew of vessel A
had been thoroughly trainedin BRM and that Master A
had a shared understandingof the Passage Plan?

1

2. Why was information on
Vessel B not reported to
Master A?

5

Shipowner and Ship managementcompany

On the vessel

Pilot AWas it because the vessel③ belonged to his afﬁliatedshipping company?
2

①

⑥

⑤

③
④

②
③

②

Design ﬂaw in the machinery

Tool box meeting was not
implemented

Health check not implemented prior
to working

Communication
Protective wear not worn
Leadership and teamwork
Covers up or tolerates dishonest
work

Intentionally dishonest regarding
work, and breaks the rules

Not“ready” towork on speculation
Judgement
based

Not enough training

The belief that the work done is satisfactory,
Cuts
corners it is inadequate
when objectively

Unaccustomed to work,
inexperienced, inadequate skills

Lacks basic knowledge of the work

Mistakes regarding work procedure/
forgetfulness

Lack of a sense of urgency andawareness

Work content not understood or
misunderstood
Judgement based on speculation
Inadequate or inappropriate knowledge
about the work to be carried out
Cuts corners

Communication

Leadership and teamwork

In ① , write down a direct cause
which was investigated basedon the facts After ② , write
down the root cause using the
Why Why Analysis. Then, circle
each applicable cause. Regarding items other than Man (Human factors), enter the sub-item
number of each item in the 4M
Classiﬁcation List.

Pilot A②

Management factors and organization

The vessel, shipowner andship management company

1. Why was it assumed
that the crew of vessel A
had been thoroughly trainedin BRM and that Master A
had a shared understandingof the Passage Plan?

1

Media connecting Man with
MachineryCause (Unsafe behaviour)

Mainly on the vessel
①

②

①

③
④
②
③

②

③

①
⑨

⑧

②

①

⑤

④

③

②

⑨

①

⑧

③

②

In ① , write down a direct cause
which was investigated basedon the facts After ② , write
down the root cause using the
Why Why Analysis. Then, circle
each applicable cause. Regarding items other than Man (Human factors), enter the sub-item
number of each item in the 4M
Classiﬁcation List.

4-2 Inadequate
4-3 Poor work ethic
skillsManagement

Necessity of re-investigation③ Communication

4-1 Inadequate knowledge

5 Managementof health andworking environment

Media

9

4 10

2 4 3

2

3

7

10

2

3 4

6

2

4

6

2

1

9. Why did he not respondto Vessel Bʼs VHF call?
Total number of circled items

14

4

2

3

17

10

2

3

1

1

4

6

2

1

115

P&I Loss Prevention BulletinJAPAN P& I CLUBP&I Loss Prevention Bulletin

P&I Loss Prevention Bulletin

JAPAN

P&I Loss Prevention Bulletin

Vessel A and B Collision Accident Accident Cause (Unsafe Behaviour):
Master A and Master B

Attachment 12

Man

MachineHuman factor (The vessel, shipowner and ship management company）
Cause (Unsafe behaviour)
2 Emotional

4-1 Inadequate knowledge

⑥

⑤

③
④

Lack of standardization

Lack of machinery and facility
maintenance, etc.

②③

Defective protection against hazards

Communication
Lack of consideration regarding
ergonomic factors
Leadership and teamwork
Lack of fundamental safety (designand ergonomic arrangement)

Tool box meeting was not
implemented②②

Health check not implemented prior
to working

Design ﬂaw in the machinery①

Protective wear not worn①④

Covers up or tolerates dishonest
work

Summary of Related Facts No.

③

1

Total number of1circled items

2

2

12

3. Why did he assume
that Vessel B would
pass the starboardbow?

②

Why did he not continue
monitoring Vessel B?

4

4. Why did he not ask
the pilot about the
movement of Vessel B,
and instead discuss port
entry with C/O A?

Example (2/3)

〇

8. Why did he not pay
attention to Cadet Aʼsreporting?

8

2

2

3

3

1

Total number of22circled items

1

〇

〇

〇

〇

〇

2

2

3 Total number
2 of circled items

2

2

1

2

3

3

2

2

1

2

2

3

1

1

1

2

2

1

2

1

1

1

1

Master B(Master of Vessel B)〇

1Intentionally dishonest regarding
work, and breaks the rules

2

②

2

Not “ready” towork on speculation
Judgement
based

Total number of circled items①⑨〇

The belief that the work done is satisfactory,
Cuts
corners it is inadequate
when objectively〇

Mainly on the vessel

Why did believe that
② Cadet Aʼs skills were insufﬁcient?

〇

11. Why did he believethat the vessel would
reach port quicker ifspeed was increased toNav. Full?

③

〇

⑧

Why did he not havethe Navigation Ofﬁcer③ report on the change ofrelative bearing and soon?

〇

Not enoughtraining
Mentalshortcuts

〇

②
⑦

〇

①

〇

3

Master B(Master of Vessel B)〇

Lacks basic knowledge of the work〇

3

Unaccustomed to work,
inexperienced, inadequate skills

3

5 Managementof health andworking environment

Why did he not re-con② ﬁrm the movement ofVessel B?

〇

2

⑤

〇

〇
1

Mistakes regarding work procedure/
forgetfulness

2

④

2

〇

〇

Master B(Master of Vessel B)

Lack of a sense of urgency andawareness〇③

Why did believe that
② Cadet Aʼs skills were insufﬁcient?

〇Work content not understood or
misunderstood〇②

8. Why did he not pay
attention to Cadet Aʼsreporting?

〇

Inadequate or inappropriate knowledge
about the work to be carried out〇①

Example (1/3)
〇

4-2 Inadequate
4-3 Poor work ethic
skillsMaster A(Master of Vessel A)〇〇

Communication

Leadership and teamwork

Cuts corners

Judgement based on speculation

Communication

Commitment (responsible
Mental shortcuts
intervention)

Leadership and teamwork

Desire and willingness

AgeingPhysical ability

Alcohol, medicine or disease

Lack of sleep

〇

③

②

⑨

⑧

④
⑦

③

②

①

⑤

④

③

②

In ① , write down a directcause which was investigated based on the facts After② , write down the root
cause using the Why Why
Analysis. Then, circle eachapplicable cause. Regarding
items other than Man (Human factors), enter the subitem number of each item inthe 4M Classiﬁcation List.

〇

Why did he not re-con② ﬁrm the movement ofVessel B?

116

Fatigue

4. Why did he not ask
the pilot about the
movement of Vessel B,
and instead discuss port
entry with C/O A?

11

①

4

Why did he only not
conﬁrm the ARPA?

Personality

〇

②

⑫

Why did he not continue
monitoring Vessel B?

10

Habituation phenomenon②

10. Why did he thinkthat Vessel B could
pass the bow of VesselA, even though he wasconcerned about thedecreasing DCPA?

⑪

3

Total number ofcircled items

3 Organizational

Master A(Master of Vessel A)

3. Why did he assume
that Vessel B would
pass the starboardbow?

8

Mistakes and perceptual illusion

Cuts corners

Judgement based on speculation

Mental shortcuts

Sense of urgency and sensitively

Unconscious acts

Personal problems

Habituation behaviour

Forgetful

Impulsive action

Master A(Master of Vessel A)

⑩

⑨

⑧

⑦

⑥

⑤

④

③

②

①
In ① , write down a directcause which was investigated based on the facts After② , write down the root
cause using the Why Why
Analysis. Then, circle eachapplicable cause. Regarding
items other than Man (Human factors), enter the subitem number of each item inthe 4M Classiﬁcation List.

4 Individual skills

Cause (Unsafe behaviour)
1 Psychological

Mechanical factors such as machinery not working properly or
being out of order

10

10. Why did he thinkthat Vessel B could
pass the bow of VesselA, even though he wasconcerned about thedecreasing DCPA?

②

Why did he only not
conﬁrm the ARPA?

Why did he not havethe Navigation Ofﬁcer③ report on the change ofrelative bearing and so
on?

〇

〇

11

2

2

11

1

2

2

3

2

11. Why did he believethat the vessel would
reach port quicker ifspeed was increased toNav. Full?

Total number of1 circled
1 items117

P&I Loss Prevention BulletinJAPAN P& I CLUBP&I Loss Prevention Bulletin JAPAN P& I CLUBAttachment 13
Media

Management

Media connecting Man with
MachineryMan

Management factors and organization

The vessel, shipowner and ship managementcompany

Cause (Unsafe behaviour)

⑥

①

②

③

④

⑤

②
⑥

Inadequate layout arrangement

Inadequate supervision of his/her
subordinates

Inadequate management/
organization

Inadequate/incomplete regulations
and procedure manual

Inadequate safety management
planning

Lack of education and training

Inadequate layout arrangement

Leadershipsupervisionand teamwork
Inadequateof his/her
subordinates

Cuts corners
Inadequate/incomplete
regulations
and procedure manual
Mental shortcuts
Inadequate management/
organization⑤⑦①

Poor working environment conditions

Lack of education and training⑤

Inadequate work space④④

Inappropriate work method

Inadequate
Judgementsafety
basedmanagementon speculation
planning③

Work preparedness/inadequate
working conditions③⑨②

Lack of information regarding work
to be carried out⑧②①

In ① , write down a directcause which was investigated based on the facts After② , write down the root
cause using the Why Why
Analysis. Then, circle eachapplicable cause. Regarding
items other than Man (Human factors), enter the subitem number of each item inthe 4M Classiﬁcation List.

Shipowner and Ship managementcompany

On the vessel

1 Psychological
1. Why was it assumed that the crew ofvessel A had been thoroughly trained in
BTM and that Master A had a shared understanding of the Passage Plan?（1- ① ,③ and ⑧〜⑪）

Necessity of re-investigation③ Communication

The vessel, shipowner andship management company

2. Why was information on Vessel B not reported to Master A?（1- ⑦〜⑨）

Risk factors（Direct cause and indirect/
root cause）

3②

Why did he not continue
monitoring Vessel B?

4

4. Why did he not ask
the pilot about the
movement of Vessel B,
and instead discuss port
entry with C/O A?

①③〇
Education
Education and training
Knowledge, skills, consciousness, being given information, etc..

Example (3/3)

Why did believe that
② Cadet Aʼs skills were insufﬁcient?

2

2

1

2

13

3

1

1

1

2

Engineering
Technology and engineering
Engineering countermeasure2

Master B(Master of Vessel B)

10

10. Why did he thinkthat Vessel B could
pass the bow of VesselA, even though he wasconcerned about thedecreasing DCPA?

②

Why did he only not
conﬁrm the ARPA?

The number in the circle applies to thenumber in Attachment 2-2 (Maritime Accidents 4M Classification List)

Why did he not havethe Navigation Ofﬁcer③ report on the change ofrelative bearing and so
on?
11

118

①

③

〇

11. Why did he believethat the vessel would
reach port quicker ifspeed was increased toNav. Full?

Total number of circled items

Management
On the vessel

Shipowner and ship management company

13. Incom13. Incomplete BRM inplete BRM
cluding pilot（2- ①）
including
13. Not enough training
pilot（2about psychological①）
factors invites human error（2- ①）

5. Why did he think the crew were paying
attention to Vessel B?（1- ① , ⑤ and ⑦〜⑨）
6. Why did he assume that Vessel B would
pass their bow, and continued to steer toport side?（1- ③ , ⑤ , ⑧ and ⑨）

3 Organizational Related Facts 1, 2, 5, 5,
7 and 9② Why could he not exert leadership as aconning ofﬁcer?
③ Why could he not communicate with the
Master?

8. Why did he not pay
attention to Cadet Aʼsreporting?

Total number ofcircled items

Media

The vessel,
Mainly on the shipowner andvesselship management company

9. Why did he not respond to Vessel Bʼs
VHF call? (1- ①）

Why did he not re-con② ﬁrm the movement ofVessel B?
8

MachineJAPAN

7. Why did he not notice Cadet A reporting?
(1- ③ and ⑨）

Master A(Master of Vessel A)

3. Why did he assume
that Vessel B would
pass the starboard
bow?

Vessel A and Vessel B Collision Accident Analysis using 4M5E andCountermeasure List (Unsafe behaviour): Pilot A

Cause
・Human beings face difﬁculty thinking differently about something once they haveit set in their mind.
・The pilot is also a member of the Bridge.
It would have been naive not to haveconsidered him part of the BTM structure.
Recurrence Prevention Countermeasures
・BTM re-training
・Training in psychology (mental state of
mind)

1

1

Enforcement
Thorough guidance and enforcement
Standardization, proceduralization, alerting, rewardand punishment KYT, Campagnes etc..

Recurrence Prevention
Countermeasures・Thorough guidanceand creation of procedure manual for pilotage regarding BRM（Pilotsʼ associations)

ExamplesCase studies, countermeasures and rules
Lead by example, experienceof success, introduce model cases, “Hiyari-Hatto” (nearmisses), etc.

Recurrence Prevention
Countermeasures
・Introduce model cases, BRM training andtraining that covers mental state ofmind(Pilotsʼ associations)

Environment
Working environment, ofﬁce
internal management, onboard organization, etc.

2

2

1

2

12

3

2

1

1

1

1
1
Each item number (bold and red coloured) corresponds to the Summary of Related Facts No. in the Attachment 3
The number applies to the number in Attachment 2-2 (Maritime Accidents 4M Classification List)

119

P&I Loss Prevention Bulletin
Attachment 14

JAPAN P& I CLUB

Vessel A and B Collision Accident Analysis using 4M5E and Countermeasure
List (Unsafe behaviour): Master A and Master B
Man

The vessel, shipowner and ship management company
Master A
1. Psychological
3. Why did he assume that Vessel B
would pass the starboard bow, without
continuously monitoring Vessel B?
4. Why did he start discussing port entry workwith C/O A?
8. Why did he not pay attention to Cadet Aʼsreporting?（１- ① , ③ , ⑤ and ⑦〜⑪）
3. Organizational factors（Related Facts No. 3,4, 8 and 9)② Why could he not exert leadership as a
Master A?
③ Why could he not communicate with the
Ship's Bridge personnel including Pilot A?
Risk factors
Master B（Direct cause and
1. Psychologicalindirect/root cause）
10. Why did he think that Vessel B could pass
the bow of Vessel A even though he wasconcerned about the decreasing DCPA?（1① , ⑨ and ⑪）
10. Why did he not conﬁrm visually and only
check ARPA data?（1- ⑤ , ⑦ and ⑨）

MachineMedia

Mainly on
the vessel

The vessel,
shipownerand shipmanagementcompany

Management

On the vessel

Shipowner andship managementcompany

Vessel A
Ship management
14. Why did he not company A
comply with the 15. Why did he not
Safety Managecomply with thement Code?（2Safety Manage①）
ment Code?（1③）
4. Why did he interrupt lookout duty 4. Why did he interto start discussrupt lookout duty
ing port entry
to start discussing
work with C/O A
port entry workin the middle ofwith C/O A in theS/B?（2- ①）
middle of S/B?
（1- ③）
Vessel B
12. Did not instructnavigation ofﬁcer to reportand lookout
thoroughly.
（BRM was not
implemented)（2- ①）

Man

Ship managementcompany B
12. Did not instructnavigation ofﬁcer
to report andlookout thoroughly.（BRM
was not implemented)（2- ①）

The vessel, shipowner and ship management company

Education
Education and training
Knowledge, skills,
consciousness, being
given information, etc..

120

Master A
Cause
・ Human beings face difﬁculty thinking
differently about something once they
have it set in their mind.
・ Collapse of communication (the foundationof BTM)・ Mistakes regarding work prioritization
Recurrence Prevention Countermeasures
・ BTM re-training (especially leadershiptraining)
・ Re-training of Safety Management Code
(SMS）
Master B
・Human beings face difﬁculty thinking
differently about something once they haveit set in their mind.
・ Collapse of communication (the foundationof BTM)
Recurrence Prevention Countermeasures
・ BTM re-training (especially leadershiptraining)
・ Re-training of Safety Management Code
(SMS）

Media

Mainly on
the vessel

The vessel,
shipownerand shipmanagementcompany

Management

On the vessel

Shipowner andship managementcompany

Engineering
Technology andengineering
Engineeringcountermeasure

Enforcement
Thorough guidanceand enforcement
Standardization,
proceduralization,
alerting, reward andpunishment KYT,
Campagnes etc..

11. Why did he believe that the vessel would
reach port quicker if speed was increased
to Nav. Full?（1- ① , ③ , ⑦〜⑨ and ⑪）
3. Organizational（Related Facts No. 10 and
11)② Why could he not exert leadership as a
Master B ?
③ Why could he not communicate with the
Ship's Bridge personnel?

MachineVessel A
Ship management
・ Review andcompany A
thorough
・ Review, training
compliance withand education
work procedureand make theregardingwork procedure
the Safety
commonlyManagement
known regarding
Code (SMS）
the Safety
when a Pilot is on
Management Codeboard
(SMS）when a
Pilot is on board
Vessel B(duty system)
・ Review andShip management
comply withcompany B
the Safety
・ Review, training
Management
and education and
Code regarding
make the Safety
duties on
Management Codedeparture andcommonly known
entry, narrow
regarding duties
channels, reduced
on departure andvisibility and soentry, narrowon.
channels, reduced
visibility and so on.

ExamplesCase studies,countermeasures andrules
Lead by example,
experience of success,introduce modelcases, “Hiyari-Hatto”(near misses), etc.
Environment
Working environment,ofﬁce internalmanagement, onboard organization,
etc.

Each item number (bold and red coloured) corresponds to the Summary of Related Facts No. in the Attachment 3
The number applies to the number in Attachment 2-2 (Maritime Accidents 4M Classification List)

121

P&I Loss Prevention Bulletin
Attachment 15
Time

Movement

06：10 Vessel A
After passing
Tomogashima
Channel, changed
course to thenortheast for Kobe
Rokko Island Berth.

Who?
Pilot A

Pilot A

JAPAN P& I CLUB

Vessel A and B Collision Accident Human Behavioural Traits and Human Error(Psychological Analysis)
Behaviour

Human characteristics

From past experience as a
⑨ Human beings sometimes
pilot, he assumed the crew ofmake assumptions
Vessel A to be trustworthy.

Pilot A

③ Conﬁrmation bias
People unconsciously collectinformation that supports what they
believe.

Assumed that Master A had⑨ Human beings sometimes② Normalcy bias
a shared understanding of themake assumptions
Assumed everything would be ﬁne,navigation plan.
⑩ Human beings are sometimes
because this method had been ﬁnelazy.
up until now.
Did not explain procedure
sufﬁciently enough to the
Master after boarding.

06：45
Approx.

Ｐ sychology

Informed port radio via VHF
of the approximate time hewould be passing throughthe breakwater to RC-７.
Obtained information from
Vessel B. Did not report it to
the Master.

③ Human beings sometimes
forgetForgot though he learned
the effectiveness of sharing
information during BTM
training.

(Osaka Bay Phoenix
Center), the Mastersteered to starboard
heading for Kobe
Central Fairway.

Tomogashima
Channel, changed
course to thenortheast for Kobe
Rokko Island Berth.

122

Who?

06：55 Vessel A
Approx. Headed for the

Pilot A

entrance of Kobe
Rokko Island East
Waterway andstarted steering toport side

Only collected information that
supported what what he/she believed.
④ Social loaﬁng
Thought he need not explain and thatsomeone else would notice later.

Behaviour

Human characteristics

Did not notice when the
Master and 1/O of A werediscussing port entry work at
the sea chart table.

④ Human beings sometimes do ③ Conﬁrmation bias
not notice
Thought that the situation was not as
sever as it may have seemed.

Instructed vessel to steer toport side in order to headfor Kobe Rokko Island East
Waterway.

⑤ Human beings have moments ② Normalcy biasof inattention
Assumed everything would be ﬁne,Started steering to port side
while cutting across.

Assumed that the vessel could
pass the bow of Vessel B, as
they were reducing speed.

⑩ Human beings are sometimeslazy.

④ Human beings sometimes do ② Normalcy bias
not notice
People ignore negative information⑤ Human beings have moments
and underestimate phenomena sayingof inattention“Iʼm special, nothing can hurt me!”⑥ Human beings are sometimes
only able to see one thing at
a time06：57 Vessel A
Pilot A
Approx.
Headedfor the entrance ofKobe Rokko Island
East Waterway andstarted steering toport side

Vessel B
MasterSteered northB
westerly heading forthe entrance of Kobe
Central Fairway

Master Visually conﬁrmed Vessel B⑤ Human beings have moments ② Normalcy biasof A
at approximately 25.0 degrees
of inattention
People unconsciously collecton its starboard bow. Because ⑨ Human beings sometimes
information that supports what they
Master A did not hear frombelieve.
make assumptions
the Pilot that Vessel B would
head for Kobe Central Fairway, ⑩ Human beings are sometimes ③ Conﬁrmation bias
Only collected information thatlazy.
he assumed that there would
supported what what he/she believed.
be no risk of collision judging
Did not conﬁrm movement of(Thought it was ﬁne because she
by his vesselʼs relative position
Vessel A.
crossed the stem of the Vessel B.
with the other ship and that
it would be heading in asouthwest direction (Outgoing
Osaka Bay）.

④ Social loaﬁng
Assumed that Pilot A would take careof the entire procedure.

Started discussing port entry
work with 1/O A.

⑥ Human beings are sometimes ③ Conﬁrmation bias
only able to see one thing at ④ Social loaﬁng
a timeAssumed that the Pilot A would take
Prioritizing tasks proved to becare of the entire procedure.
difﬁcult.

because this method had been ﬁne
up until now.

People ignore negative information
and underestimate phenomena saying“Iʼm special, nothing can hurt me!”Because Vessel A was in the ⑨ Human beings sometimes② Normalcy bias
middle of reducing speed inmake assumptions
Assumed everything would be ﬁne,relation to Vessel B, it wasAssumed that the vessel could
because this method had been ﬁneassumed that Vessel B could
pass the bow of Vessel B, as
up until now.
pass the bow, and Vessel A
they were reducing speed.
People ignore negative information
continued to steer to port sideand underestimate phenomena saying
along with reducing speed.
“Iʼm special, nothing can hurt me!”

Pilot A, Did not notice Cadet A
Master reporting.
A and
3/O A

⑦ Human beings are sometimes
in a hurry

Ｐ sychology

Assumed crew of Vessel⑨ Human beings sometimes④ Social loaﬁng
A were paying attention to
make assumptions
Assumed bridge shift personnel werethe movement of Vessel B,⑩ Human beings are sometimes
paying attention.
because Master A and 1/O A
lazy.
were watching the ECDIS. Pilot
Because of this assumption,
A himself conﬁrmed Vessel B
he did not instruct crew
visually by pointing.
clearly.

⑨ Human beings sometimes
make assumptions

Although Master B understoodthat there might have been arisk of collision if he steered to
starboard, he was concerned
about entering port late if he
was to follow the originallyscheduled course.
06：53 Vessel A
Approx. After passing

Movement③ Conﬁrmation bias

Thought that it would be
too tedious to explain theprocedure to the Master.
06：52 Vessel B
Master Steered to starboard without
Approx. After passing Osaka B
checking the movement ofVessel A.
Offshore Landﬁll Site

Time

Concerned about decreasing
CPA, but assumed that thevessel could pass the bow,according to the vector
indicated on ARPA.

④ Human beings sometimes do ① Psychological reactance
not notice
Did not trust Cadet Aʼs reporting.
Did not want to do what he was told.
This may be the so called cocktailparty effect.
⑨ Human beings sometimes
make assumptions⑤ Human beings have moments
of inattention② Normalcy bias
People ignore negative information
and underestimate phenomena saying“Iʼm special, nothing can hurt me!”⑩ Human beings are sometimeslazy.
⑥ Human beings are sometimes
only able to see one thing at
a timeOnly conﬁrmed information via
ECDIS and ARPA

123

P&I Loss Prevention Bulletin
Attachment 16
Date
and
time

Movement

Who?

JAPAN P& I CLUB

Vessel E Ōshima Bridge Collision Accident:
Human Characteristics, Human Error and Psychology
Behaviour

Human characteristics

Date
and
time

Movement

Psychology

Who?

Behaviour

2/O E

Duty take over from 3/O E② Human beings are sometimes
careless: Master E could notreconﬁrm in advance.

Created Passage Plan: Onsan - Etajima
・2/O E did not conﬁrm information
regarding Obatake-Seto (including
bridge beam height) using pilot
directions③ Human beings sometimes forget:
Forgot the procedures of the
Safety Management Code
⑩ Human beings are sometimes
lazy: Knew the procedure, but cut
corners

・Worked according to the following
procedure when creating a Passage Plan

13 Oct.
approx.

Navigating
en route to
Qingdao.

１）Created using software forordering charts ｈ① Human beings sometimes makemistakes: The software was notfor creating Passage Plans

Copied the data over to the ECDIS⑩ Human beings are sometimes
lazy: Knew the procedure, but cut
corners３）Did not input Draft and Air Draft
data into the ECDIS② Human beings are sometimes
careless, ③ Human beings
sometimes forget

2/O E

As a result, although some warnings
were detected by the route check
function of ECDIS, as the vesselʼs Draft
and Air Draft had not been input, thewarning for Óshima Bridge showed
up as “Unconﬁrmed” and was thus
overlooked.

16 Oct.
approxWhen mooredat Qingdao

・The previous Master had checked andsigned the Passage Plan document for
Qingdao under his command. He only checked a summary of the Passage
Master E
Plan between Qingdao-Onsan, andOnsan-Etajima, and did not sign for it.
・Master E believed that the previous
Master had conﬁrmed this because
the Passage Plan had already beencreated.

20
Oct.
approxWhen mooredat the port of
Onsan

Master E

The Master E checked the Passage Planbetween Onsan-Etajima with 2/O E
using the ECDIS. However, this was not
carried out in detail.

Normalcy bias
Human beings have thecharacteristic to underestimate
or ignore information regarding
him or herself.

⑩ Human beings are sometimes
lazy: Neglected to take overproperly⑨ Human beings sometimes makeassumptions: It was assumed thatthe previous Master had approved
the Passage Plan up until
completion of voyage discharge

00:00Ōshima (westof Yashiro
Island)Peer pressure
・Human beings are prone
to make a judgement or
decision inﬂuenced bysomebody elseʼs ideas andthoughts.

While it may be easy to use
・When normalcy bias andconvenient software for orderingpeer pressure are combined,
charts, if ECDIS is not used correctly
a deviation from what wasthen it will return incorrect results
the standard occurs. Then,
as a result, and in no timeat all, this then becomes the
new standard.

The next Master E took over from theprevious Master

Normalcy bias
Human beings have thecharacteristic to underestimate
or ignore information regarding
him or herself.

Social loaﬁng
There is the psychologicaltendency to cut corners in the
belief that someone else willtake care of it⑨ Human beings sometimes makeassumptions: Based on theabove, he assumed that the
Passage Plan had been enteredinto the ECDIS correctly

00:09

00:11

Ōshima(north west of
Yashiro Island)

As Master E felt uneasy about theheight of the bridge, he ordered 2/O E
to conﬁrm it.

2/O E

2/O E tried in vain to ascertain
information regarding the height of thebridge beam using pilot directions⑪ Human beings sometimes panic
Had he remained calm, he may havebeen able to have conﬁrmed it, butinstead panicked

2/O E

Tried to check the height of the bridge
beam operating the ECDIS, but did not
notice the bridge beamʼs height which
was displayed

Master E
2/O E

Bridge manning checked for bridge
lights, but were unable to see them due
to it being too dark.

Master E

Master E worried about being pressedby the westerly current. Continued tonavigate to the east at half ahead

00:26

Shortly before
Hakata-Ōshima Bridge

2/O E

00:27

Shortly before
Hakata-Ōshima Bridge

Master E

00:36⑩ Human beings are sometimes lazy:Knew the procedure, but cut cornersŌshima(north west of
Yashiro Island)

Master E④ Human beings sometimes do notnotice, ③ Human beings
sometimes forget
At the time of approving the Passage
Plan, it was believed that preparation
for navigating the narrow channel
had been carried out, thus no double
check was conducted

East of
Hakata-Ōshima Bridge

Master E

Departed theport of Onsan.

22:00

The west of
Heigun Island

Master E

Manned the bridge in preparation for
navigating the narrow channel

No speciﬁc problem

No speciﬁc problem

04:00

Off the Port ofKure.

Master E

Psychology
Conﬁrmation bias
There is the psychologicaltendency to underestimate
somethingPeople are unconsciously
prone to believe only “whatthey want to believe” and“information that supports
what they believe” rather
than purposefully seeking
information to the contrary.
When investigating two
conﬂicting opinions, there is atendency to set a high value
on afﬁrmative information,
disvalue or even take no noticeof negative information.

PanickIt is said that self-induced
panic tends to occur when
there are high levels of mental
stress among the group,④ Human beings sometimes do
especially in an emergency.
not notice, ⑪ Human beings
Unable to calmly judge thesometimes panic
situation, this leads to the
Had he remained calm, he may have taking of drastic measures.
been able to have conﬁrmed it, but ・When there is imminent
instead panickedthreat to oneʼs values oroneself.
⑪ Human beings sometimes panic
・There was no solution Even if
Was unable to calmly judge thethere were a solution, it would
situation at hand
have only beneﬁted a limited⑪ Human beings sometimes panic
number of crew. (E.g. There
Abort Point: Was there a clear plan
was only one exit, or limited
if the Passage Plan got interrupted
capacity)or if there were non-returnable
・The sound of an explosion
points?（Re-examination necessary)
was heard.

2/O E instructed hard to starboard andthe AB responded to the order.

⑪ Human beings sometimes panic
Took right to manoeuvre instead ofMasterShortly after Master E ordered midships,
the 1st, 3rd and 4th cranes and theaft mast collided with the bridge insuccession.

⑪ Panicked
The entire bridge team panicked,
and were unable to calmly judge thesituation.

Although Master E made a call to theagency requesting them to report thisto the Japan Coast Guard, the person
in charge at the agency could not hear
what was being explained well, thus it
did not get reported
Master E kept navigating because it seemedthat there was no appropriate point ofanchor in the vicinity and it would be safe tocontinue to the destination

21 Oct.
08:30

Human characteristics

Started anchor mooring

22 Oct.

124

125

P&I Loss Prevention BulletinJAPAN P& I CLUBP&I Loss Prevention Bulletin

Attachment 17

Maritime Accident Summary of Related Facts（Collision with Ōshima Bridge)

2 Emotional

3 Organizational

②

③

④

⑤

①

②

FatigueLack of sleep

Alcohol, medicine or disease

Physical ability

AgeingDesire and willingness

Leadership and teamwork

2/O E and Ship managementcompany E

1

〇

〇

〇

5

2

2/O E created the Passage
Plan between Onsan andEtajima without conﬁrming the height of the Ōshima
Bridge

〇

〇

〇

〇

〇

〇

〇

What was the data copied③
over to the ECDIS?

〇

〇

〇

〇

〇

〇

Why was Draft and Air Draft④ data not input into the ECDIS?

〇

2/O E did not conﬁrm bridge beam heightusing pilot directions and the ECDIS〇

3Master E

Continued navigating without conﬁrming
the height of the bridge beam

〇

6

Ship
No intervention was taken into accountmanagement whatsoever, regarding the vesselʼs
company E Passage Plan

〇

6

2

〇

Example (1/3)

Master E and 2/O E

2/O E

Why did the Master E believe that the previous Master had signed the Passage
Plan?
Why was the Master E un② able to take over effectively
from the previous Master?

〇Why did the 2/O E create
the Passage Plan between③ Onsan and Etajima without
conﬁrming the height of theŌshima Bridge?

Accident cause assessment: Prioritized according to the scale of the cause〇

Why was the Passage Plan
② created using nautical chartordering software?

Regarding the Passage Plan,⑤ why did the managementcompany not intervene?

4

〇

〇

〇

〇

〇

〇

〇

〇

Master E and 2/O E

4

Why did the Master E continue navigating even though
he felt uneasy about theheight of the bridge?

〇

〇

〇

〇

〇

〇

Why did the 2/O E not② re-conﬁrm the height of thebridge beam?
Master E

6

Why did he continue navigating regardless?
Why was an Abort Point not②
arranged?
Total number of circled items

126

〇
3

1

〇

〇

〇

4

8

5

〇
3

2

6

1

②

①

Personality①⑫

Habituation phenomenon④⑪

Mistakes and perceptual illusion

Communication⑩

Judgement based on speculation

Work content not understood or
misunderstood
Inadequate or inappropriate knowledge about the work to be carried out
Commitment (responsible
intervention)⑨

Mental shortcuts

Cuts corners

③

⑧

⑥

⑦

00:11

Unconscious acts

22 Oct.

00:00

Master E

Sense of urgency and sensitively

7

22 Oct.

00:00

As Master E felt uneasy about the heightof the Ōshima Bridge, he ordered his 2/O
E to conﬁrm it.

⑤

6

22 Oct.

Passage Plan between Onsan-Etajima
were not conﬁrmed in detail on the
ECDIS.

Personal problems

5

20 Oct.

Master E
and 2/O E

Habituation behaviour

4

Master E④

3

16 Oct.

Believed that the previous Master had
checked and signed the Passage Plan
both between Qingdao-Onsan andbetween Onsan-Etajima.

Forgetful

Did not input Draft, Air Draft and Safety
isobaths data into the ECDISCreated Passage Plan using nautical chartordering software and copied the dataover to the ECDIS as is2

In ① , write down a direct cause
which was investigated basedon the facts After ② , write
down the root cause using the
Why Why Analysis. Then, circle
each applicable cause. Regarding items other than Man (Human factors), enter the sub-item
number of each item in the 4M
Classiﬁcation List.

③〇

1 Psychological

②

2/O E

1

Cause (Unsafe behaviour)

Impulsive action

13 Oct.
approx.

〇Man
Human factor (The vessel, shipowner and ship management company）①

Check facts and problem areas
Created Passage Plan: Onsan - Etajima
without checking the bridge beam heightof Ōshima Bridge. Abort Point procedure
was unclear

Re-examination necessity

Caused by

Unsafe conditions

1

Time

Unsafe behaviour

Reference No.
Date

Accident cause evaluation

Direct cause

Identiﬁed problems from survey ﬁndings

Maritime Accident Accident Cause (Unsafe Behaviour) Collision withŌshima Bridge

Attachment 18

3

127

P&I Loss Prevention BulletinJAPAN P& I CLUBP&I Loss Prevention
P&I
Bulletin
Loss Prevention Bulletin

P&I PLoss
Prevention Bulletin& I CLUB
JAPAN
MachineMediaManagement

Mechanical factors such asmachinery not working properly or being out of orderMedia connecting Manwith Machinery

Management factors and organizationMan

4 Individual skills

Cause (Unsafe behaviour)

Cause (Unsafe behaviour)
The vessel, shipowner andship management company

Mainly on the vessel

Work content not understood or
misunderstood
Inadequate or inappropriate knowledge about the work to be carried out

Lack of education and training①④

Inadequate safety management
planning⑥③

Inadequate/incomplete regulations
and procedure manual①

Inadequate layout arrangement②

Inadequate management/
organization①

Inadequate supervision of his/her
subordinates

①

②

⑤

⑥

Inadequate layout arrangement②

Inadequate supervision of his/her
subordinates

Lack of education and training①⑤

Judgement based on speculation
Inadequate safety management
planning
Cuts corners
Inadequate/incomplete regulations
and procedure manual④⑧②Inadequate management/
organization
Senseof urgency and sensitively

⑨
③

①
⑥

⑤

Inadequate work space

Poor working environment conditions〇

Why was the Passage Plan
② created using nautical chartordering software?

〇

〇

〇

〇

〇

〇

〇

〇

Why was the Passage Plan
② created using nautical chartordering software?

What was the data copied
over to the ECDIS?

〇

〇

〇

〇

〇

〇

〇

〇

③

Why was Draft and Air Draft④ data not input into the ECDIS?

〇

〇

〇

〇

〇

〇

〇

〇

Why was Draft and Air Draft④ data not input into the ECDIS?

2/O E created the Passage
Plan between Onsan andEtajima without conﬁrming the height of the Ōshima
Bridge1Regarding the Passage Plan,⑤ why did the managementcompany not intervene?

①

③

③

Master E and 2/O E

Master E and 2/O E

Why did the Master E believe that the previous Master had signed the PassagePlan?

Why did the Master E believe that the previous Master had signed the Passage
Plan?

〇

2

Why was the Master E un② able to take over effectively
from the previous Master?

Example (2/3)

Why did the 2/O E create
the Passage Plan between③ Onsan and Etajima without
conﬁrming the height of theŌshima Bridge?

Master E and 2/O E

Master E and 2/O E

Why did the Master E continue navigating even though
he felt uneasy about theheight of the bridge?

Why did the Master E continue navigating even though
he felt uneasy about theheight of the bridge?

4

〇

〇

〇

〇

〇

〇

〇

Master E②①①

Example (3/3)
The number in the circle applies to thenumber in Attachment 2-2 (Maritime Accidents 4M Classification List)

Why did the 2/O E not② re-conﬁrm the height of thebridge beam?

〇〇

What was the data copied
over to the ECDIS?

Regarding the Passage Plan,⑤ why did the managementcompany not intervene?

Master E

Why did he continue navigating regardless?

Why did he continue navigating regardless?

6

Why was an Abort Point notarranged?

〇

〇

〇

〇

〇

〇

〇

〇

②

Total number of circled items

6

6

6

7

6

6

6

6

Total number of circled items

②

④

〇

6

Inappropriate work method〇

Why did the 2/O E not② re-conﬁrm the height of thebridge beam?

③

〇

4

Work preparedness/inadequate
working conditions〇

Why did the 2/O E create
the Passage Plan between③ Onsan and Etajima without
conﬁrming the height of theŌshima Bridge?

②〇

Why was the Master E un② able to take over effectively
from the previous Master?

Lack of information regarding work
to be carried out

〇

2

①

〇

③

Shipowner and Ship managementcompany

On the vessel

2/O E and Ship managementcompany E

2/O E created the Passage
Plan between Onsan andEtajima without conﬁrming the height of the Ōshima
shima
Bridge1

128

Intentionally dishonest regarding
work, and breaks the rules

Not “ready” to work

Unaccustomed to work, inexperienced, inadequate skills
Lacks basic knowledge of thework
Mistakes regarding work procedure/ forgetfulness
Lack of a sense of urgency andIntentionally dishonest regarding
awarenesswork, content
and breaks
rules
Work
not theunderstoodormisunderstoodNot“ready” to work
Inadequate or inappropriate knowledge about the work to be carried out
Lack of machinery and facility
maintenance, etc.

Lack of standardization
Unaccustomed to work, inexperienced,
Lack of inadequate
considerationskills
regardingergonomic factors
Lacks
basic
knowledgeof thework
Lack of fundamental safety (designand ergonomic
arrangement)
Mistakesregardingwork procedure/ forgetfulness
Defective protection against hazards
Lack of a sense of urgency andawareness
Design ﬂaw in the machinery
Work content not understood or
misunderstood
Tool box meeting
was not knowlInadequate
or inappropriate
implementededge about the work to be carried out

Protective wear not worn

Health check not implemented prior
to working

Covers up or tolerates dishonest
work
Intentionally dishonest regarding
work, and breaks the rules

Not “ready”based
to work
Judgementon speculation

Not enough training

The belief that the work done is satisfactory,
Cuts
corners it is inadequate
when objectively

Unaccustomed to work, inexperiSense of urgency and sensitively
enced, inadequate skills
Lacks basic knowledge of thework
Mistakes regarding work procedure/ forgetfulness
Lack of a sense of urgency andawareness
Work content not understood or
misunderstood
Judgement
based on speculation
Inadequate or inappropriate knowledge about
the work to be carried out
Cuts
corners

In ① , write down a direct cause
which was investigated basedon the facts After ② , write
down the root cause using the
Why Why Analysis. Then, circle
each applicable cause. Regarding items other than Man (Human factors), enter the sub-item
number of each item in the 4M
Classiﬁcation List.

2/O E and Ship managementcompany E

ems

②

①

①

⑤

④

③
②

②

①
①

⑥

⑤
①
④
⑤
③
④

②
③

①
②

②
①

①

④

③

②

③

①
⑨

⑧

①
⑥

②

⑤

④

③

②

⑨
①

Sense of urgency and sensitively

ment

⑧

⑥

In ① , write down a direct cause
which was investigated basedon the facts After ② , write
down the root cause using the
Why Why Analysis. Then, circle
each applicable cause. Regarding items other than Man (Human factors), enter the sub-item
number of each item in the 4M
Classiﬁcation List.

4-2 Inadequate
4-3 Poor work ethic
skills5 Managementof health andworking environment

Necessity of re-investigation

4-1 Inadequate knowledge

JAPAN P& I CLUBJAPAN

Why was an Abort Point notarranged?

1

1

1

1

1

2

2

2

1

129

P&I Loss Prevention Bulletin
Attachment 19

JAPAN P& I CLUB

Maritime Accident Analysis using 4M5E and Countermeasure List
(Unsafe behaviour) Collision with Ōshima Bridge
Man

MachineMedia

The vessel,
The vessel, shipowner andMainlyshipowner andship management company on the vessel ship managementcompany

1. 2/O E created the
Passage Plan between
Onsan and Etajima
without conﬁrming thebridge beam height of
the Hakata-Oshima
Bridge（1- ③ and ⑤〜⑪）

Risk factors（Direct cause
and indirect/root
cause）

2. Regarding the Passage
Plan between OnsanEtajima, Master E did
not receive details fromthe previous Master.（1① , ⑧ and ⑨）

Management
On the vessel

1. Vague setting 3. Vague
7. No intervention
method ofprocedure forwas taken into
ECDIS (inputconﬁrming
account whatsoeverting basic daand approving regarding theta) (1- ③ , ⑤
the Passage
vesselʼs Passage〜⑧ and ⑪） Plan（1- ①
Plan (Management
and ⑦〜⑨） 2- ②，3- ① and
4- ①）
2. What the
Master did
receive fromthe previous
Master wasvague (1- ① ,⑧ and ⑨）

6. Continued navigating
while feeling uneasy
about the height of thebridge,（1- ① , ⑥ , ⑨
and ⑩）

Education
Education andtraining
Knowledge, skills,
consciousness,being given
information, etc.

・Re-training regarding
handling of Abort Point
procedure

MachineMedia

The vessel,
The vessel, shipowner andMainlyshipowner andship management company on the vessel ship managementcompany

・Re-training for taking
over from previous
Master・In particular, procedure
manual compliance
Thorough guidance
regarding the approvaland enforcement
procedure of Passage
Standardization,
Plans.
proceduralization,
alerting, reward and ・Formulation of handling
method (procedure)
punishment KYT,
regarding the route checkcampagnes etc.
function of ECDISEnforcement

Management
On the vessel

・Creation
・Thoroughof Passage
compliance
Plans usingwith theECDIS andreviseda procedure
procedure
manual on
manualhow to utilize
the routefunction

Shipowner andship managementcompany

・Review of SMS
procedure manual
regarding creation,
conﬁrmation andapproval of Passage
Plans. (To include
basic setting methodof ECDIS)
・Guidance andcompleteness ofrevised procedure
manual for all ships
under management
・Enforcement ofinternal auditing

ExamplesCase studies,countermeasuresand rules
Lead by example,
experience of
success, introduce
model cases,“Hiyari-Hatto” (nearmisses), etc.

1. Abort Point: Was there aclear plan if the Passage
Plan got interrupted
or if there were nonreturnable points?（Reexamination necessary)（1- ① , ② and ⑥〜⑨）
・Re-training for the
personnel in charge ofcreating the Passage Plan
(2/O E)Man

Shipowner andship managementcompany

Environment
・Formulation ofcontinued training
and education for
Crew

Workingenvironment,ofﬁce internalmanagement, onboard organization,
etc.

・Re-training on how tohandle feeling uneasinessregarding navigation
・Re-training for MasterE regarding Safety
Management CodeEngineering
Technology andengineering
Technologicalcountermeasures

130

131

P&I Loss Prevention Bulletin

Author (photograph):

Maritime Counselour/ Captain Takuzo Okada
Loss Prevention and Ship Inspection Dept., JAPAN P&I CLUBTranslated by:Mr.Geoff England
Co-founder and CEO YUZEN Translation LLC
Tel/Fax: 050-1407-1394 geoff@yuzentranslation.com

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